How many inspection deficiencies does BALLARD CENTER have?

BALLARD CENTER has 53 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at BALLARD CENTER?

BALLARD CENTER has a four-star staffing rating from CMS with 1.02 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is BALLARD CENTER located?

BALLARD CENTER is located in SEATTLE, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does BALLARD CENTER have?

BALLARD CENTER has 142 certified beds.

Who owns BALLARD CENTER?

BALLARD CENTER is a for profit - limited liability company facility and is part of the GENESIS HEALTHCARE chain.

What questions should families ask when visiting BALLARD CENTER?

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

How does BALLARD CENTER compare to other nursing homes?

BALLARD CENTER has a 2-star overall rating, which is below average compared to other nursing homes in WA. Families should carefully review inspection findings and consider alternatives.

BALLARD CENTER

Name: BALLARD CENTER
Address: 820 NORTHWEST 95TH STREET, SEATTLE, WA, 98117, US
Telephone: (206) 782-0100
Rating: 2.0

820 NORTHWEST 95TH STREET, SEATTLE, WA 98117 · (206) 782-0100

For profit - Limited Liability company 142 Beds GENESIS HEALTHCARE Data: November 2025

Trust Grade

50/100

#131 of 190 in WA

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Last Inspection: January 2025

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

Overview

Ballard Center has a Trust Grade of C, which means it is average and ranks in the middle of the pack among nursing homes. In Washington, it is ranked #131 out of 190 facilities, placing it in the bottom half, and #31 out of 46 in King County, indicating limited options for better local care. The facility's trend is worsening, with issues increasing from 1 in 2024 to 26 in 2025, which is concerning. Staffing is a relative strength with a 4 out of 5 rating and a turnover rate of 49%, which is average but indicates room for improvement. Notably, the facility had no fines, which is a positive sign, and it boasts more RN coverage than 89% of other facilities, suggesting that residents are likely to receive better oversight. However, several specific concerns were noted, including the lack of a qualified Director of Food and Nutrition Services, failure to conduct proper reference checks for staff, and not completing required annual performance evaluations, which could jeopardize resident care. Overall, while the staffing and RN coverage are strengths, the increasing number of issues and specific compliance failures raise significant concerns for potential residents and their families.

Trust Score: C
In Washington: #131/190
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Washington facilities.
Skilled Nurses: Each resident gets 61 minutes of Registered Nurse (RN) attention daily — more than 97% of Washington nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 53 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 1 issues

2025: 26 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

2-Star Overall Rating

Below Washington average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 49%

Near Washington avg (46%)

Higher turnover may affect care consistency

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 53 deficiencies on record

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of sexual abuse for 2 of 3 residents (Resident 1 & Resident 2), reviewed for abuse reporting. The facility's failure to report an allegation of sexual abuse to law enforcement placed the residents at risk for repeated incidents and unidentified abuse. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, Abuse-Sexual, means any form of non-consensual conduct, including but not limited to, unwanted or inappropriate touching. It further showed that sexual contact may include interactions that do not involve touching including, but not limited to, sending sexually explicit messages, cueing, or encouraging a resident to perform sexual acts. Review of the facility's Abuse Policy titled, Abuse Investigating and Reporting, revised in July 2017, showed, all alleged violations involving abuse will be reported by the facility Administrator or his/her designee to the following persons or agencies: local law enforcement officials. An alleged violation of abuse will be reported immediately but no later than two hours if the alleged violation involves abuse. RESIDENT 1 Review of the significant change in status Minimum Data Set (MDS-a required assessment) dated 03/28/2025 showed Resident 1 was readmitted to the facility on [DATE] and had intact thinking/memory and required assistance with care. Review of the investigation report dated 04/08/2025, showed that Resident 1 reported to Staff C, Therapist, on 04/07/2025 that during the night while they received care for toileting, two African American males tickled them and made them feel uncomfortable. Resident 1 also reported that the men told them that they would make them feel good. In an interview on 05/08/2025 at 12:42 PM, Staff E, Director of Rehabilitation, stated they discussed Resident 1's allegation of sexual abuse with Staff C. Staff E further stated they informed Staff A (Administrator) of Resident 1's allegation of sexual abuse on 04/07/2025. RESIDENT 2 Review of the significant change in status MDS dated [DATE] showed Resident 2 was admitted to the facility on [DATE] and had impaired thinking/memory and required assistance with care. Review of the investigation report dated 04/11/2025 showed Resident 2 reported to Staff D, Physical Therapist, that a staff member took them to the bathroom and was sexually inappropriate with them. In an interview on 05/08/2025 at 1:00 PM, Staff D stated that they reported Resident 2's allegation of sexual abuse to Staff A on 04/11/2025. In an interview on 05/08/2025 at 3:20 PM, Staff B, Director of Nursing Services, stated they followed the Purple Book guidelines and that they should report allegations of sexual abuse to law enforcement. In an interview on 05/08/2025 at 4:42 PM, Staff A stated they were aware of the allegations of sexual abuse for Resident 1 and Resident 2 and the allegations should have been reported to law enforcement. Staff A further stated that the allegations were not reported to law enforcement for Resident 1 or Resident 2. Reference: (WAC) 388-97-0640 (5)(a) .

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0925 (Tag F0925)

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 an effective pest control system was in place for 2 of 3 residents (Residents 1 & 2), reviewed for pest control. This failure placed the residents at risk for unsafe living conditions, emotional distress and a diminished quality of life. Findings included . Review of the facility's Pest Control Policy, revised on May 2008, showed, Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. RESIDENT 1 Review of the Significant change in Status Minimum Data Set (MDS- an assessment tool) dated 12/31/2024 showed Resident 1 readmitted to the facility on [DATE] and required a foley catheter (a tube used to drain urine from the bladder) due to body paralysis from waist down. Review of a nursing progress note dated 02/03/2025 showed Resident 1 requested to go to the hospital on [DATE] for evaluation and treatment of pain and was transported to the hospital emergency room on [DATE]. Further review of the nursing progress notes showed the resident was in the 200 nursing unit. Review of hospital records dated 02/03/2025 showed when the emergency medical transport staff arrived at the facility to transport Resident 1 to the emergency room, insects (ants) were noted on their foley catheter. RESIDENT 2 Review of the quarterly MDS assessment dated [DATE] showed Resident 2 was readmitted to the facility on [DATE]. In an interview on 04/03/2025 at 1:58 PM Collateral Contact (CC1), stated that during a visit on 04/02/2025, while Resident 2 was in bed, they saw ants that crawled all over Resident 2 and the bed was infested with ants that were in their clothes and on their skin. CC1 further stated they saw ants in the room of Resident 2 about two weeks prior to the visit on 04/02/2025 and that they told the staff both times. Review of a service request form dated 01/20/2025 showed ants were on the call button cord and the bed in a resident room on the 400 nursing unit. Review of another service request form dated 03/15/2025 and 04/02/2025 showed ants were in a resident room on the 500 nursing unit. In an interview on 04/21/2025 at 2:32 PM, Staff C, Housekeeping Supervisor, stated the housekeepers reported about two weeks ago that they saw ants in the 200, 300, 400 and 500 nursing units. Staff C further stated they told maintenance and Staff A, Administrator, about the ants on the nursing units. In an interview on 04/21/2025 at 4:36 PM, Staff A stated the pest control service may need to be increased to stop the ants from entering the facility. Reference: (WAC) 388-97-3360(1) .

Mar 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to timely initiate and/or investigate an allegation of neglect for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigation. This failure placed the resident at risk for potential unidentified neglect and lack of protection from abuse/neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that all alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. Review of the facility's undated policy titled, Abuse Investigating and Reporting, showed all reports of resident abuse, neglect, exploitation and misappropriation of resident property shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Review of the quarterly Minimum Data Set (an assessment tool) dated 03/06/2025 showed Resident 1 was cognitively intact. Review of the complaint hotline form dated 02/27/2025, showed Staff F, Social Services, submitted to the state agency that the facility received communication from an outside agency that Resident 1 reported to them that they had multiple concerns with the facility. It further showed that in the communication, Resident 1 stated multiple issues of negligence, falls, and disrespectful language. In an interview on 03/27/2025 at 1:01 PM, Staff F stated that the outside agency emailed me and it was something that Resident 1 reported to them, and I submitted a report to the online incident reporting line. We had a care conference with Resident 1, and I completed grievance forms when I was informed about the multiple concerns, the negligence, the falls and the disrespectful language. I think I told the Director of Nursing Services (DNS) that was here at the time, not the one that is here now. I did not tell the Administrator. I did not start an investigation, I did a care conference with Resident 1 and started the grievances, I thought that would be enough. In an interview on 03/27/2025 at 4:40 PM, Staff B stated, I was not here during that time; an allegation of neglect should have been thoroughly investigated. In an interview on 03/27/2025 at 4:43 PM, Staff G, Regional Nurse Consultant, stated the investigation would have been placed in a red folder when the investigation was complete. Staff G further stated, I did not see one. In an interview on 03/27/2025 at 4:51 PM, Staff A, Administrator, stated they managed the allegations and the investigations of abuse/neglect in the facility and that an allegation of neglect for Resident 1 was not reported to them or investigated. Reference: (WAC) 388-97-0640 (6)(a)(b) .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency 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 interview and record review, the facility failed to timely develop a care plan for lice (insects that live on the human body and hair that can be transmitted through contact with an infected person or their belongings like clothing and /or bedding) infestation for 1 of 1 resident (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at increased risk for further infestation, and unmet care needs. Findings included . Review of the readmit Advanced Registered Nurse Practitioner (ARNP) progress note dated 03/04/2025, showed Resident 2 was readmitted to the facility that day, with orders for permethrin (treatment for lice) external liquid apply to hair and scalp one time. Review of Resident 2's care plan, initiated on 03/24/2025 [20 days later since the date of admission], showed, Resident 2 was on contact precautions for head Lice. In an interview on 3/27/2025 at 4:54 PM, Staff B, Interim Director of Nursing Services, stated that the care plan for Resident 2's head lice and treatment started on 03/24/2025 and that the care plan should have been started when they readmitted to the facility on [DATE]. Reference (WAC): 388-97-1020 (5)(b) .

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure contact precautions (set of safeguards used to prevent the spread of infection transmitted through direct or indirect contact with a resident or their environment) signage was placed on the outside of the room for 1 of 1 Resident (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at increased risk of further infestation of lice (insects that live on the human body and hair that can be transmitted through contact with an infected person or their belongings like clothing and /or bedding) and related complications. Findings included . Review of the facility's undated policy titled, Isolation-Categories of Transmission Based Precautions, showed when a resident is placed on transmission-based precautions, appropriate notification is placed on the entrance door so that personnel and visitors are aware of the need and the type of precaution. The policy further showed the signage informed the staff of instructions for use of personal protective equipment (PPE-gown and gloves). Review of the quarterly Minimum Data Set (an assessment tool) dated 12/30/2024 showed Resident 2 was cognitively intact. Review of a nursing progress note in Resident 2's Electronic Health Record (EHR) dated 03/04/2025, showed Resident 2 requested to go to the local hospital for treatment of abdominal pain, nausea, and vomiting that was not relieved with medication. The progress notes further showed Resident 2 was transported to the local emergency department by emergency transport that day. Review of the hospital record dated 03/04/2025 showed Resident 2 was shown to have pediculosis (infestation of lice) and needed permethrin (a topical medication used to treat lice) treatment before going to have a scan. Review of the readmit Advanced Registered Nurse Practitioner (ARNP) progress note dated 03/04/2025, showed Resident 2 was readmitted to the facility that day, with orders for permethrin external liquid apply to hair and scalp one time for lice until 03/21/2024. In a joint observation and interview on 03/24/2025 at 3:06 PM, Staff C, Registered Nurse, stated the contact precautions sign should still be on the outside of Resident 2's room to inform staff and visitors that they needed to wear a gown and gloves before they entered Resident 2's room. Staff C stated that they did not know why the contact precautions sign was removed because Resident 2 still had symptoms of having lice when they had ongoing itching of their scalp, hair, arms and legs. Staff C further stated they were going to inform the physician that Resident 2 continued to have persistent itching of their scalp, and hair even after the last treatment was applied. In an interview on 03/24/2024 at 3:13 PM with Staff D, ARNP, stated Resident 2 should still be on contact precautions because they still had something in their hair that looked like lice. Staff D further stated that Resident 2 got treated in the hospital for lice and that they ordered additional treatments for the lice when Resident 2 returned to the facility from the hospital. In an interview on 03/24/2024 at 3:33 PM, Staff E, Infection Preventionist, stated Resident 2 should still be on contact precaution. In an interview on 03/24/2024 at 3:38 PM, Resident 2 stated their scalp still itched all the time and that they had picked their skin so bad from itching that it bled at times. Resident 2 further stated that they had been treated at the hospital for lice and that they needed additional treatments at the facility to get rid of the lice and stop the itching. In an interview on 03/24/2024 at 3:44 PM, Staff B, Interim Director of Nursing Services, stated the contact precaution sign was up for Resident 2 earlier that day and that they were not sure why it was removed. Reference: (WAC) 388-97-1320 (1)(a) .

Jan 2025 19 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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to initiate and resolve a grievance for 2 of 4 residents (Residents 44 & 36), reviewed for grievances. The failure to resolve grievances for missing personal items and discharge planning placed the residents at risk for frustration, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Grievance/Concern, dated on 08/25/2021, showed that the purpose of the policy was To assure prompt receipt and resolution of Resident/Representative grievance/concern. It further showed, Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log. When the formal grievance/concern is logged, the Administrator and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated .The department manager will: Contact the person filing the grievance to acknowledge receipt. Investigate the grievance. Take corrective actions, as needed .Notify the person filing the grievance of resolution and/or status within 72 hours. RESIDENT 44 Review of the Quarterly Minimum Data Set (MDS-an assessment tool) dated 10/17/2024, showed Resident 44 was cognitively intact. In an interview on 01/03/2025 at 11:43 AM, Resident 44 stated that their personal television remote control was missing and that they had to replace it themselves. Resident 44 stated that they reported it to Staff F, Social Services Assistant, and that they never got reimbursed. Resident 44 further stated that staff looked for it, and they could not find it and that it's been a month now. Review of the facility's grievance log for August 2024 through December 2024 did not show that a grievance was logged for Resident 44's missing television remote control. In an interview on 01/06/2025 at 10:45 AM, Staff F stated that when grievances were handed to them, they would go over it with the Administrator, evaluate it and send the grievance to the correct department. Staff F stated that when they resolved a grievance, they would follow up with the resident. Staff F stated when Resident 44's television remote control was missing, I was still new and that they did not know about the reimbursement process. Staff F stated they were not sure if there was a grievance filed for Resident 44's missing television remote control and believed it happened in the beginning of November 2024. When asked if Resident 44 was reimbursed for their missing remote control, Staff F stated, I don't think so. In an interview and joint record review on 01/07/2025 at 3:33 PM, Staff C, Interim Administrator, stated that they expected grievances were resolved in a timely manner, investigated and come to a good conclusion that residents were happy with. Staff C stated that they expected a grievance to be filed for Resident 44's missing television remote control. Joint record review for August 2024 through December 2024 grievance log did not show a grievance was logged for Resident 44's missing television remote control. Staff C stated that they were not aware that Resident 44's was missing a remote control and were not aware if a grievance was filed. Staff C further stated they would fill out a grievance for Resident 44 and reimburse them. RESIDENT 36 Resident 36 readmitted to the facility on [DATE]. Review of Resident 36's Significant Change of Condition Assessment (SCSA - a comprehensive MDS) dated [DATE], showed Section C (Cognitive Patterns) item C0500 (BIMS -Brief Interview for Mental Status) was scored at 15, indicating that Resident 36's cognitive function was intact. It further showed that Section Q (Participation in Assessment and Goal Setting), item Q0400 was coded 0 to indicate that active discharge planning was not already occurring for the resident to return to the community. Item Q0500 (Return to Community) was coded 1 to indicate that Resident 36 wanted to talk to someone about the possibility of leaving the facility to return to live and receive services in the community. In an interview on 01/03/2025 at 8:41 AM, Resident 36 stated they have had issues with the facility not returning phone calls to Collateral Contact 2 (CC2) who wanted to be involved with Resident 36's discharge planning. Resident 36 stated their goal was to transfer to another facility to be near CC2. In a phone interview on 01/03/2025 at 8:41 AM, CC2 stated they have not been contacted by the facility to participate in Resident's 36's plan of care since October 2024 and that they have not received returned phone calls from the facility to discuss discharge planning. CC2 further stated that they filled out a grievance form in December 2024 related to their concern about Resident 36's discharge planning process. Review of a grievance form dated 10/30/2024 showed that the grievance was reported to social services and was submitted by Resident 36. The nature of the concern showed that [Resident 36] says that [they] are not happy here at [the facility]. It showed that Staff F was the employee assigned to address the grievance and that Staff F's department findings, was that Found out that [Resident 36] just wanted to be close to [CC2]. The findings of this grievance were undated by Staff F. It further showed that Staff F's action plan, dated 11/08/2024, was that Planning discharge for another facility closer to [CC2] .when [CC2] and social services finds a facility. Review of the facility 's grievance log dated December 2024 showed that a grievance was submitted for Resident 36 on 12/08/2024 and that the disposition of the complaint did not show it was resolved. Further review of the facility's grievance log for December 2024 showed that a grievance was logged/received on 12/23/2024 for an incident that took place on 12/08/2024 and that it was submitted by CC2 (15 days after the grievance was logged). Review of the grievance form dated 12/08/2024 showed that the grievance was reported to Staff F and submitted by CC2. It showed that the nature of concern was that I have been contacting Social Services since October 24 [2024]. They never call back. They tell [Resident 36] that they do. I only want to help get [Resident 36] transferred closer to their family, which I feel will help with [Resident 36's] care and morale. It further showed that Staff F was the employee assigned to address the grievance and that Staff F's action plan to address the grievance was completed on 12/30/2024. The grievance form did not show that complete resolution/satisfaction was achieved. Review of Resident 36's comprehensive care plan printed on 01/05/2025, showed Resident 36's discharge care plan was created on 10/02/2024 and was last revised on 12/31/2024. It further showed that Resident 36's discharge care plan goal was that Resident/Patient will have an ongoing discharge plan that provides for a safe and effective discharge. It did not show a resident centered discharge goal consistent with Resident 36's and CC2's stated goal. In an interview on 01/06/2025 at 2:26 PM, Staff F stated they were responsible for arranging care conferences to discuss discharge planning, as well as to send out referrals related to the discharge planning process. Staff F further stated that they were responsible for addressing grievances assigned to social services. In an interview and joint record review on 01/07/2024 at 1:15 PM, Staff F stated they addressed the grievance form dated 12/08/2024 for Resident 36. Staff F stated Yes, it was done by me, I was new and didn't get it until 12/23/2024. Joint record review of a grievance form dated 12/08/2024 for Resident 36 showed it was addressed on 12/30/2024. Staff F stated, This grievance [dated 12/08/2024] was put in my mailbox, instead of giving it to me directly. Staff F was asked if they expected grievances to be addressed timely and Staff F replied, Right away, if I get a grievance like this, I would [will] show the administration right away. Staff F was asked if the grievance dated 12/08/2024 was addressed timely, Staff F replied, I saw that [grievance dated 12/08/2024] on 12/23/2024 and I didn't email [CC2] until [12/24/2024]. Further joint review of the grievance form showed that the concern was that CC2 did not receive communication from the facility to discuss Resident 36's discharge planning from 10/24/2024 through 12/08/2024. Staff F stated they could not remember receiving communication from CC2 at those times. Joint record review of Resident 36's progress notes from 10/24/2024 through 12/29/2024 showed there was no documentation of communication between social services and CC2 to discuss discharge planning. Staff F stated, I don't think so. In an interview on 01/07/2025 at 2:24 PM, Resident 36 stated that their discharge goal had been to transfer to another facility closer to CC2. When asked if Resident 36 had a discharge goal of returning home alone with a caregiver, Resident 36 answered, No, I don't want to, my number one choice is to be closer to [CC2]. Resident 36 was tearful and stated I don't think [the facility] has done enough to try to get me transferred because I'm still here. I'm sad that I'm not near my [CC2] and it's not good for my morale, it's not good! My situation is upsetting. I don't feel like they're working hard enough to get me transferred. In an interview on 01/08/2024 at 3:15 PM, Staff A, Administrator, stated that they expected grievances to be logged timely, investigated thoroughly, and that the goal was to complete them within 72 hours. Staff A was asked if they expected the grievances for Resident 36 to have been addressed or acted upon timely, Staff A replied, I expect all grievances to be addressed timely. In a phone interview on 01/08/2025 at 5:27 PM, Staff C was asked if they were aware of Resident 36's grievance submitted on 12/08/2024 and Staff C replied, I expect [social services] to speak with the resident in a timely manner, and that the length of time for Resident 36's grievance to have been addressed was lengthy. Staff C further stated that their expectation was not met, and that Resident 36's grievance should have been addressed timely. Reference: (WAC) 388-97-0460 (2) .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 46 In an interview on 01/03/2025 at 1:26 PM, Resident 46 stated that on 12/21/2024 or 12/22/2024, their previous roommate (Resident 95) had jumped on me in bed and kissed me on the lips. Resident 46 stated I didn't [did not] ask for it and it was unwanted. In an interview on 01/08/2025 at 6:29 PM, Staff A provided the completed investigation documents and stated, it's locked, so yes it's complete. When asked if this was everything, Staff A stated, yes. Review of the investigation report showed no documentation that staff interviews or additional resident interviews were done as part of the investigation. It further showed that the investigation summary did not include that abuse had been ruled out. In an interview on 01/08/2025 at 6:34 PM, Staff T stated that they had completed part of the investigation and prepared the report. Staff T stated that the allegation made by Resident 46 of inappropriate touching/kissing was considered abuse and that they conducted an abuse investigation. When asked if they expected to have interviews from additional residents and staff members as part of the investigation, Staff T stated that would be great, to get more information to support the investigation. When asked if the investigation summary showed that abuse was ruled out, Staff T stated, I don't see it there. I should have put it there. When asked if it was a thorough investigation, Staff T stated, it would be better to interview other residents to prevent other occurrences. In an interview on 01/08/2025 at 6:55 PM, Staff A stated that they were the abuse coordinator and I signed off on the investigation. Staff A stated that they would consider it [Resident 46's allegation] sexual abuse. Staff A stated that they expected an abuse investigation to include interview staff members who have taken care of them [alleged victim] and other residents to see if they had seen or heard anything about it [abuse allegation]. When asked if staff and additional resident interviews were done, Staff A stated, I think it was done. I don't [do not] see it in the report. I will look for the interviews. Staff A further stated that I expect it [the abuse investigation report] to say that it was ruled out. A review of an email communication received on 01/09/2025 at 5:04 PM, showed additional documentation for the investigation for Resident 46's abuse allegation, which included the alleged victim and alleged perpetrators statements. Staff A stated that the records provided was what they had. Further review of the email did now show include staff or additional resident interviews. Reference: (WAC) 388-97-0640 (6)(a)(b) Based on interview and record review, the facility failed to ensure resident to resident altercations were thoroughly investigated for 3 of 5 residents (Residents 44, 55 & 46), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, showed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy further showed that the individual conducting the investigation at minimum .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, Requirements for reporting resident to resident assaults to the Department are the same as the reporting requirements for any incident of physical assault against a resident. It showed under Appendix D-Reporting Guidelines to Nursing Homes that resident to resident mental abuse with psychological harm, physical abuse/assault with bodily harm/injury, physical abuse with psychological harm, sexual abuse/assault and misappropriation/exploitation were to be called in to the department's hotline and logged within 5 days. It further showed, mental abuse without psychological harm and physical abuse without bodily or psychological harm were to be logged within 5 days. Additionally, it showed under The investigation Process that All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. The investigation is done to determine, as far as possible: What occurred; and to make necessary changes to the provision of care and services to prevent reoccurrence. A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences. RESIDENT 44 A review of the Quarterly Minimum Data Set (MDS-an assessment tool) dated 10/17/2024, showed Resident 44 was cognitively intact. In an interview on 01/03/2025 at 11:18 AM, Resident 44 stated that Resident 95 verbally assaulted them, that they reported it to the facility staff and filed a grievance. When asked if it was their choice to file a grievance, Resident 44 stated it was not their choice to file a grievance, it was just filed as a grievance. In a follow up interview at 2:23 PM, Resident 44 stated that the incident happened on 12/22/2024. In an interview on 01/05/2025 at 8:33 AM, Resident 44 stated that the incident was reported to Staff S, Licensed Practical Nurse (LPN). Resident 44 stated that the original incident occurred in front of Station 1 Nursing Station and that no one intervene until Staff S stepped in. Resident 44 further stated Staff S did everything they could, none of the other nurses bothered to step in. In an interview on 01/06/2025 at 9:10 AM, Resident 44 stated that Resident 95 told them they were not allowed in the hallway, and that Resident 95 stated, this is my hall. Resident 44 stated that Resident 95 would not let them pass and that Resident 95 tried to get in their way when they tried to pass. Resident 44 stated that Resident 95 would say, this is my space, you're [you are] not allowed here. Resident 44 stated that an unknown staff that was there did not do anything to stop Resident 95 and when they had enough, they said they were going to call the police, and that was when the unknown staff stood up and asked Resident 44 why they were going to call the police. Resident 44 further stated that Staff S was the only one that stood up and helped. A review of the grievance report dated 12/22/2024 initiated by Resident 44, showed, I am complaining about [Resident 95]. I was trying to go past the hallway, going to my room, she kept going into my way, telling me I can't go. Nobody stopped her. I said I'm [going to] call the police and the nurse stopped her. A review of Resident 44's nursing progress notes dated 12/22/2024 did not show progress notes related to an altercation with Resident 95. A review of Resident 44's assessment tab in their Electronic Health Record (EHR) did not show that a change of condition assessment was completed [when there was a resident to resident altercation] on 12/22/2024. A joint record review and interview on 01/08/2025 at 11:45 AM with Staff S, showed a grievance report dated 12/22/2024 initiated by Resident 44. Staff S stated that it was not the one that they had filled out for Resident 44. Staff S stated that they filled out a grievance for the resident for the same week and that they did not remember the day but may have been before the grievance report dated 12/22/2024 that was shown to them. Staff S stated that there was an incident where Resident 46 was down the hall, Resident 95 was behind Resident 44. Staff S stated they heard someone yelling, Resident 95 was standing in front of Resident 46 and Resident 44. Resident 44 and Resident 95 were yelling at each other, back and forth. Staff S stated that they intervened, told them to quiet down and calm them both down. Staff S stated that Resident 46 and Resident 44 wanted to file a grievance because Resident 95 was harassing them. Staff S stated that Resident 44 stated they wanted to talk to Resident 46 in private, but Resident 95 started following them and that was when they started arguing. Staff S stated that was when they came in and attempted to calm them down. Staff S stated they filed a grievance for both Resident 46 and Resident 44 the same day and was not the grievance form dated 12/22/2024 that was shown to them. When asked what their definition of a resident to resident altercation was, Staff S stated, altercation means physical with each other. When asked what they thought about residents yelling at each other, Staff S stated they thought of it as a disagreement or dispute. When asked if Resident 44 reported to them that they were verbally assaulted, Staff S stated that Resident 44 stated they felt like they were being attacked. When asked if they reported it to anyone, Staff S stated they completed a grievance report and that they notified the other charge nurse and Social Worker about it. Staff S stated they did not believe that [Interim] Administrator [Staff A], or Director of Nursing [Staff B], were notified of the incident. Staff S stated that they did not have time to write a progress note and that they were dealing with a lot of things. Staff S stated that Resident 95 was moved to a different room that day because they did not want any physical altercation between them. Staff S further stated that at that time they did not think of it as a resident to resident altercation because their definition of an altercation was physical, Staff S stated, they were yelling at each other. In an interview and joint record review on 01/08/2025 at 12:15 PM, Staff B stated that they used the Purple Book as a guide for reporting abuse. Staff B stated that their process for resident to resident altercation was to immediately intervene, notify the Administrator, Director of Nursing and Social Services, offer room change, report to the State Agency, complete an investigation and interview residents. When asked for some examples of a resident to resident altercation, Staff B stated that residents yelling at each other or not having normal conversations. Staff B stated that if a resident reported a resident yelled at me, they would investigate it. Staff B stated that they would expect resident to resident altercations to be logged in the incident log and expect it to be investigated. Staff B was informed of Resident 44's concern of being verbally assaulted, Staff B stated that they were already investigating it. Joint record review of the grievance report dated 12/22/2024 that the facility provided showed, I am complaining about [Resident 95]. I was trying to go past the hallway, going to my room, [they] kept going into my way, telling me I can't [cannot] go. Nobody stopped [them]. I said I'm [going to] call the police and the nurse stopped [them]. Staff B stated it was a different grievance report that was written by Staff S. Staff B stated that Staff S should have notified the Administrator and that it should have been communicated to them. Staff B stated that Staff S should have followed their process and should have notified them and the Administrator when a resident to resident altercation happened. When asked what they would have done if it was reported to them, Staff B stated they would have investigated it and followed their process. A review of the grievance report for Resident 44 dated 12/22/2024 [received by Staff S that day], and provided to the survey team on 01/08/2025, showed Patient 533A [Resident 95] complained of the walls and wanted the patient to make false report. Patient [Resident 44] states 533A [Resident 95] followed him and took notes when talking to roommate 533B [Resident 46]). Patient [Resident 44] states he has been harassed by 533A [Resident 95]. In an interview on 01/08/2025 at 1:46 PM, Staff A, Administrator, stated that they followed the guidance in the Purple Book for resident to resident altercation. Staff B stated they expected staff to separate them, keep them safe, and if they were roommates, separate them. Staff B further stated they would complete an investigation and would notify the family and the provider. Staff A stated there were verbal, physical and sexual resident to resident altercations. Staff A stated that they would have expected staff to notify them and Staff B of the altercation between Resident 44 and Resident 95 and that they would have expected it to be investigated. RESIDENT 55 A review of the admission record showed Resident 55 admitted to the facility on [DATE] and that they were in room [ROOM NUMBER]B. A review of the Quarterly MDS dated [DATE], showed Resident 55 was cognitively intact. In an interview on 01/03/2025 at 2:43 PM, Resident 55 stated that their former roommate (Resident 39) threw a fork at them, missed them by a little and that it scared me. Resident 55 stated that staff were aware and moved their roommate to a different room. Resident 55 further stated that it happened around August 2024. A review of Resident 55's nursing progress notes dated 08/01/2024 through 08/31/2024, did not show a progress note of an altercation with their roommate. A review of the August 2024 grievance log did not show that a grievance was logged for Resident 55. A review of the August 2024 incident log did not show that a resident to resident altercation was logged for Resident 55. Review of Resident 39's census tab in the EHR showed that they were in room [ROOM NUMBER]A from 06/24/2024 and was transferred to room [ROOM NUMBER]B on 08/31/2024. Review of Resident 39's nursing progress note dated 08/31/2024 showed, [Resident 39] is expected to transfer rooms on Reason for transfer: altercation with roommate. In an interview and joint record review on 01/07/2025 at 2:09 PM, Staff EE, LPN/Charge Nurse, stated that their process for resident to resident altercation was to report it to Staff A and Staff B, complete a risk management and change of condition assessment. Staff EE further stated that they would assess the resident, investigate what happened and that if it was the roommate, they would have to transfer the roommate to another room. When asked what types of residents to resident altercation, Staff EE stated it can be verbal and/or physical altercation. A joint record review of Resident 55's assessment tab in the EHR did not show that a change of condition was completed. Staff EE stated, I don't see anything completed. A joint record review of Resident 55's August 2024 nursing progress notes did not show documentation of any resident to resident altercation. Staff EE stated, I don't [do not] see any notes for the resident to resident altercation. A joint record review of Resident 39's progress notes showed, [Resident 39] is expected to transfer rooms on Reason for transfer: altercation with roommate. Staff EE stated, yes, it's [it is] there. Staff EE further stated that no change of condition was completed for 08/31/2024 and that if it was completed, the change of condition would have shown if the administrator, provider and if the resident representative was notified. Staff EE further stated that there was no documentation showing that Staff A or Staff B were notified of the altercation. In an interview on 01/08/2025 at 8:14 AM, Staff T, Charge Nurse, stated that Resident 55 reported to them that their previous roommate (Resident 39) threw a fork at them. Staff T reported that they did an incident report, change in condition, investigation was called in and reported to the authorities. Joint record review of Resident 39's census and progress note dated 08/31/2024 showed, [Resident 39] is expected to transfer rooms on Reason for transfer: altercation with roommate. Staff T stated they were not sure what happened on 08/31/2024, but when it was brought to their attention on 10/15/2024, that was when they did an investigation, change of condition, and notified the appropriate authorities. In an interview and joint record review on 01/08/2025 at 12:15 PM, Staff B stated that the altercation between Resident 55 and Resident 39 was investigated in October 2024. Joint record review of Resident 39's progress note dated 08/31/2024, showed, [Resident 39] is expected to transfer rooms on Reason for transfer: altercation with roommate. Staff B stated they see it and that Resident 39 had behaviors. When asked if they would have expected staff to notify them on 08/31/2024, Staff B stated, Definitely, if there was an altercation, definitely. Staff B further stated that if they were notified of the altercation, they would have followed their process, they would have investigated and notified the State Agency. In an interview on 01/08/2025 at 1:46 PM, Staff A stated that they expected to be notified of resident to resident altercations and expected it to be investigated.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 1 of 26 residents (Resident 36), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding collecting information during the entire look-back period for MDS Section L (Oral/Dental Status), Section N (Medications), Section O (Special Treatments, Procedures, and Programs), Section P (Restraints and Alarms) and Section Q (Participation in Assessment and Goal Setting), placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). Most MDS items themselves require an observation period, such as seven or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. When completing the MDS, only those occurrences during the look-back period will be captured. RESIDENT 36 Resident 36 readmitted to the facility on [DATE]. Review of Resident 36's Significant Change in Status Assessment (SCSA) dated 10/21/2024, showed Section Z (Assessment Administration) revealed that item Z0400 (Signature of Persons Completing the Assessment), included the following instruction: I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. It further showed that Section Z0400 had signatures from Staff D, MDS Coordinator, dated 10/18/2024 for Sections L, N, O, P and Q. In an interview and joint record review on 01/08/2025 at 9:11 AM, Staff D stated they followed the RAI Manual for coding accuracy and that they had access to the RAI Manual October 2024 version whenever they completed an MDS. Staff D further stated that the observation period was the ARD plus six days before. Joint record review of Resident 36's SCSA dated 10/21/2025 showed that Section Z0400 had signatures from Staff D dated 10/18/2024 for Sections L, N, O, P and Q. Staff D stated Resident 36's SCSA Sections L, N, O, P and Q were not accurate because they were completed before the end of the entire observation period (10/15/2024 through 10/21/2024). In an interview on 01/08/2025 at 1:25 PM, Staff B, Director of Nursing, stated that the facility followed the RAI Manual for MDS completion. Staff B further stated they expected the MDS to be completed accurately. Reference: (WAC) 388-97-1000(1)(b) .

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** RESIDENT 22 Review of the admission record printed on 01/07/2025 showed that Resident 22 had diagnoses that included anxiety and major depressive disorder (mental illness that involves a persistent low mood and loss of interest in activities) with an onset date of 02/02/2018. Review of Resident 22's Level I PASARR dated 01/30/2023, showed that they were marked yes for SMI indicators for mood disorders and anxiety disorders. Further review showed, No level II evaluation indicated. In an interview and record review on 01/06/2025 at 10:38 AM, Staff E stated when a resident admits with a Level I PASARR and needs a Level II PASARR evaluation, they would send it to the PASARR evaluator. When asked if a resident was marked with an SMI, would they need a Level II PASARR referral, Staff E stated, Yes, they will need a Level II for evaluation. Joint record review of Resident 22's Level I PASARR showed that they were marked for SMI and no Level II PASARR evaluation was indicated. Staff E stated, I do see that. Staff E further stated that they had completed a new Level I PASARR for Resident 22 and sent it to the PASARR evaluator. When asked for a copy, Staff E stated that they were not able to find a copy and that they would send an email to the PASARR evaluator to see if they had a copy of Resident 22's updated Level I PASARR form. In a follow up phone interview on 01/07/2025 at 3:04 PM, Staff E stated that the PASARR evaluator did not have Resident 22's updated Level I PASARR and that they submitted a new Level I PASARR for Resident 22 on 01/06/2025. Staff E further stated that if a resident were to have an inaccurate PASARR, they would have expected staff to complete an accurate PASARR and submit it to the PASARR evaluator. In an interview on 01/07/2025 at 3:27 PM, Staff C, Interim Administrator, stated they expected PASARRs to be reviewed in a timely manner, before and after admission and periodically if there was a significant change. Staff C stated that if a Level II PASARR was needed, it would be submitted to the PASARR evaluator. Staff C further stated they expected that if Resident 22's inaccurate Level I PASARR was identified by staff, they would have expected staff to correct it and send it to the PASARR evaluator. Reference: (WAC) 388-97-1915 (2); 1975(1)(2)(3) Based on interview and record review, the facility failed to ensure accurate Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 2 of 6 residents (Residents 103 & 22), reviewed for PASARR screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR Completion Policy, revised on 9/30/2024, showed the facility will make sure that all admissions have the appropriate PASARR completed. The policy showed the facility's administrator would designate either the admissions director or the social worker to make sure the PASARR was done on all potential residents. The policy further showed the administrator would be accountable for monitoring the process of completing the necessary paperwork for the admission and that the Business Office Manager must have copies of the PASARR in the Business Office resident file. RESIDENT 103 Review of the face sheet showed Resident 103 admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function). A review of Resident 103's PASARR form showed the Level 1 PASARR was completed on 12/05/2024 and that Resident 103 met the criteria for an exempted hospital discharge. The Level I PASARR further showed that a Level II PASARR evaluation must be completed if Resident 103's scheduled discharge did not occur. In an interview on 01/07/2025 at 10:04 AM, Staff F, Social Services Assistant, stated that the facility was unable to discharge Resident 103 as planned because Resident 103 had pneumonia (lung infection). In an interview and joint record review on 01/07/2025 at 10:16 AM, with Staff E, Social Services Director, stated that they sent the Level II PASARR when the resident had diagnosis of anxiety (characterized by excessive fear and worry that are strong enough to interfere with one's daily activities) or any SMI indicated on the form. Joint record review of the Level I PASARR showed Resident 103's was exempted when discharged from the hospital and the facility had 30 days to send the Level II PASARR. Further review of Resident 103's electronic health record did not show the facility sent the Level II PASARR to the PASARR State Coordinator by 01/05/2025. Staff E stated that they would send out Resident 103's PASARR today [01/07/2025] for a Level II evaluation. In an interview on 01/08/2025 at 12:42 PM, Staff A, Administrator, stated that they expected PASARR forms to be completed timely. Staff A further stated that for PASARR Level II, if it was needed, then that assessment needs to get done in a timely manner.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 17 Review of the quarterly Minimum Data Set (MDS-an assessment tool), dated 12/04/2024, showed that Resident 17 had limited ROM in their upper extremity on one side. Review of Resident 17's ROM care plan revised on 04/16/2020, showed interventions that included LN [Licensed Nurse] applies right rigid resting splint for 3-4 hours and PROM [Passive ROM] to RUE [right upper extremity] .AROM [Active ROM] to LUE [left upper extremity]. Review of Resident 17's EHR showed no documentation for splint use and no documentation that PROM and AROM was provided for Resident 17. Observations on 01/03/2025 at 9:09 AM and on 01/04/2025 at 2:08 PM, showed Resident 17 was not wearing any splints. In an interview on 01/06/2025 at 9:05 AM, Staff N, Certified Nursing Assistant (CNA), stated that Resident 17 had ROM impairment in their arms and legs. Staff N stated that they did not perform any ROM exercises for Resident 17. Staff N further stated that Resident 17 had splints and that they had not been wearing them recently. In an interview and joint record review on 01/06/2025 at 9:23 AM, Staff L, RN, stated that nursing was responsible for putting on splints. Staff L stated that Resident 17 was supposed to wear splints. A joint record review of Resident 17's ROM care plan showed that LN applies right hand splint for 3-4 hours and PROM to RUE and AROM to LUE. Staff L stated, I can't [cannot] say it is consistently being done. Staff L further stated that they expected the ROM care plan to be followed. In an interview and joint record review on 01/07/2025 at 2:05 PM, Staff B stated that they did not have a restorative program, and they expected CNAs to do exercises recommended by therapy and that nursing was responsible for implementing the splint program. Staff B stated that if a resident had limitations in ROM, they need to do exercises to maintain or prevent decline. Joint record review of Resident 17's ROM care plan showed to apply right hand splint for 3-4 hours and to provide PROM to RUE and AROM to LUE. Staff B stated that ROM exercises should be done and I will work on finding documentation. Joint record review of the Medication Administration Record and the Treatment Administration Record showed no documentation that splints were applied for Resident 17. Staff B stated that they expected splints to be applied for Resident 17. Staff B further stated that they expected the ROM care plan to be followed. In a follow up interview on 01/08/2025 at 8:13 AM, Staff B stated, just to confirm we cannot find documentation for the PROM and AROM for Resident 17. Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 4 of 26 residents (Residents 39, 89, 17 & 99), reviewed for comprehensive care plans. The failure to implement care plans for edema (swelling caused by buildup of fluid in the body's tissues), nutrition, Range of Motion (ROM) and discharge planning placed the residents at risk for unmet care needs, complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plan Comprehensive, dated 08/25/2021, showed the facility's Interdisciplinary Team, in coordination with the resident or representative must develop and implement a comprehensive person-centered care plan for each resident. RESIDENT 39 Resident 39 admitted to the facility on [DATE] with a diagnosis of Lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph [fluid that is part of the body's immune system] fluid). Review of Resident 39's edema care plan initiated on 12/27/2023 showed an intervention for applying and removing compression stockings (used to help prevent swelling in the legs and ankles and improve circulation) as ordered. Multiple observations on 01/04/2025 at 12:23 PM, on 01/05/2025 at 10:42 AM, on 01/06/2025 at 11:34 AM, and on 01/07/2025 at 8:43 AM, showed Resident 39's bilateral (both) lower legs were swollen and was not wearing any compression stockings. Joint observation and interview on 01/07/2025 at 3:31 PM with Staff G, Registered Nurse (RN), showed Resident 39's bilateral lower legs were swollen and that the resident did not have any compression stockings. Staff G stated that it was their responsibility to ensure that the treatment was implemented and that they did not on 01/07/2025. Joint record review and interview on 01/08/2025 at 9:10 AM with Staff H, RN, showed Resident 38's edema care plan had an intervention to apply and remove compression stockings as ordered. Staff H stated that staff should have followed the care plan. RESIDENT 89 Resident 89 admitted to the facility on [DATE]. Review of Resident 89's nutrition care plan initiated on 12/11/2024, showed that Resident 89 was at a nutritional risk and had a significant weight gain of 15.6% since their admission. The care plan further showed an intervention to alert the dietitian and physician to any significant weight loss or gain. Review of the summary for providers note dated 12/16/2024, showed the provider recommended to send out Resident 89 to the emergency room for anasarca (severe swelling of the body's tissues caused by a buildup of fluid) evaluation and treatment. Review of Resident 89's electronic health record (EHR) showed no documentation that the physician/provider had been notified of Resident 89's significant weight gain prior to 12/16/2024. On 01/07/2025 at 11:18 AM, Staff I, Nurse Practitioner (NP), stated that Resident 89 had gained twenty pounds since their admission. Staff I stated that staff had not reported to them that Resident 89 was gaining weight, further stating, not before I found it. Staff I further stated that they would expect to get report on a change like this, but they had not. On 01/08/2025 at 7:55 AM, Staff J, Physician, stated that if there was weight gain the staff would let the NP know, and that they had not been made aware of the significant weight gain. Staff J further stated that the staff should have let the provider know and that they provided 24-hour services a day. On 01/08/2025 at 2:35 PM, Staff B, Director of Nursing (DON), stated that their expectation was for staff to follow the resident's care plan. Staff B further stated that the provider should have been notified immediately of Resident 89's significant weight gain and that they did not document that the provider was notified.Resident 99 A review of Resident 99's face sheet showed Resident 99 admitted to the facility on [DATE]. A review of Resident 99's comprehensive care plan did not include a discharge care plan. In an interview on 01/06/2025, Staff F, Social Services Assistant, stated that they were in the process of planning Resident 99's discharge. Staff F further stated that they did not include a discharge plan in the comprehensive care plan because they did not know where the resident was going to discharge. In a joint record review and interview on 01/06/2025 at 10:42 AM with Staff D, MDS Coordinator, showed Resident 99's comprehensive care plan did not have a discharge plan. Staff D stated Resident 99's comprehensive care plan did not have a discharge care plan and that the social worker usually completed this section in the care plan. In an interview on 01/08/2025 at 10:38 AM, Staff B stated that they expected discharge planning started at admission and should have a preliminary discharge plan within 48 to 72 hours. Staff B further stated that the discharge plan should be included in the comprehensive care plan. Reference: (WAC) 388-97-1020 (1)(2)(a) .

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 develop and revise the comprehensive care plans for 3 of 26 residents (Residents 36, 87 and 91), reviewed for care plan timing and revision. The failure to develop comprehensive care plans for discharge planning, smoking behaviors and oxygen use, placed the residents at risk for unmet care needs, burns, injury, and potential negative outcomes. Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.19.11, revised in October 2024, showed that The comprehensive care plan is an interdisciplinary (IDT) communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically .The overall care plan should be oriented towards: assisting the resident in achieving their goals, managing risk factors to the extent possible or indicating the limits of such interventions, involving the resident, resident's family and other representative as appropriate .The seven day requirement for completion or the modification of the care plan applies to the Admission, SCSA (Significant Change in Status Assessment) and or Annual RAI assessments .Care Plan Completion Date No Later Than CAA (Care Area Assessment) completion date plus seven calendar days. RESIDENT 36 Resident 36 readmitted to the facility on [DATE]. Review of Resident 36's SCSA dated 10/21/2024, Section C (Cognitive Patterns) item C0500 (BIMS -Brief Interview for Mental Status) was scored at 15, indicating that Resident 36's cognitive function was intact. Section Z (Assessment Administration) showed that item Z0500 (Signature of RN Assessment Coordinator Verifying Assessment Completion) showed Resident 36's SCSA and CAAs were signed as completed on 10/29/2024. Review of Resident 36's care plan showed the focus care plans for pressure ulcer, surgical wound, risk for fall, anticoagulation (blood thinner medication) therapy, risk for psychosocial (relating to the relation of social factors and individual thought and behavior) distress, risks for cardiovascular (refers to the heart and blood vessels) symptoms or complications, and physical therapy, were created/revised by Staff D, MDS Coordinator, on 11/12/2024 (seven days late after the completion of Resident 36's SCSA and CAAs worksheet). In a phone interview on 01/03/2025 at 8:41 AM, Collateral Contact 2 (CC2) stated they have not been contacted by the facility to participate in Resident's 36's plan of care since October 2024. CC2 further stated that the facility was not following a plan of care and that they have not seen Resident 36's care plan. In an interview on 01/05/2025 at 8:25 AM, Resident 36 stated that their care plan had not been discussed with them. In an interview on 01/07/2024 at 4:19 PM, Staff B, Director of Nursing, stated that the facility IDT was involved in care planning. Staff B further stated they expected initial care conferences with the resident and their representative would be scheduled within 72 hours [of admission]. Staff B further stated that during the initial conference, the resident's care plan would be discussed, and copies would be offered. In an interview and joint record review on 01/08/2024 at 9:11 AM, Staff D stated that they were part of the IDT that was responsible for developing Resident 36's comprehensive care plan. Joint record review of Resident 36's care plans for pressure ulcer, surgical wound, risk for fall, anticoagulation therapy, risk for psychosocial distress, risks for cardiovascular symptoms or complications, and physical therapy were developed or revised on 11/12/2024. Staff D further stated that Resident 36's comprehensive care plan was not completed within seven days of Resident 36's SCSA completion. When asked if the resident or their representative participated in the development of Resident 36's comprehensive care plan, Staff D stated they discussed it with Resident 36 but that they did not contact CC2 to participate. When asked to show documentation of the care plan discussion with Resident 36, Staff D stated that they did not document their discussion with Resident 36. In an interview on 01/08/2024 at 1:25 PM, Staff B stated they expected comprehensive care plans to be completed timely. RESIDENT 87 Resident 87 admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and repeated falls. Review of Resident 87's nursing progress note dated 12/16/2024 showed that Resident outside smoking with roommate pushing wheelchair. SS [Social Services] educated resident on smoking policy. Review of Resident 87's smoking evaluation dated 12/17/2024 showed that Resident 87 was marked yes to have used oxygen, was marked yes to be able to safely hold a cigarette, was marked no to dispose of ashes or butts properly, and was marked no to resident could smoke safely without use of a smoking apron. It further showed that Resident not allowed to smoke and that the reason was unsafe to smoke. Review of Resident 87's physician orders showed an order for O2 [oxygen] concentrator set to two liters/min [l/min - unit of measurement] every day and every evening for O2 supplement to enhance breathing, dated 08/08/2024. Review of Resident's 87's comprehensive care plan printed on 01/07/2025 did not show care plan revision was completed to include smoking behaviors identified on 12/16/2024. It further showed that Resident 87 did not have a care plan related to oxygen use. In an interview and joint record review on 01/07/2025 at 4:08 PM, Staff H, Registered Nurse, stated they were involved in care planning for Resident 87. Joint record review of Resident 87's care plan did not show Resident 87 had a care plan related to oxygen therapy or smoking behaviors. Staff H stated, I don't see it. When asked if there should be a care plan for residents who are on oxygen and are known to have smoked, Staff H stated Yes, there's [there are] hazards, oxygen explodes when you smoke with it. In an interview on 01/07/2024 at 4:19 PM, Staff B stated they expected a resident's care plan would reflect identified smoking behaviors and a care plan related to oxygen use. Staff B stated Yes, they shouldn't be smoking while using oxygen, the staff will follow the plan of care. RESIDENT 91 Resident 91 admitted to the facility on [DATE]. Review of Resident 91's progress note dated 12/16/2024 showed that Resident pushing [their] roommate in wheelchair to smoke. SS [Social Services (Staff E)] educated resident on smoking policy. Review of Resident 91's comprehensive care plan printed on 01/02/2025 did not show that Resident 91's comprehensive care plan was revised to include smoking behaviors identified on 12/16/2024. Review of Resident 91's December 2024 and January 2025 medication administration record (MAR) showed a physician's order for nicotine patch one time a day for smoking cessation was started on 12/18/2024. It further showed that Resident 91 refused their nicotine patch on 12/18/2024 through 12/20/2024 and refused again from 12/23/2024 through 01/02/2025. Review of a smoking evaluation dated 12/17/2024 showed that Resident 91 was marked yes for having a history of unsafe smoking habits and a history of sharing/selling cigarettes or smoking material. It further showed that Resident 91's smoking evaluation decision was that supervised smoking was required and that the reason was [Resident 91 was] unsafe to smoke. It further showed that the evaluation was not signed by Resident 91. Observation on 01/02/2025 at 8:17 AM showed Resident 91 walked through the lobby unaccompanied and headed toward the facility entrance. Further observation showed Resident 91 smoked a cigarette while in the facility's entrance lot. In an interview on 01/02/2025 at 8:49 AM, Resident 91 stated I don't just stand in the middle of the parking lot most of the time. I know the smoking policy. I'm working on the patch, but it's not something I can do today or overnight. My nurse offers it to me, but I'm not ready. In an interview on 01/08/2025 at 12:28 PM, Staff H stated they completed Resident 91's smoking evaluation dated 12/17/2024. When asked how a smoking evaluation was conducted, Staff H stated they asked Resident 91 for answers to specific questions on the evaluation form. Staff H stated that Resident 91 answered yes, when asked if they shared smoking materials. Joint record review of Resident 91's comprehensive care plan did not show care plan revision, prior to 01/02/2025, included smoking behaviors identified after the smoking evaluation was completed on 12/17/2024. Staff H stated, I can't remember, if it's not there, I probably didn't [did not revise]. In an interview on 01/08/2025 at 1:34 PM, Staff B stated they were aware of the staff observation on 12/16/2024 of Resident 91 to have smoked with their roommate and that the incident prompted a smoking evaluation to be completed on 12/17/2024. When asked if they expected Resident 91's care plan to have been revised once smoking behaviors were identified on 12/16/2024 and the smoking evaluation completion on 12/17/2024, Staff B stated, Yes, I agree, we should care plan everything. Joint record review of Resident 91's comprehensive care plan did not show revision to include identified smoking behaviors before 01/02/2025. Staff B stated, I don't see anything. Reference: (WAC) 388-97-1020 (2)(a)(c)(5)(b) .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** BLOOD PRESSURE MEDICATION Review of the facility's policy titled, Administering Medications, revised in April 2019, showed that vital signs [measurements of the body's essential functions], if necessary, are checked/verified for each resident prior to administering medications. RESIDENT 46 Resident 46 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure [BP]). Review of Resident 46's January 2025 MAR showed Resident 46 had an order for Hydralazine (medication to treat hypertension) to be given two times a day and with the parameters to hold for Systolic BP (SBP-the pressure in the arteries when the heart contracts) less than 110 or heart rate less than 60. In an interview and record review on 01/07/2025 at 10:30 AM, Staff L, Registered Nurse, stated that if an order showed parameters to hold a BP medication for SBP less than 110 or pulse less than 60, then you should hold the medication. Staff L stated that vital signs should be checked prior to each medication that had parameters for administration. Joint record review of the January 2025 MAR showed Resident 46 was given hydralazine twice a day. A joint record review of the vital signs tab in the Electronic Health Record (EHR), showed Resident 46 had their BP checked in the mornings prior to their morning dose of hydralazine and no documentation that their BP was checked prior to their evening dose. Staff L stated that based on looking at this [vital signs tab] it did not show that Resident 46's BP was checked prior to getting their evening dose of hydralazine. In an interview and record review on 01/07/2025 at 2:05 PM, Staff B stated that they expected licensed nurses to follow parameters for medication administration. Staff B stated if an order showed parameters to hold a BP medication for SBP less than 110 or pulse less than 60, then vital signs should be checked before each dose. Staff B stated that if hydralazine was given twice a day, they expected vitals to be taken before each time it was given. Joint record review of the vital signs tab in the EHR, showed no documentation that Resident 46 had their vitals done prior to their evening dose of hydralazine. Staff B stated that they expected there to be documentation of vital signs. Reference: (WAC) 388-97-1620 (2)(b)(i)(ii) Based on observation, interview, and record review, the facility failed to follow physician's order in accordance with professional standards when administering medications for 3 of 11 residents (Resident 42, 43 & 46), reviewed for medication administration. These failures placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . A review of the facility's policy titled, Physician Orders, effective date 03/22/2022, showed they would ensure that all physician orders were complete and accurate. The policy showed that the Medical Records Department would verify that physician orders were complete, accurate and clarified as necessary. Whenever possible, the Licensed Nurse receiving the order would be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to the other health care disciplines will be transcribed on the appropriate communication system for that discipline. The policy further showed that supplies and medications required to carry out the physician order would be ordered. A review of the facility's policy titled, Administering Medication, revised in April 2019, showed medications were to be administered in a safe and timely manner, as prescribed. The policy further showed that medications were administered in accordance with prescriber orders, including any required time frame. RESIDENT 42 A review of Resident 42's December 2024 Medication Administration Record (MAR) showed an order for Sertraline (medication that treats depression) 25 milligram (mg-a unit of measurement) to be given with Sertraline 100 mg to equal 125 mg a day. The order showed it started on 10/21/2023 and was discontinued on 12/26/2024. The MAR further showed a new order for Sertraline 100mg one tablet daily to start on 12/27/2024. A review of Resident 42's January 2025 MAR showed an order for Sertraline 100mg one tablet daily. On 01/05/2025 at 8:09 AM, Staff DD, Licensed Practical Nurse (LPN), was observed preparing medications for Resident 42. Staff DD did not have Resident 42's MAR up and stated, I have to go fast in the morning or else it's hard to find them [residents]. Staff DD pulled the bingo card (medications that are bubble packed per dose on a card) for Sertraline 100 mg then started searching for the Sertraline 25 mg bingo card. Staff DD stated that Resident 42 gets a 100 mg [tablet] with a 25 mg [tablet]. When asked to check the Sertraline order, Staff DD could not find an order for Sertraline 125 mg to be given at this medication pass. In another interview on 01/05/2025 at 2:04 PM, Staff DD stated she found the [new] order for Sertraline, it was 100 mg. RESIDENT 43 A review of Resident 43's January 2025 MAR showed they admitted to the facility on [DATE]. The MAR showed an order for Multivitamin (supplement) one tablet daily. In an observation and interview on 01/05/2025 at 8:13 AM, Staff DD pulled out a bottle of a multivitamins with minerals. Staff DD stated that they had been giving the multivitamin with minerals because the facility's house supply of multivitamin only came with minerals. Staff DD further stated that the order had been inputted incorrectly and needed to be corrected to reflect what was available in their house supply. In an interview on 01/05/2025 at 9:08 AM, Staff DD stated that they had spoken to another coworker and was informed that the facility did have a house supply of multivitamins without minerals. Staff DD stated, the doctor had told us we had to give what is in the house, what we have available. I've never seen it [multivitamin without minerals] before. In an interview on 01/05/2025 at 2:04 PM, Staff DD stated that their medication administration process included the six rights of medication pass. Staff D was able to name three of these six rights but was unable to recall the rest. Staff DD stated they were fast because they had 30 residents to pass medications to. Staff DD further stated that they try to check the orders and when they give medications, they sometimes goes by the label on the bingo card, but technically if the order changed, we should get another bingo card. In an interview on 01/05/2025 at 3:02 PM, Staff B, Director of Nursing, stated that staff should be checking the new orders and placing them on alert charting. Staff B stated that multivitamins and multivitamins with minerals were not the same. Staff B further stated that they [Staff DD] should have stopped and clarify the order.

CONCERN (D)

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an effective resident centered discharge plan was in place for 1 of 5 residents (Resident 36), reviewed for discharge planning. The failure to develop a discharge care plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-morale, sadness, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Transfer or Discharge Resident-Initiated, showed that Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility. It further showed, The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated. RESIDENT 36 Resident 36 readmitted to the facility on [DATE]. Review of Resident 36's Significant Change in Condition Assessment (SCSA) dated 10/21/2024, Section C (Cognitive Patterns) item C0500 (BIMS -Brief Interview for Mental Status) was scored at 15, indicating that Resident 36's cognitive function was intact. It further showed that Section Q (Participation in Assessment and Goal Setting), item Q0400 was coded 0 to indicate that active discharge planning was not already occurring for the resident to return to the community. Item Q0500 (Return to Community) was coded 1 to indicate that Resident 36 wanted to talk to someone about the possibility of leaving the facility to return to live and receive services in the community. Review of a grievance form dated 10/30/2024 showed that the grievance was reported to social services and was submitted by Resident 36. The nature of the concern showed that [Resident 36] says that [they] are not happy here at [facility]. It showed that Staff F, Social Services Assistant, was the employee assigned to address the grievance and that Staff F's department findings was that Found out that [Resident 36] just wanted to be close to [Collateral Contact (CC2)]. It further showed that Staff F's action plan was that Planning discharge for another facility closer to [CC2] .when [CC2] and social services finds a facility. Review of Resident 36's comprehensive care plan printed on 01/05/2025, showed Resident 36's discharge care plan was created on 10/02/2024 and was last revised on 12/31/2024. It further showed that Resident 36's discharge care plan goal was that Resident/Patient will have an ongoing discharge plan that provides for a safe and effective discharge. It did not show a resident centered discharge goal consistent with Resident 36 and CC2's stated goal. In an interview on 01/03/2025 at 8:41 AM, Resident 36 stated they have had issues with the facility not returning phone calls to CC2 who wanted to be involved with Resident 36's discharge planning. Resident 36 stated their goal was to transfer to another facility to be near CC2. In a phone interview on 01/03/2025 at 8:41 AM, CC2 stated they have not been contacted by the facility to participate in Resident's 36's plan of care since October 2024 and that they have not received returned phone calls from the facility to discuss discharge planning. CC2 further stated that they filled out a grievance form in December 2024 related to their concern about Resident 36's discharge planning process. Review of the grievance form dated 12/08/2024 showed that the grievance was reported to Staff F and submitted by CC2. It showed that the nature of concern was that I have been contacting Social Services since October 24 [2024]. They never call back. They tell [Resident 36] that they do. I only want to help get [Resident 36] transferred closer to their family, which I feel will help with [Resident 36's] care and morale. It further showed that Staff F was the employee assigned to address the grievance and that Staff F's action plan to address the grievance was completed on 12/30/2024. The grievance form did not show that complete resolution/satisfaction was achieved. In an interview on 01/06/2025 at 2:26 PM, Staff F stated they were responsible for arranging care conferences to discuss discharge planning with the resident, the IDT (Interdisciplinary team) and the resident's representative, as well as to send out referrals related to the discharge planning process. Staff F stated that discharge planning starts from the resident's admission to the facility and that a resident's discharge goal was identified by completing a social services assessment. Staff F further stated that discharge planning was discussed with the resident and their representative during a care conference. Review of Resident 36's social services assessment dated [DATE] showed that Resident 36 planned to be discharged home alone with a caregiver. Review of Resident 36's Post admission Resident/Resident Representative Conference, dated 11/18/2024, showed that the objective of the conference was to Review and communicate the person-centered baseline care plan and identify further resident and family expectations. It did not show that Resident 36 or CC2 attended the conference. It showed that Resident 36's post SNF (skilled nursing facility) disposition was marked as undetermined. It further showed that the Post admission Resident/Resident Representative Conference was completed by Staff E, Social Services. In an interview and joint record review on 01/07/2025 at 1:15 PM, Staff F stated that Resident 36's discharge goal was that they wanted to transfer to another facility to be close to family. When asked if they expected that the discharge care plan would be updated timely when there are updates to a resident's discharge goal, Staff F answered, Yes. Joint review of Resident 36's discharge care plan, revised on 12/31/2024, did not show it included Resident 36's discharge goal to transfer to another facility to be closer to family. When asked if Resident 36's discharge care plan reflected Resident 36's stated goal, Staff F stated, I don't see it on here and that Resident 36's discharge care plan should have been updated to include Resident 36's stated discharge goal. Staff F further stated that they expected Resident 36 and CC2 would have been included in the care conference held on 11/08/2024. In an interview on 01/07/2025 at 2:24 PM, Resident 36 stated that their discharge goal had been to transfer to another facility closer to CC2. When asked if Resident 36 had a discharge goal of returning home alone with a caregiver, Resident 36 answered, No, I don't want to, my number one choice is to be closer to [CC2]. Resident 36 was tearful and stated, I don't think [the facility] has done enough to try to get me transferred because I'm still here. I'm sad that I'm not near [CC2] and it's not good for my morale, it's not good! My situation is upsetting. I don't feel like they're working hard enough to get me transferred. In a phone interview on 01/08/2025 at 11:18 AM, Staff E, Social Services, stated they completed Resident 36's Post admission Resident/Resident Representative Conference, dated 11/18/2024 and that Resident 36 and CC2 did not attend the conference. Staff E stated CC2 was not offered to attend the conference and that they were not sure if Resident 36 was offered to attend. Staff E stated they could not find documentation in Resident 36's progress notes that showed Resident 36 was offered to attend the conference. Staff E stated both Resident 36 and CC2 should have been invited to attend the conference. When asked if Resident 36's discharge care plan, revised on 12/31/2024, reflected Resident 36 and CC2's goal to transfer Resident 36 to another facility to be close to family, Staff E stated, It does not. Staff E further stated that the discharge care plan should be updated periodically to reflect the resident's discharge goal and to include interventions that support that goal. In an interview and joint record review on 01/08/2025 at 1:20 PM, Staff B, Director of Nursing, stated that the facility's process on discharge planning was that whenever there is a discharge goal or changes in [the resident's] discharge goal, this triggers discharge planning to start. Staff B stated they expected that the resident or their representative would be included in the discharge planning process and that care conferences were scheduled to discuss discharge planning with the resident and/or their representative. Joint record review of Resident 36's Post admission Resident/Resident Representative Conference, dated 11/18/2024, did not show that Resident 36 or CC2 attended the conference. Staff B stated they expected that Resident 36 and CC2 would have been offered to attend the conference. Staff B further stated they expected that Resident 36's discharge care plan would have been updated to include the resident centered discharge goal and when community referrals were made to support the goal. Reference: (WAC) 388-97-0080 (2)(a)(d)(e)(i)(ii) (4)(a)(5)(6) .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 2 of 4 residents (Residents 8 & 65), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with getting out of bed, showers, and nail care, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2018, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. It showed that support and assistance with hygiene included, bathing, dressing, grooming, and oral care. It further showed that support and assistance with mobility included, transfer and ambulation. RESIDENT 8 TRANSFERRED OUT OF BED Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 11/26/2024, showed Resident 8 required substantial/maximal assistance (helper does more than half the effort) with transfers and bathing. It further showed that Resident 8 was dependent for getting in and out of the tub/shower. Review of Resident 8's ADL care plan, revised on 10/26/2024, showed that Resident requires assistance with ADL cares. Observations on 01/03/2025 at 9:07 AM, on 01/04/2025 at 9:29 AM, on 01/05/2025 at 1:17 PM, and on 01/06/2025 at 8:56 AM, showed Resident 8 in bed. In an interview on 01/05/2025 at 12:20 PM, Resident 8's representative asked Resident 8 if they would like to get into their wheelchair, Resident 8 stated, yes, I would. Resident 8's representative stated, they haven't got her out of bed since [Resident 8] came back from the hospital. In an interview on 01/06/2025 at 9:05 AM, Staff N, Certified Nursing Assistant (CNA), stated that Resident 8 needed help to get out of bed. In an interview on 01/06/2025 at 9:23 AM, Staff L, Registered Nurse, stated they expected that all residents be offered every day to see if they wanted to get out of bed. Staff L further stated that the last time Resident 8 got up out of bed was a few weeks ago and they should be offering [it] every day. SHOWERS Review of the facility's document titled, Task: BATHING, for the dates from 12/07/2024 through 01/05/2025, showed no documentation that Resident 8 was given a shower. In an interview on 01/05/2025 at 12:20 PM, Resident 8's representative stated that Resident 8, hasn't [has not] had a shower since she came back from the hospital. When asked if they would like a shower, Resident 8 stated, of course. In an interview on 01/06/2025 at 9:05 AM, Staff N stated, I haven't given [Resident 8] a shower in a while. When asked when Resident 8's last shower was, Staff N stated, I don't know. In an interview and joint record review on 01/06/2025 at 9:23 AM, Staff L stated that Staff NN, Scheduler, scheduled the showers for residents. Staff L stated that if a resident refused a shower, the nurse will document the refusal. Staff L stated that Resident 8 had no history of refusing showers. A joint record review of the Task: BATHING, for the dates from 12/07/2024 through 01/05/2025, showed no documentation that Resident 8 had been given a shower and showed N/A (not applicable). Staff L stated, I use it [N/A] for when not you're not supposed to do [the task]. Staff L further stated that it was not appropriate to chart N/A. In an interview and joint record review on 01/06/2025 at 11:01 AM, Staff NN stated that every resident should be scheduled for a shower. Staff NN stated that Resident 8 was scheduled for a shower every Friday. Joint record review of two documents titled, Mandatory shower sign off sheet, dated 12/06/2024 and 12/20/2024, showed Resident 8 refused a shower on 12/06/2024 and 12/20/2024. Staff NN stated that these were the only ones [Mandatory shower sign off sheet] for the last 30 days that documented Resident 8's showers or refusals. In an interview and joint record review on 01/07/2025 at 2:05 PM, Staff B, Director of Nursing, stated that we offer everybody to get out of bed and that was their expectation. Staff B stated they expected showers to be done per patient preference and that the facility will offer once or twice a week. Staff B stated that if a resident refused a shower, they would document the refusal in a progress note. Joint record review of the Task: BATHING, for the dates from 12/07/2024 through 01/05/2025, showed no documentation that Resident 8 had been given a shower and showed N/A. Staff B stated it was not appropriate to chart N/A, and it did not look like Resident 8 had a shower from 12/07/2024 through 01/05/2025. Joint record review of Resident 8's progress notes showed no documentation that Resident 8 had refused any showers. Staff B stated, it should be documented when getting a shower and/or a bed bath.NAIL CARE RESIDENT 65 Review of the significant change of condition MDS dated [DATE], showed that Resident 65 had diagnoses that included diabetes mellitus (high blood sugar). Review of Resident 65's January 2025 MAR showed an order for a weekly body check, fingernails/toenails trim/care every evening shift, every Thursday, dated 11/28/2024. Further review showed that Resident 65 was marked to have received a weekly body check, fingernails/toenails trim/ care on 01/02/2025. Observation and interview on 01/03/2025 at 9:24 AM, showed Resident 65's third, fourth and fifth fingernails on their left hand were long and curving inwards with brown discoloration under their fingernails. Resident 65's fingernails on their right hand were long and curving inwards with brown discoloration under their fingernails. Resident 65 stated that they had asked staff several times to cut their fingernails. Additional observations on 1/04/2025 at 1:04 PM, on 01/05/2025 at 9:13 AM and on 01/06/2025 at 9:31 AM, showed Resident 65's third, fourth and fifth fingernails on their left hand were long and curving inwards with brown discoloration under their fingernails. Resident 65's fingernails on their right hand were long and curving inwards with brown discoloration under their fingernails. In an interview and joint observation on 01/06/2025 at 2:20 PM, Staff L stated that residents who had an order for nail care received nail care weekly. Staff L further stated that nurses provided nail care to residents with diabetes and CNAs provided nail care for residents who did not have diabetes. Joint observation showed Resident 65 hand long fingernails to both hands. Staff L stated, it's long and that [Resident 65] needs nail care. Joint record review of the January 2025 MAR showed Resident 65 was marked to have received fingernails/toenails trim care on 01/02/2025. Staff L further stated that Resident 65's fingernails should have been trimmed. In an interview on 01/06/2025 at 4:21 PM, Staff B stated that nail care should be done. You cannot sign it [MAR] if it's not done. Staff B further stated, only sign what you done. Reference: (WAC) 388-97-1060 (1)(2)(c) .

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 46 Review of Resident 46's constipation care plan, revised on 12/19/2024, showed interventions to ask [Resident 46] if she has gone independently for documentation: document bowel movements [BMs] q [every] shift. It showed to start bowel protocol if no bowel movement within 9 shifts. Review of the facility's document titled, Task: PERSONAL HYGIENE: Toileting, dated 12/10/2024 through 01/08/2025, showed Resident 46 did not have a BM from 12/16/2024 through 12/26/2024 (10 days). It showed Resident 46 did not have a BM from 12/28/2024 through 01/02/2025 (five days). It further showed Resident 46 did not have a BM from 01/03/2025 through 01/06/2025 (four days). Review of Resident 46's December 2024 Medication Administration MAR (MAR) showed no documentation that any as needed (PRN) medications were given for not having a BM from 12/16/2024 through 12/26/2024 and from 12/28/2024 through 01/02/2025. Review of Resident 46's January 2025 MAR showed no documentation that any PRN medications were given for not having a BM from 12/28/2024 through 01/02/2025 and from 01/03/2025 through 01/06/2025. In an interview on 01/05/2025 at 8:35 AM, Resident 46 stated that several times .I've had to ask for medication like a suppository for constipation. Resident 46 stated that they were not sure if the aides were keeping up with the charting of BMs. In an interview on 01/08/2025 at 8:20 AM, Staff N, Certified Nursing Assistant (CNA), stated that Resident 46 had constipation quite frequently. In an interview and joint record review on 01/08/2025 at 8:30 AM, Staff L, RN, stated that if a resident went three days without a BM, it triggers a clinical alert, and someone goes around and will tell us that the resident has had no BM for three days and to start PRN medications as part of the bowel protocol. Joint record review of the Task: PERSONAL HYGIENE: Toileting, dated 12/10/2024 through 01/08/2025, showed Resident 46 did not have a BM from 12/16/2024 through 12/26/2024. Staff L stated it showed nine or 10 days without a BM. Staff L stated that BMs should be documented, but aides might not be charting. It showed that Resident 46 did not have a BM from 12/28/2024 through 01/02/2025 and from 01/03/2025 through 01/06/2025. Staff L stated Resident 46 did not have a BM according to these records. Joint record review of the December 2024 and January 2025 MARs showed no documentation that Resident 46 received any PRN bowel medications for having no BM on those dates. Staff L stated that Resident 46 should have had PRN bowel medications based off the documentation. In an interview and joint record review on 01/08/2025 at 4:43 PM, Staff B stated that CNAs/direct staff are responsible for documenting when a resident had a BM. Joint record review of the Task: PERSONAL HYGIENE: Toileting, dated 12/10/2024 through 01/08/2025, showed Resident 46 did not have a BM from 12/16/2024 through 12/26/2024. It showed that Resident 46 did not have a BM from 12/28/2024 through 01/02/2025 and from 01/03/2025 through 01/06/2025. Staff B stated that they did not expect that many days for a resident to not have a BM. Staff B further stated that they expected BMs to be documented and that even if the resident did not want to be asked about their BMs, they expected staff to check with the patient or document if they refused to say if they had one. Reference: (WAC) 388-97-1060 (1) Based on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for 3 of 5 residents (Residents 39,89 & 46), reviewed for quality of care. The failure to follow treatment orders for edema (swelling) and bowel management and/or the failure to notify medical providers for a significant weight gain placed the residents at risk for unmet care needs, pain/discomfort, and related complications. Findings included . Review of the facility's policy titled, Skin Integrity Management, dated 05/26/2021, showed that the implementation of an individual resident's skin integrity management occurred within the care delivery process. Review of the facility's undated policy titled, Weight Management, showed it was the facility's policy to obtain a baseline weight and identify a significant weight change and determine possible causes of the significant weight change. The policy showed that in the event of a patterned or significant, unplanned weight loss/gain of at least 2 percent (%) in a week, 5% in 30 days, 7.5% in 90 days, or 10% in 180 days, nursing staff should notify the physician, family member/responsible party. The policy further showed that the facility Interdisciplinary team would collaborate to determine the need for initiation/discontinuation of weights other than weekly or ordered by the physician. Review of the facility's policy titled, Administering Medications, revised in April 2019, showed medications are administered in accordance with prescribers' orders, including any required time frame. Review of the facility's policy titled, Change in Condition: Notification of, dated 08/25/2021, showed the facility must immediately inform the resident, consult with the resident's physician/nurse practitioner (NP), and notify, when there is a significant change in the resident's physical, mental, or psychosocial status (deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) The policy further showed that the physician/NP should be notified of a decision to transfer or discharge the resident from the center. RESIDENT 39 Resident 39 admitted to the facility on [DATE] with a diagnosis of Lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph [fluid that is part of the body's immune system] fluid). Review of Resident 39's order summary showed an order for BLE [bilateral (both) lower extremities] compress with Tubi-grips ([Tubigrip, a bandage used to help with swelling] start from foot NOT including toes extending two fingers below knee), in the morning with a start date of 02/23/2024. The order summary further showed an order to remove BLE Tubigrip at bedtime for lymphedema. Review of Resident 39's edema care plan initiated on 12/27/2023 showed an intervention for applying and removing compression stockings (used to help prevent swelling in the legs and ankles and improve circulation) as ordered. Multiple observations on 01/04/2025 at 12:23 PM, on 01/05/2025 at 10:42 AM, on 01/06/2025 at 11:34 AM, and on 01/07/2025 at 8:43 AM, showed Resident 39's bilateral lower legs were swollen and was not wearing any compression Tubigrip/stockings. Review of Resident 39's January 2025 Treatment Administration Record (TAR) showed the orders for Tubigrip compression had been applied in the morning on 01/04/2025, 01/05/2025, 01/06/2025, and 01/07/2025. The TAR further showed that the Tubigrip had been removed at night on 01/04/2025, 01/05/2025, 01/06/2025, and 01/07/2025. Joint observation and interview on 01/07/2025 at 3:31 PM with Staff G, Registered Nurse (RN), showed Resident 39's bilateral lower legs were swollen and that the resident did not have any compression Tubigrip/stockings. When asked if Resident 39 had any treatment in place for the swelling to the lower extremities, Staff G stated, I think [Resident 39] has compression socks. Staff G stated that they had finished all the TAR documentation for the day. Staff G stated that they were responsible for carrying out the physician's orders. Staff G stated that they did not carry out the order to apply the Tubigrip compression that day and they documented that they had. Staff G further stated that their documentation was inaccurate, and that they should have paid attention to what they were documenting. On 01/08/2025 at 9:10 AM, Staff H, RN, stated that staff should have followed the physician order to apply and remove the Tubigrip as ordered and documented it correctly. On 01/08/2025 at 2:35 PM, Staff B, Director of Nursing, stated that they expected staff to follow the physician's orders. Staff B further stated that if staff did not complete an order, they should only document on things that they did. RESIDENT 89 Resident 89 admitted to the facility on [DATE]. Review of Resident 89's weights from 11/29/2024 through 12/16/2024 while in the facility showed the following: - 11/29/2024 - weighed 168 pounds (lbs. - unit of measurement). - 12/02/2024 - weighed 181.2 lbs. - 12/06/2024 - weighed 194.2 lbs. Resident 89 gained 26.2 lbs. in one week since admission to the facility. Review of Resident 89's nutrition care plan initiated on 12/11/2024, showed that Resident 89 was at a nutritional risk and had a significant weight gain of 15.6% in less than one month since their admission. On 01/05/2025 at 12:44 PM, Collateral Contact 1 (CC1), stated that Resident 89 had called them very early in the morning stating that they could not feel their feet, and to please call 911 to transport them to the hospital. CC1 stated that Resident 89 said that they really needed to go to the emergency room (ER) and no one was listening. CC1 further stated that staff called them to report that the resident had gained a lot of water weight and was going to go to the ER. Review of Resident 89's nursing progress note dated 12/16/2024 at 6:41 AM, showed that Resident 89 wanted to be discharged to the hospital. The progress note stated that Resident 89 thought, [they] should be at the hospital due to [their] condition. The note showed that 911 had called to inquire about the resident's condition because CC1 had called 911 to come and transport the resident to the hospital. The note showed that Resident 89 had, no c/o [complaints of] pain/any distress, edema 3+ [Deep pitting, significant indentation (6 millimeter-a unit of measurement), takes about 30 seconds to rebound] to all extremities (baseline [or a minimum or starting point for comparison]), pass on for day nurse to let house provider visit the resident during rounds. Further review of the note showed the provider was not notified at this time of the above. Review of Staff I, NP, provider note date of service of 12/16/2024, showed they had noted Resident 89 with increased weight and edema of bilateral upper and lower extremities and that they had gained more than twenty pounds in the last two weeks. Further review of the note showed that Staff I discussed this with Resident 89 and their representative and would send the resident out to the ER for further evaluation of anasarca (severe swelling of the body's tissues caused by a buildup of fluid). Review of Resident 89's electronic health record showed no documentation that the physician/provider had been notified of Resident 89's significant weight gain prior to 12/16/2024. In an interview on 01/07/2025 at 11:18 AM, Staff I stated that Resident 89 had gained twenty pounds since their admission. Staff I stated that staff had not reported to them that Resident 89 was gaining weight, further stating, not before I found it. Staff I further stated that they would expect to get report on a change like this, but they had not. On 01/08/2025 at 7:55 AM, Staff J, Physician, stated that if there was a weight gain the staff would let the NP know, and that they had also not been made aware of the significant weight gain. Staff J further stated that the staff should have let the provider know and that they provided 24-hour services a day. On 01/08/2025 at 1:37 PM, Staff EE, Licensed Practical Nurse, stated that they were the assigned nurse for Resident 89 on 12/16/2024. Staff EE stated that they had received report that the resident wanted to go to the hospital, and that CC1 had called wanting the resident to be sent out, but that the previous nurse did not mention why CC1 wanted Resident 89 to be sent out. Staff EE stated that they were not familiar with Resident 89's baseline as it was their first time working with them, but did note edema to their arms, face, and legs and notified the NP that was in the facility at the time. Staff EE stated that if a resident or their representative wanted them to go to the hospital, or if there was a significant weight change, they should notify the provider. On 01/08/2025 at 2:44 PM, Staff B stated that if a resident requested to go to the hospital their expectation was for staff to complete an assessment, notify the provider and family, and do their due diligence as a facility before sending the resident out. Staff B stated that ultimately the resident had the right to go to the ER. Staff B further stated that the provider should have been notified immediately of Resident 89's significant weight gain and that they did not document that the provider was notified [prior to 12/16/2024].

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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Based on observation, interview, and record review, the facility failed to ensure services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 1 of 3 resident (Resident 17), reviewed for ROM and mobility. This failure placed the resident at risk for unmet care needs, a decline in ROM, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set (an assessment tool) dated 12/04/2024, showed Resident 17 had limited ROM in their upper extremity on one side. Review of Resident 17's ROM care plan revised on 04/16/2020, showed interventions that included, LN [Licensed Nurse] applies right rigid resting splint for 3-4 hours and PROM [Passive ROM] to RUE [right upper extremity] .AROM [Active ROM] to LUE [left upper extremity]. Review of Resident 17's electronic health record showed no documentation for splint use and no documentation that PROM and AROM was provided for Resident 17. Observations on 01/03/2025 at 9:09 AM and on 01/04/2025 at 2:08 PM, showed Resident 17 was not wearing any splints. In an interview on 01/06/2025 at 9:05 AM, Staff N, Certified Nursing Assistant (CNA), stated that Resident 17 had ROM impairment in their arms and legs. Staff N stated that they did not perform any ROM exercises for Resident 17. Staff N further stated that Resident 17 had splints and that they had not been wearing them recently. In an interview and joint record review on 01/06/2025 at 9:23 AM, Staff L, Registered Nurse, stated that nursing was responsible for putting on splints. Staff L stated that Resident 17 was supposed to wear splints. A joint record review of Resident 17's ROM care plan showed that LN applies right hand splint for 3-4 hours and PROM to RUE and AROM to LUE. Staff L stated, I can't [cannot] say it is consistently being done. In an interview and joint record review on 01/07/2025 at 2:05 PM, Staff B, Director of Nursing, stated that they did not have a restorative program and that they expected CNAs to do exercises recommended by therapy and that nursing was responsible for implementing the splint program. Staff B stated that if a resident had limitations in ROM, they need to do exercises to maintain or prevent decline. Joint record review of Resident 17's ROM care plan showed to apply right hand splint for 3-4 hours and to provide PROM to RUE and AROM to LUE. Staff B stated that ROM exercises should be done and I will work on finding documentation that it was done. Joint record review of the Medication Administration Record and the Treatment Administration Record showed no documentation that splints were applied for Resident 17. Staff B stated that they expected splints to be applied for Resident 17. In a follow up interview on 01/8/2025 at 8:13 AM, Staff B stated, just to confirm we cannot find documentation for the PROM and AROM for Resident 17. Reference: (WAC) 388-97-1060 (3)(d) .

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** Review of the facility's policy titled, Bed Safety, dated 03/22/2022, showed, the bed safety policy's purpose was to strive to prevent/reduce hazards such as resident entrapment associated with hospital beds when side rails were required. The policy further showed that the facility would provide a properly working bed, and properly fitting mattress and/or side rails to reduce the hazard of resident entrapment. RESIDENT 34 A review of Resident 34's face sheet showed they admitted to the facility on [DATE]. A review of Resident 34's comprehensive care plan, printed on 01/08/2025, showed Resident 34 used side rails to assist with bed mobility, and getting in and out of bed. A joint observation and interview on 01/7/2025 at 1:47 PM with Staff K, Registered Nurse (RN), showed Resident 34's bed had 1/4 side rails in the up position on both sides. Staff K stated that both side rails felt loose and need to be maintained. Staff K further stated that they would put in a work order to have Resident 34's side rails tightened. In an interview and joint observation on 01/08/2025 at 8:47 AM, Staff X, Maintenance Assistant, stated that they did not check on the side rails unless they were listed in the work order. A joint observation with Staff X showed Resident 34's bed had 1/4 side rails in the up position on both sides. Staff X moved the siderails from side to side, Staff K stated that both side rails were loose because they would loosen over time and that they would add a washer to the siderails to help tighten them. In an interview on 01/08/2025 at 12:42 PM, Staff A stated that side rails should be maintained and should be working properly. Reference: WAC 388-97-1060(3)(g)(vi) Based on observation, interview, and record review, the facility failed to follow and implement smoking assessment and care plan, and did not ensure smoking materials were securely maintained for 1 of 10 residents (Resident 91), and failed to ensure side rails were secured and maintained for 1 of 2 residents (Resident 34), reviewed for accident hazards. These failures placed the residents at risk of potential burns, injury, potential harm and other negative outcomes. Findings included . In a meeting with Staff C, Interim Administrator, Staff A, Administrator and Staff B, Director of Nursing, on 01/02/2025 at 10:40 AM, a request for documentation of the facility's list of residents who smoke, designated smoking times, locations as well as the facility's smoking policy. Staff C and Staff B stated that the facility was a Smoke-Free Center, and that their current list of residents who smoked were grandfathered participants. Documentation of the facility's smoking policy was not provided. Review of the facility's admission agreement packet showed an undated document titled, Smoke-free Center Acknowledgement Form. It further showed that recipients of this document were asked to acknowledge that the facility is a smoke-free environment and agree not to smoke while residing in the Center. Review of the facility's admission agreement packet showed an undated documented titled, Facility Rules, showed that the facility prohibited items such as possession of common incendiary devices such as matches or lighters since these represent a fire hazard. If any of these items are found, they will be secured by the facility and asked to be picked up by the family. Review of the facility's document titled Smoking Audit, dated 01/02/2025 showed a list of current 12 residents who smoked. Further review of the list did not show Resident 91 was listed. RESIDENT 91 Resident 91 admitted to the facility on [DATE] with diagnoses that included unsteadiness, muscle weakness, and generalized anxiety (constant feeling of unease, worry and nervousness) disorder. Review of Resident 91's nursing progress note dated 12/16/2024 showed that Resident pushing [their] roommate in wheelchair to smoke. SS [Social Services (Staff E)] educated resident on smoking policy. Review of Resident 91's comprehensive care plan printed on 01/02/2025 did not show that Resident 91's care plan was revised to include smoking behaviors identified on 12/16/2024. Review of Resident 91's December 2024 and January 2025 medication administration record showed a physician's order for nicotine patch one time a day for smoking cessation was started on 12/18/2024. It further showed that Resident 91 refused their nicotine patch on 12/18/2024 through 12/20/2024 and refused again from 12/23/2024 through 01/02/2025. Review of a smoking evaluation dated 12/17/2024 showed that Resident 91 was marked yes for having a history of unsafe smoking habits and a history of sharing/selling cigarettes or smoking material. It showed that Resident 91's smoking evaluation decision was that supervised smoking was required and that the reason was [Resident 91 was] unsafe to smoke. It further showed that the evaluation was not signed by Resident 91. Observation on 01/02/2025 at 8:17 AM showed Resident 91 walked through the facility entrance lobby unaccompanied and smoked a cigarette while in the facility's entrance lot. Further observation at 8:22 AM showed Resident 91 entered the facility through the front lobby and Resident 91 did not provide their smoking materials to staff for safe storage, prior to entering their room. In an interview on 01/02/2025 at 8:49 AM, Resident 91 stated, I don't just stand in the middle of the parking lot most of the time. I know the smoking policy. I'm working on the patch, but it's not something I can do today or overnight. My nurse offers it to me, but I'm not ready. Observation on 01/02/2025 at 8:58 AM showed Resident 91's roommate, Resident 87, had a portable oxygen concentrator placed between Resident 91 and Resident 87's bed. In an interview and joint record review on 01/08/2025 at 12:28 PM, Staff H, Registered Nurse, stated they completed Resident 91's smoking evaluation dated 12/17/2024. When asked how a smoking evaluation was conducted, Staff H stated they asked Resident 91 for answers to specific questions on the evaluation form. Staff H stated that Resident 91 answered, yes, when asked if they shared smoking materials. When asked if Resident 91 was asked during the smoking evaluation, where they stored their smoking materials, Staff H stated, [Resident 91] didn't want to answer. When asked if the Resident 91 should have signed the smoking evaluation completed on 12/17/2024, Staff H stated, [Resident 91] didn't sign and date it. Joint record review of Resident 91's care plan did not show that their care plan was revised prior to 01/02/2025 to include smoking behaviors identified after the smoking evaluation was completed on 12/17/2024. When asked if Resident 91's care plan should have been revised after the smoking evaluation, Staff H answered, I can't remember, if it's not there, I probably didn't [did not revise]. In an interview and joint record review on 01/08/2025 at 1:34 PM, Staff B stated they were aware of the staff observation on 12/16/2024 of Resident 91 and their roommate to have smoked and that the incident prompted a smoking evaluation to be completed on 12/17/2024. Joint record review of Resident 91's smoking evaluation dated 12/17/2024 showed that Resident 91 was marked yes for having a history of unsafe smoking habits and a history of sharing/selling cigarettes or smoking material. It further showed that Resident 91's smoking evaluation decision was that supervised smoking was required and that the reason was [Resident 91 was] unsafe to smoke. Staff B stated that it was the facility's policy that smoking materials were kept in a cart with the smoking aid. When asked if they expected smoking materials to be managed/stored by residents independently, Staff B stated No, residents cannot keep it in the room. We would offer to lock it in a safe. When asked if there should have been an attempt from staff to determine where Resident 91 kept their smoking material once the smoking evaluation was completed on 12/17/2024, Staff B stated, I don't see any [progress] note regarding it. When asked if the potential for Resident 91 keeping smoking materials on their person posed a risk for a hazard to themselves and others in the building, Staff B stated, Yes, that's why we educate them to keep it safely stored. When asked if they expected Resident 91's care plan to have been revised once smoking behaviors were identified on 12/16/2024 and the smoking evaluation completion on 12/17/2024, Staff B stated, Yes, I agree, we should care plan everything. Joint record review of Resident 91's care plan did not show it was revised to include identified smoking behaviors before 01/02/2025. Staff B stated, I don't see anything.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 2 of 3 residents (Residents 22 & 87), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy, and properly store oxygen equipment placed the residents at risk for respiratory infections and related complications. Findings included . Review of the facility's policy titled, Oxygen Administration, revised in October 2010, showed, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. RESIDENT 22 Review of the Quarterly Minimum Data Set (an assessment tool) dated 10/11/2024, showed Resident 22 was cognitively intact and that they received oxygen therapy. It further showed that they had diagnoses that included chronic obstructive pulmonary disease (a condition that blocks air flow and make it difficult to breathe). Review of Resident 22's January 2025 Medication Administration Record (MAR) printed on 01/05/2025, showed an order for oxygen at two to three liters (unit of measurement) per minute via nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) continuously except when smoking every shift, dated 08/15/2022. Further review showed that Resident 22 received oxygen from 01/01/2025 through 01/05/2025. Observation on 01/03/2025 at 9:41 AM, showed Resident 22 was receiving four and a half liters of oxygen via nasal cannula. Observation on 01/05/2025 at 8:48 AM, showed Resident 22 was lying in bed asleep receiving five liters of oxygen via nasal cannula. In another observation at 12:44 PM, showed Resident 22 was sitting up in bed receiving five liters of oxygen via nasal cannula. When asked how many liters of oxygen they received, Resident 22 stated three liters. When asked if they touched the oxygen flow meter, Resident 22 stated, No and that the nurses do it. Observation on 01/06/2025 at 9:34 AM, showed Resident 22 was lying in bed asleep receiving five liters of oxygen via nasal cannula. In an interview and joint record review on 01/06/2025 at 1:27 PM, Staff U, Registered Nurse (RN), stated that their process of oxygen use was to verify physician order, which type of delivery (mask or nasal cannula) and to adjust the oxygen to what was ordered. Staff U stated that they checked for correct liter flow at the beginning and during the shift if the resident got up. Joint record review of Resident 22's physician orders showed oxygen two to three liters per minute via nasal cannula continuously except when smoking every shift. Joint observation with Staff U showed Resident 22 was lying in bed receiving five liters of oxygen via nasal cannula. Staff U stated Resident 22's oxygen liter should have been between two to three liters per physician's order. When asked if they checked Resident 22's oxygen flow meter, Staff U stated, I have not checked it today. In an interview on 01/06/2025 at 3:23 PM, Staff T, Charge Nurse, stated their expectation for residents' receiving oxygen was for staff to ensure oxygen tubing was dated, oxygen tank was cleaned, and physician's orders were followed. Staff T further stated that Resident 22 should have received two to three liters of oxygen per physician orders and should not have been receiving five liters of oxygen. In an interview on 01/06/2025 at 4:21 PM, Staff B, Director of Nursing, stated that they expected Resident 22 to have received two to three liters of oxygen as ordered. RESIDENT 87 Resident 87 admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and chronic pain syndrome. Review of Resident 87's physician orders showed Resident 87 had an order for O2 [Oxygen] concentrator set to 2 [two] liters per minute every day and every evening shift for O2 supplement to enhance breathing, dated 08/08/2024. Review of Resident 87's January 2025 MAR showed an order for O2 concentrator set to 2 liters per minute every day and every evening shift for O2 supplement to enhance breathing, dated 08/08/2024. It further showed that the oxygen order was signed to have been administered every day, from 01/01/2025 through 01/07/2025. Review of Resident 87's documentation of oxygen saturation readings printed 01/07/2025 did not show oxygen saturation levels were read for Resident 87 since 10/26/2024. Observation and interview on 01/02/2025 at 8:58 AM, showed there was a magnet on Resident 87's room door that showed Oxygen in use. Further observation showed that Resident 87 had a portable oxygen concentrator in their room and that it was not in use. Resident 87 was asked when they received oxygen therapy and Resident 87 replied When they check my oxygen levels and it's low, that's when they put it on me. Observation on 01/05/2025 at 1:14 PM, showed Resident 87 was up in their wheelchair. It did not show that Resident 87 had their oxygen therapy in use. A joint record review and interview and on 01/07/2025 at 12:55 PM with Staff JJ, RN, showed Resident 87's January 2025 MAR had an order for O2 concentrator set to 2 liters per minute every day and every evening shift for O2 supplement to enhance breathing. It further showed that the oxygen order was signed to have been administered every day from 01/01/2025 through 01/07/2025. Staff JJ was asked if Resident 87 received their oxygen therapy every day and every evening and Staff JJ stated they did not think they needed to [administer Resident 87's oxygen therapy] routinely. Staff JJ stated, We would administer it if their oxygen saturation was below 90% [percent]. Joint record review of Resident 87's documentation of oxygen saturation readings did not show that oxygen saturation levels were read for Resident 87 since 10/26/2024. Staff JJ stated there was no documentation of oxygen saturation readings for Resident 87 since 10/26/2024. When asked if the physician's order instructed staff to hold oxygen administration for oxygen saturation readings less than 90%, Staff JJ replied, it did not, and that Resident 87's oxygen therapy physician's order was not as needed. Staff JJ was asked if they expected staff to follow Resident 87's physician order as it was written and Staff JJ answered, Yes. Staff JJ further stated, I should follow the order. A joint record review and interview on 01/07/2025 at 1:20 PM with Staff EE, Licensed Practical Nurse/Charge Nurse, showed Resident 87's physician order for O2 concentrator set to 2 liters per minute every day and every evening shift for O2 supplement to enhance breathing, dated 08/08/2024. Staff EE stated routinely scheduled orders would be reflected in the physician's order and that Resident 87's physician's order was scheduled for routine administration and not as needed. Staff EE stated, That's written there, every day and evening shift, it doesn't say PRN [as needed]. Staff EE further stated that they expected Resident 87's oxygen therapy to have been administered as ordered. A joint observation and interview with Staff EE and Staff JJ on 01/07/2025 showed Resident 87 in their room and that they did not have their oxygen therapy administered as ordered. Staff JJ stated they were about to put it on [Resident 87]. Observation of the nasal cannula showed it was placed across Resident 87's bedside table. Further observation showed it was placed on top of their personal belongings. Staff EE stated that Resident 87's nasal cannula should have been stored in a bag when not in use. Staff JJ was asked if Resident 87's nasal cannula was stored in a bag and Staff JJ replied, No, I'll change it. In an interview and joint record review on 01/08/2025 at 10:40 AM, Staff B stated they expected nasal cannulas to be bagged when they are not used and that nasal cannulas should not touch any surfaces. Joint record review of Resident 87's physician orders showed an order for oxygen therapy. Staff B stated Resident 87's physician order for oxygen therapy was routine and that they expected staff would follow the physician's order. Staff B further stated they expected nurses to clarify with the medical provider when they were unsure about a physician's order. Reference: (WAC) 388-97-1060(3)(j)(vi) .

CONCERN (E)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to implement their abuse policy and procedure by not ensuring reference checks were conducted prior to hire for 4 of 5 staff (Staff Y, Z, AA & BB), reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included . Review of the facility's policy titled, Abuse Prohibition Policy and Procedure, reviewed on 02/23/2021, showed, The Center will implement an abuse prohibition program through the following: screening of potential hires .The center will screen potential employees for a history of abuse, neglect, or mistreating patients/residents, including attempting to obtain information from previous employers. Review of employee records for Staff Y, Certified Nursing Assistant, Staff Z, Weekend Registered Nurse Manager, Staff AA, Nursing Assistant Registered, and Staff BB, Smoking Aide, did not show that reference checks were conducted by the facility prior to their respective hire dates. In an interview on 01/06/2025 at 12:34 PM, Staff A, Administrator, stated that reference checks were not completed for Staff Y, Z, AA and BB prior to their hire in year 2024. Staff A provided an undated document titled, Personal Reference Checks, and stated the facility used this document for completion of reference checks. Staff A further stated that Staff Y, Z, AA and BB did not have a completed reference check document in their employee files. Review of the facility's blank and undated document titled Personal Reference Checks, showed that instructions for completion of the form included, State law, Federal law, and company policy require a minimum of 2 reference checks for each new hire. In an interview on 01/08/2025 at 8:22 AM, Staff W, Accounts Payable/Payroll/Human Resources, stated the facility's personal reference checks form was used by the facility and that there was a process in place to complete reference checks for potential hires since January 2023. Staff W further stated that reference checks were not completed for Staff Y, Z, AA and BB. In another interview on 01/08/2025 at 11:45 AM, Staff A stated that they expected reference checks to be competed for potential hires. Staff A further stated that It's part of the hiring process, we shouldn't hire staff without doing them. Reference: (WAC) 388-97-0640(2)(a) .

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to complete the required annual performance evaluations for 5 of 5 staff (Staff M, N, O, P & Q), whose personnel files were reviewed for Certified Nursing Assistant (CNA) performance evaluations. The failure to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews, placed residents at risk for receiving care from underqualified nursing staff and unmet care needs. Findings included . Review of the facility's policy titled, Performance Evaluations, revised in September 2020, showed, The job performance of each employee shall be reviewed and evaluated at least annually. Review of personnel file on 01/07/2025, showed Staff M, CNA, was hired on 12/02/2012. Further review showed that Staff M's most recent annual performance evaluation was completed on 07/15/2015. Review of personnel file on 01/07/2025 for Staff N, CNA, showed they were hired on 12/01/2012. Further review showed that Staff N's most recent annual performance evaluation was completed on 10/13/2015. Review of personnel file on 01/07/2025 for Staff O, CNA, showed that they were hired on 05/07/2020. The facility was not able to provide documentation that an annual performance evaluation was completed for Staff O. Review of personnel file on 01/07/2025 for Staff P, CNA, showed they were hired on 12/19/2019. Further review showed that STAFF P's most recent annual performance evaluation was completed on 03/15/2022. Review of personnel file on 01/07/2025 for Staff Q, CNA, showed they were hired on 08/26/2014. The facility was not able to provide documentation that an annual performance evaluation was completed for Staff Q. In an interview on 01/08/2025 at 12:45 PM, Staff B, Director of Nursing, was asked how often they conducted performance evaluations for nursing staff, Staff B stated that they did not know but thinks it should be done yearly. In an interview on 01/08/2025 at 1:33 PM, Staff R, Senior [NAME] President of Operations, stated, Everyone should get an annual evaluation. Staff R was informed that Staff M, N, O, P, and Q did not have any current performance evaluations, Staff R stated, let me check and see, if they're not in the employee file then they're probably not up to date on those. On 01/08/2025 at 3:15 PM, Staff W, Human Resources, provided the following documentation: - Staff M's Employee Performance Appraisal Form dated 07/15/2015. - Staff N's Performance Appraisal Form dated 06/11/2015 and Employee Performance Appraisal Form dated 10/13/2015. -Staff P's Certified Nursing Assistant Evaluation dated 04/09/2020 and 03/15/2022. In an interview on 01/08/2025 at 3:37 PM, Staff W stated that the performance evaluations provided were the most current performance evaluations they had on file. In an interview and joint record review on 01/08/2025 at 4:18 PM, Staff A, Administrator, stated that they expected each department heads to complete evaluations for their staff. Staff A stated that for nursing it would be the Director of Nursing or Nursing Managers and that they should be doing the evaluations timely. Joint record review of the performance evaluations provided by Staff W showed that Staff O and Q did not have performance evaluations, and that Staff M, N, and P's performance evaluations were late. Staff A further stated that they expected staff performance evaluations to be completed timely. Reference: (WAC) 388-97-1680 (2)(b)(i) .

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

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 appropriately store drugs and/or biologics (diverse group of medicines made from natural sources) for 2 of 3 medication carts (Medication Carts 2 & 3), reviewed for medication storage. This failure placed the residents at risk for receiving compromised/ineffective medications and potential adverse outcome. Findings included . Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed that the facility stored all medications and biologicals in locked compartments under proper temperature humidity and light controls. The policy showed the facility medications were stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle drawer, or other holding area to prevent the possibility of mixing medications of several residents. The policy further showed that multi-dose vials that had been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specified a shorter or longer date for the open vial. MEDICATION CART 2 A joint observation and interview on [DATE] at 2:47 PM with Staff G, Registered Nurse (RN), showed one opened vial of Humulin (insulin-injectable medication to treat high blood sugar) 100 units (a unit of measurement) for Resident 36 in the top drawer of the medication cart that was half empty, dated 11/27 [[DATE], 40 days from the date it was opened]. Further observation showed the bottom drawer of the cart had a box with different tubes of creams, ointments and powders for multiple residents. These medications were not properly stored or separated by resident, which included the following medications: - Two opened bottles of nystatin powder (used to treat fungal infections) and one opened tube of triamcinolone (topical ointment used to treat skin conditions) labeled for Resident 36. - One opened tube of bacitracin (a topical antibiotic that treats infections), house supply. - One opened bottle of nystatin powder for Resident 27. - One open bottle of Aspercream (brand name, a topical cream to treat pain), no label - One opened tube of nystatin cream for Resident 41. - One unopened tube of TheraHoney (brand name, a medical-grade wound dressing made from Manuka honey), unlabeled. Staff G stated that they had planned to discard the vial of insulin and that some of the residents no longer use some of the medications included in the box of creams, powders, and ointments found on the bottom drawer. MEDICATION CART 3 A joint observation and interview on [DATE] at 2:28 PM with Staff HH, RN, showed the last drawer of medication cart 3 had a box with various creams, ointments and powders for different residents. These medications were not properly stored or separated by resident. These medications included: - One opened tube of a triple antibiotic ointment (topical treatment for minor skin issues), for house supply. - One opened tube of Halobetasol (topical cream used to treat minor skin irritations) and one opened bottle of nystatin for Resident 34. - One opened tube of bacitracin, house supply. - One opened tube of clotrimazole cream for Resident 88. - One opened bottle of nystatin for Resident 60. Staff HH stated that some of these treatments were discontinued and would discard them. In an interview on [DATE] at 10:38 AM, Staff B, Director of Nursing, stated that they expected discontinued medications to be sent back to the pharmacy and any medications that were expired and/or discontinued should be removed from the medication cart immediately. Staff B further stated that treatment creams should not be mixed and should be separated in the medication cart. Reference: (WAC) 388-97-1300(2) .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 52 Review of the quarterly MDS dated [DATE], showed that Resident 52 was cognitively intact. Review of Resident 52's nutrition care plan, revised on 01/02/2025, showed to Honor food preferences within meal plan. It showed that Resident 52 was allergic to shellfish, chili powder and red and green bell pepper. Review of the menu titled, Week-at-a-Glance, printed on 01/07/2025, showed that Resident 52 did not have an entrée ordered for three meals in a three-week period. In an interview on 01/07/2025 at 2:46 PM, Resident 52 showed a picture they took of their dinner meal from 01/06/2025, which showed Brussel sprouts, a roll, and no entrée. Resident 52 stated it was supposed to be fish, but I can't eat that. They didn't give me an alternative, they never do. In another interview on 01/08/2025 at 3:45 PM, Resident 52 was shown the Bistro Menu, Resident 52 stated that they had never seen the Bistro menu. Resident 52 stated that the facility used to have an alternative menu on the back of the menu that showed options if the main menu did not offer a resident's food preference. Resident 52 stated that this week the alternative to fish was stir fry that had peppers in it and I'm allergic to peppers. In an interview and joint record review on 01/08/2025 at 4:17 PM, Staff CC stated that if a resident did not want the entrée or the alternative, they provided residents with their always available/bistro menu and it comes on the back of the menu. When asked when the last time the bistro menu was on the back of the main menu, Staff CC stated, probably around the time the [previous] Dietary Manager resigned. Staff CC stated they would be posting the bistro menu in residents' rooms so they would know the additional options. Joint record review of Resident 52's menu showed three days in a three-week period where Resident 52 did not have an entrée. Staff CC stated that I went and spoke with [Resident 52] to fix that. So, moving forward [Resident 52] will have a cheeseburger or chef salad if they did not want the entrée or the alternative. In an interview on 01/08/2025 at 5:22 PM, Staff A stated that they expected that residents should be able to choose from the always available menu, if they did not want the main dish or the alternative. Staff A stated that they did not expect a resident to not be provided an entrée and it [the entrée] should be given as appropriate for their preferences and dietary needs. Reference: (WAC) 388-97-1120 (2)(3)(a) Based on observation, interview, and record review, the facility failed to ensure residents received current food menus and/or alternative menus that meets their needs including daily fresh fruits and vegetables for 5 of 6 residents (Residents 14, 309, 89, 55 & 52), reviewed for dining services. This failure placed the residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life. Findings included . Review of the USDA Dietary Guidelines for Americans 2020-2025 [retrieved on 01/15/2025], stated nutritional needs should be from nutrient dense foods such as vegetables from all vegetable subgroups like dark green; red and orange; as well as whole fruits. The recommended intake for an adult (Age 19 - 59): Vegetables: 2 - 4 cups/day; Fruits: 1 ½ - 2 ½ cups/day; (Age 60 and up): Vegetables: 2 - 3 ½ cups/day; Fruits: 1 ½ - 2 cups/day. Review of the facility's policy titled, Menus, revised on 09/2017, showed that menu cycles would include nutrient analysis to ensure that all client nutritional needs were met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans. The policy further showed that menus would be posted in resident/patient care areas. Review of the facility provided menus, printed on 01/04/2025, showed the following: Week Two Menu: - Sunday lunch, only meal with a fresh vegetable, and no fresh fruit was offered that day. - Monday, no fresh fruits/vegetables offered that day. - Wednesday dinner, only meal with fresh vegetables, no fresh fruit was offered that day. - Thursday, no fresh fruits/vegetables offered that day. - Friday dinner, only meal with fresh vegetable, and no fresh fruit was offered that day, - Saturday lunch, only meal with fresh vegetable, and no fresh fruit was offered that day. Week Three Menu: - Sunday, no fresh fruits/vegetables offered that day. - Monday, no fresh fruits/vegetables offered that day. - Tuesday dinner, only meal with a fresh vegetable, and no fresh fruit offered that day. - Wednesday lunch, only meal with fresh vegetables, no fresh fruit was offered that day. - Thursday lunch and dinner meal with fresh vegetables, and no fresh fruit offered that day. - Friday lunch, only meal with fresh vegetable, and no fresh fruit offered that day. - Saturday lunch, only meal with fresh vegetable, and no fresh fruit offered that day. Review of the undated Bistro Menu (always available menus) on 01/08/2025 at 8:15 AM, provided by Staff CC, Regional Dietary Manager, showed different food options, available for pre-order (place your order by 11 AM the day prior) that included breakfast options such as cream of wheat, eggs, toast and cold cereal and for lunch and dinner, cottage cheese and fruit plate, chef's salad, veggie burger and hamburger. RESIDENT 14 Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 12/17/2024, showed that Resident 14 was cognitively intact. On 01/03/2025 at 10:03 AM, Resident 14 stated they did not receive a food menu. On 01/04/2025 at 12:29 PM, Resident 14 stated that they did not receive food menus and that they don't have a choice. Resident 14 stated that staff just posted the menu out there, and that they had to get up into a wheelchair and look at the menu to see what they were having. Resident 14 further stated that they did not get fresh fruits or vegetables, that it was mostly canned and not fresh. Observations on 01/05/2025 at 8:11 AM and on 01/07/2025 at 8:09 AM, showed Resident 14 had no fresh fruit for breakfast. On 01/08/2025 at 12:00 PM, Resident 14 was shown the Bistro Menu, Resident 14 stated that they had not been made aware of a Bistro menu. RESIDENT 309 Review of the admission MDS dated [DATE], showed that Resident 309 was cognitively intact. Joint observation and interview on 01/07/2025 at 1:52 PM with Resident 309 showed an old menu from the first week of December 2024 on their bulletin board. Resident 309 stated that they did not get to choose what to eat. On 01/08/2025 at 11:26 AM, Resident 309 was shown the Bistro Menu, Resident 309 stated that they had not seen the Bistro menu, and that it was not available to them. RESIDENT 89 On 01/03/2025 at 12:53 PM, Resident 89 stated that they did not always get a menu, and that there was no consistency. Resident 89 stated that staff needed to go over the menu with them, but they have not seen one in forever. Resident 89 further stated that the fruit was not fresh, and it was mostly canned. Observation on 01/07/2025 at 3:00 PM, showed no menu on Resident 89's side of the room. On 01/08/2025 at 11:27 AM, Resident 89 was shown the Bistro Menu, Resident 89 stated that the Bistro menu was not made available to them. RESIDENT 55 Review of the quarterly MDS dated [DATE] showed Resident 55 was cognitively intact. On 01/07/2025 at 1:25 PM, Resident 55 stated that they never received fresh fruits or vegetables, and it was either canned or frozen. On 01/08/2025 at 4:46 PM, Resident 55 was shown the Bistro Menu, Resident 55 stated that they had never seen a Bistro menu. On 01/08/2025 at 8:09 AM, Staff CC stated that the menus were corporate preloaded and used a preference-based system. Staff CC stated that this system would take residents' preferences and automatically swap out with the alternative option if they disliked something. Staff CC stated that residents received menus a week in advance, and that there was a Bistro menu where they could order things like a chef salad, or deli sandwiches, and that this menu was kept at the nurses' station. Staff CC stated that the activities staff was responsible for passing out the menus to the residents and that sometimes they would get menus back filled out. When asked about the percentage of population that turned in a filled menu, Staff CC stated that 5-10% of the facility's residents turned in a menu, and that, not very many turn it back in. Staff CC further stated that fresh fruits and vegetables were not always on the menu but were available if the resident requested and was told to them verbally during the initial preference meeting. When asked if they could prove that residents were made aware of this, Staff CC stated, You won it. On 01/08/2025 at 9:17 AM, Staff OO, Recreation Assistant, stated that they delivered a food menu to every single resident in the facility either Friday or Saturdays, as the menus started on Sunday. Staff OO stated that the dietary manager was responsible for giving them the menus to pass out to the residents, but that the dietary manager had resigned right before Christmas (12/25/2024) and had not handed them out for a few weeks, and believed they were available upon request from dietary. Staff OO stated that during this time the menus were not given to each resident individually, and that they probably should have been. On 01/08/2025 at 10:37 AM, Staff CC stated that they printed out a snack list and menu alternates from one of their other facilities and were going to pass it out to all the residents and post them at the nurses' station so everyone knows what is available. On 01/08/2025 at 11:59 AM, Staff PP, Dietitian, stated that fresh fruits were available every day, but not always served every day. On 01/08/2025 at 2:19 PM, Staff A, Administrator, stated that their expectation was for the residents to know what their choices were and what they were going to be eating, by receiving a menu. Staff A further stated that the facility should have fresh fruit daily.

CONCERN (E)

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

Infection Control (Tag F0880)

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 Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 4 of 4 residents (Residents 51, 27, 64 & 93), reviewed for infection control. In addition, the facility failed to ensure hand hygiene, proper glove use, and infection control practices were followed for 3 of 13 staff (Staff DD, Staff II & Staff V). These failures placed the residents, staff, and visitors at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Isolation-Initiating Transmission-Based Precautions, revised in August 2019, showed that Transmission-Based Precautions may include Contact Precautions and when Transmission-Based Precautions are implemented, the Infection Preventionist .clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. It also showed that there should be appropriate notification on the room entrance door that informs the staff of the type of .precautions. It further showed that there should be an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. CONTACT PRECAUTIONS RESIDENT 51 Review of Resident 51's physician orders showed an order to observe contact precautions related to a wound infection on Resident 51's left lower leg starting on 01/04/2025. Observation on 01/05/2025 at 8:21 AM, showed Staff M, Certified Nursing Assistant (CNA), entered Resident 51's room (Contact Precautions room) wearing Personal Protective Equipment (PPE-special equipment worn to protect from germs which included a disposable gown and gloves). It showed that there was no hazardous waste container inside Resident 51's room. It further showed Staff M took off their gown, left the room, and brought the gown down the hallway to the soiled utility room. On 01/05/2025 at 1:22 PM, Staff M stated that when entering a Contact Precautions room, they would wear a gown and gloves and when they took off their PPE, they should put it in a separate bin or put in a bag and take it to the soiled utility room. Staff M stated they couldn't [could not] find anywhere to put it [the soiled gown], so I took it took it to the soiled utility room and did not put it in a plastic bag. In an interview and joint observation on 01/05/2025 at 1:31 PM, Staff MM, Registered Nurse (RN), stated they would put PPE on every time they entered a Contact Precautions room and when they exited, they would put the gown and gloves in the can that's designated for it. We used to have a black garbage can. A joint observation showed nothing by the door to dispose of PPE in Resident 51's room. Staff MM stated, I'm going to look for a black garbage can. In an interview on 01/08/2025 at 9:59 AM, Staff T, Infection Preventionist, stated that they expected staff to remove PPE and place in a bin in the residents' rooms by the door. Staff T further stated if there was nowhere to dispose of the PPE then it should be placed in a bag when carried to the soiled utility room. In an interview on 01/08/2025 at 4:43 PM, Staff B, Director of Nursing, stated that they expected staff to take off their PPE prior to exiting a Contact Precautions room and place it in a designated container inside the room. STAFF V Observation on 01/02/2025 at 1:23 PM, in the 500 Wing Hallway showed Staff V, CNA, was carrying a meal tray down the hallway when the cover on the meal tray fell onto the floor. Staff V picked up the cover off the floor, placed it back onto the meal tray and delivered it to room [ROOM NUMBER]-A. In an interview on 01/02/2025 at 1:45 PM, Staff V stated that when a cover fell on the floor it's dirty and that they would place it in the dirty meal cart. Staff V further stated that you're [you are] not supposed to pick it up. It's already dirty. In an interview on 01/08/2025 at 9:30 AM, Staff T stated that when a cover fell on the floor during meal tray delivery, they expected staff to return it to the kitchen or the dirty dishes because it's already contaminated, it touched the ground. Staff T further stated that Staff V should have returned it to the kitchen and got a new tray. In an interview on 01/08/2025 at 4:10 PM, Staff B stated that they expected Staff V to not put it back on the tray and that It's already dirty. Staff B further stated that they expected them to place it in the dirty meal tray cart. Reference: (WAC) 388-97-1320 (1)(a)(c) RESIDENT 27 Review of Resident 27's order summary printed on 01/08/2025, showed an order for contact precautions due to a wound. Observation on 01/02/2025 at 8:05 AM, showed Staff HH, CNA entered Resident 27's contact precaution room without gowning up or applying gloves prior to delivering their breakfast tray. Observation on 01/02/2025 at 12:36 PM, showed the call light was on for Resident 27. Staff L, RN, entered the resident room without the appropriate PPE [gown and gloves] to answer the call light and turn it off. Staff L took a soiled water pitcher out of Resident 27's room and gave it to Staff K, RN. Staff K then took that water pitcher and walked down the hallway into the clean utility room to fill it with ice and brought it back into Resident 27's room without wearing the appropriate PPE prior to entering the room. RESIDENT 64 Review of Resident 64's physician orders showed an order dated for 12/27/2024 for contact precautions related to Multidrug-resistant organism (MDRO- bacteria that are resistant to multiple classes of antibiotics) and Extended-spectrum beta-lactamases (ESBL) E. Coli (a type of bacteria that is resistant to many antibiotics [medication to treat infection]) to wound. Observation on 01/02/2025 at 7:58 AM, showed Staff K entered Resident 64's contact precaution room and did not put on the appropriate PPE. Observation on 01/02/2025 at 8:03 AM, showed Staff HH, entered Resident 64's room without gowning up or applying gloves prior to delivering their breakfast tray. Observation on 01/02/2025 at 12:08 PM, showed Staff FF, Physical Therapist, Staff GG Occupational Therapist, and Staff K were in Resident 64's room without the appropriate PPE. Joint observation and interview on 01/02/2025 at 12:24 PM with Staff FF and Staff GG, showed contact precaution signage outside Resident 64's room that indicated to gown and glove prior to entering the room. Both Staff FF and Staff GG stated that based on the contact precaution sign they did not follow what it said and that they should have done hand hygiene and put on the appropriate PPE before entering. On 01/02/2025 at 12:41 PM, Staff K stated they had to wear PPE prior to entering a contact precaution room when they had direct physical contact with the resident, but if they were in the room quick or just passing out medication they did not. Joint observation and interview on 01/02/2025 at 12:48 PM, with Staff K, showed a contact precaution sign outside of Resident 27's room indicating staff and visitors to do hand hygiene, and wear a gown and gloves prior to entering the resident room. Staff K stated that they saw that the sign said to put on a gown prior to entering the room and that they did not do that when handing out medication. Staff K further stated that they took the water pitcher and filled it up with ice in the clean utility room and brought it back to Resident 27, and that they should not have done that as the pitcher was contaminated probably, instead they should have brought ice in a different pitcher into the room. Joint observation and interview on 01/02/2025 at 12:58 PM with Staff HH, showed a contact precaution sign outside of Resident 27's room that showed to gown and glove prior to entering the room. Staff HH stated that you had to wear PPE when going into a contact precaution room, but if you did not touch the resident or just stopped to deliver something you did not have to gown up. After reviewing the sign, Staff HH stated that the sign did not specify the above and that going forward they would gown up with everything. Joint observation and interview on 01/02/2025 at 1:10 PM with Staff L showed a contact precaution sign outside of Resident 27's room. Staff L stated that if the resident was on contact precaution they had to wear all the appropriate PPE prior to entering the resident room. Staff L stated that when they entered Resident 27's room to remove the water pitcher they did not gown or glove up because they thought the resident was on enhanced barrier precautions (precaution to protect residents from MDROs during high contact activity and not on contact precautions) and that they should have read and followed the sign outside the door. On 01/08/2025 at 9:39 AM, Staff T stated that anyone entering a contact precaution room should do hand hygiene and wear the appropriate PPE prior to entering. Staff T stated that Resident 27 was on contact precautions due to a wound, and Resident 64 due to ESBL. Staff T stated that Staff HH, FF, GG, L, and K, should have put on the appropriate PPE before entering the resident's rooms and taken it off prior to exit. Staff T further stated that Staff L should not have taken the soiled water pitcher out of a contact precaution room, and Staff K taken it down the hallway into the clean utility room to fill with ice and brought it back to Resident 27 as it placed a potential for spread of contamination. On 01/08/2025 at 2:37 PM, Staff B stated it was their expectation for staff to do hand hygiene and wear the appropriate PPE prior to entering a contact precaution room. Staff B further stated Staff K should not have taken the water pitcher from Resident 27's room and taken it into the clean utility room to fill it with ice. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 9/18/2023, showed all personnel should be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. The policy showed that the use of gloves did not replace hand washing/hand hygiene, and that integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The policy further showed that single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Review of the facility's policy titled, Subcutaneous Injections [applied beneath the skin], revised in March 2011, showed its purpose of this procedure is to provide guidelines for the administration of medication by subcutaneous injection. The policy further showed procedure steps included performing hand hygiene, put on gloves, and placing the equipment on the bedside table or overbed table where it is easily reached. When administration is completed, gloves are discarded, and hand hygiene is performed. STAFF DD Observation and interview on 01/05/2025 at 8:31 AM, showed Staff DD, LPN, prepared Resident 75's medication. Staff DD dispensed a potassium chloride (a mineral supplement used to treat or prevent low blood levels of potassium) capsule and placed it aside in a separate medication cup. When Staff DD finished dispensing the rest of Resident 75's medications, Staff DD took the potassium chloride capsule and opened it with their ungloved hands and poured the capsule's contents into the medication cup with the crushed medications. Staff DD stated that they did not touch the inside of the capsule, only the outside. STAFF II Observation and interview on 01/05/2025 at 12:42 PM, showed Staff II, LPN, prepared an insulin (medication to treat/regulate blood sugar) pen for Resident 25 by placing a new insulin pen tip without swabbing the end of the insulin pen with an alcohol swab. Staff II stated that they did not sanitize the tip of the [insulin] pen because it was already clean. Still wearing the same pair of gloves used to prepare the insulin pen, Staff II was observed locking up the medication cart, walked down the hall, knocked on the door and opened it, administered the insulin, then removed their gloves. Staff II stated that after they prepared the insulin pen with their gloved hands, the insulin pen was still in their hand. Staff II further stated that if they placed the insulin pen down to change gloves, the insulin pen would get contaminated. In an interview on 01/05/2025 at 3:02 PM, Staff B stated that they expected staff to perform hand hygiene before preparing medications for residents. Staff B further stated that staff should be cleaning the end of the insulin pen before attaching a new needle. Resident 93 admitted to the facility on [DATE] with diagnoses that included paraplegia (a condition in which a person is unable to move or feel their lower part of the body because of an injury to the spine). Review of Resident 93's contact precautions care plan revised on 12/25/2024 showed that Resident 93 was on contact precautions due to multiple wounds, had a history of MDRO infection, nephrostomy tube status (a small tube that is placed directly into the kidney to help drain urine when it can't flow normally due to a blockage) and foley catheter status (a flexible tube that is inserted into the bladder to help drain urine). Observation on 01/05/2025 at 9:17 AM, showed Staff KK, RN, entered room [ROOM NUMBER] while wearing gown and gloves, followed by Staff X, Maintenance Assistant, who did not wear gown and gloves. Further observation showed room [ROOM NUMBER] had signage for contact precautions posted and that an orange sticker [to indicate the resident is on contact precautions] was placed on Resident 93's name label. In an interview and joint record review on 01/05/2025 at 9:24 AM, after exiting room [ROOM NUMBER], Staff X was asked what their purpose was of entering room [ROOM NUMBER], Staff X stated they tried to put [bed] side rails for Resident 93. Staff X stated they touched Resident 93's privacy curtains and bed during their encounter with Resident 93. Joint record review of the contact precautions signage posted for room [ROOM NUMBER] showed that staff were instructed to don [put on] gloves and gown before entering the room. Staff X stated, Today I forgot, sorry. When asked if they should have followed contact precautions for Resident 93, Staff X stated Yeah. In an interview on 01/05/2025 at 9:28 AM, Staff II, Licensed Practical Nurse (LPN), stated they expected staff would have followed contact precautions for Resident 93 before entering the room. In an interview on 01/05/2025 at 9:30 AM, Staff KK stated they observed Staff X fixed the bed for Resident 93 and that they did not wear gown and gloves. Staff KK further stated that Staff X should have worn them and followed contact precautions for Resident 93. Observation on 01/05/2025 at 1:26 PM showed Staff LL, CNA, entered room [ROOM NUMBER] without donning gown and gloves and brought in a lunch tray. In an interview on 01/05/2025 at 1:59 PM, Staff LL stated they followed contact precautions for Resident 93 because they had an orange sticker on their name label and that they did not need to follow contact precautions for Resident 93's roommate. In an interview on 01/08/2025 at 12:43 PM, Staff T stated they expected all staff would follow contact precautions for a room regardless of the orange sticker on the name labels. Staff T stated contact precautions were to be followed by staff whenever they entered a room that was placed under contact precautions and that [staff] need to wear appropriate PPE. In an interview on 01/08/2025 at 1:07 PM, Staff B stated they followed the Centers for Disease Control and Prevention (CDC) guidelines on infection prevention control in nursing homes. Staff B further stated that all staff must wear PPE whenever they entered a room under contact precautions.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0838 (Tag F0838)

Minor procedural issue · This affected most or all residents

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Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to include plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Facility Assessment, dated in December 2023, showed, The facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Review of the facility's document titled, Facility Assessment Tool, updated on 08/14/2024, did not show how the facility plans to maximize direct care staff recruitment and retention. A joint record review and interview on 01/08/2025 at 2:47 PM with Staff A, Administrator, showed that the facility assessment tool did not include a plan to maximize direct care staff recruitment and retention. Staff A stated, Looks like it was missed. A joint record review and interview on 01/08/2025 at 3:11 PM with Staff C, Interim Administrator, showed that the facility assessment tool did not include a plan to maximize direct care staff recruitment and retention. Staff C stated that it was not addressed in the facility assessment tool and that it should have been included. No associated WAC .

Jan 2025 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0804 (Tag F0804)

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, record review, the facility failed to ensure foods were served at proper temperature for 2 of 5 nursing units (500 and 200 Unit), and 6 of 6 residents (Residents 7, 3, 6, 4, 5 & 1), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included . FOOD TEMPERATURES 500 NURSING UNIT During a joint observation and interview on 12/12/2024 at 12:55 PM with Staff D, Corporate Dietary Manager (CDM), showed Staff D used the facility's kitchen thermometer to check the temperature of a cooked chicken patty that was delivered to the 500 nursing unit, the tray was removed from a closed cart which, contained individual, closed plastic containers with the resident's lunch meals. A chicken patty temped at 100 degrees Fahrenheit (F), interview at this time with Staff D stated that the temperature for the chicken patty to be served to the residents should be 135 degrees F, the stuffing was temped at 107 degrees F and the Brussel sprouts temped 97 degrees F. Staff D stated the temperature for the stuffing and Brussel sprouts should be 135 degrees F and that the temperature of the food was low. The temperature of the banana pudding was temped at 58 degrees F and an eight ounce glass of milk temped at 57 degrees F. Staff D stated they should both be at 40 degrees F. 200 NURSING UNIT During a joint observation and interview on 12/12/2024 at 1:18 PM with Staff C, Dietary Manager (DM), showed Staff C used the facility's kitchen thermometer to check the temperature of a cooked chicken patty that was delivered to the 200 nursing unit, the tray was removed from a closed cart, which contained individual, closed plastic containers with the resident's lunch meals. A chicken patty temped at 100 degrees F, interview at this time with Staff C stated the temperature for the chicken patty to be served to the residents should be 135-140 degrees F, the stuffing was temped at 115 degrees F and the Brussel sprouts temped 100 degrees F. Staff D stated that the temperature for the stuffing and Brussel sprouts should be 135-140 degrees F. The temperature of the banana pudding was temped at 59 degrees F, Staff D stated it should be at 40 degrees F. FOOD TEMPERATURES AND PALATIBILITY RESIDENT 7 Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 11/05/2024 showed the resident did not have impaired thinking or problems with their memory. During an interview on 12/04/2024 at 1:28 PM, Resident 7 stated, the food is cold and doesn't taste like anything, just cold and no flavor. RESIDENT 3 Review of the significant change of condition MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory. During an interview on 12/04/2024 at 1:40 PM, Resident 3 stated, the food is the worst, nobody can eat it. It has no taste. RESIDENT 6 Review of the quarterly MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory. During an interview on 12/10/2024 at 1:13 PM, Resident 6 stated they could not eat the food because it was cold and taste bad. Resident 6 further stated that they had to buy things to eat or just not eat. RESIDENT 4 Review of the quarterly MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory. During an interview on 12/12/2024 at 1:03 PM, Resident 4 stated, The food was served ice cold and that they were not able to eat it because it was so cold and had no flavor. Resident 4 further stated, you can't even get a cup of coffee here like you can in most places and were told they must wait for the mealtimes when coffee is served. Usually that is the best thing to have here, because you can't eat the cold food. I don't understand this. RESIDENT 5 Review of the quarterly MDS dated [DATE] showed the resident did not have impaired memory. During an interview on 12/12/2024 at 1:06 PM, Resident 5 stated, the food is cold, and it tastes terrible. RESIDENT 1 Review of the quarterly MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory. During an interview on 12/12/2024 at 4:12 PM, Resident 1 stated, I want what is being served to be hot, at least warm and edible. Resident 1 further stated that the food tastes bad when the food is served cold. Who can eat that, it's terrible. During an interview on 12/12/2024 at 1:28 PM, Staff C stated, I do get a lot of complaints about cold food, the residents have been sliding notes under my office door about the food being cold and not tasting good. I have to serve their meals in those plastic containers, and they don't help to hold the heat and keep the food warm. During an interview on 01/06/2025 at 5:45 PM with Staff B, Director of Nursing Services, stated that my expectation is that we would serve food for the residents that they could eat, at the right temperatures. Reference: (WAC) 388-97-1100 (2) .

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to have a boiler that consistently supplied hot water to the kitchen sink for dishwashing for 1 of 1 kitchen, reviewed for essential equipment. This failed practice caused the meals to be served from plastic containers that did not keep the meals at proper temperatures when served to residents and had the potential to cause weight loss and a diminished quality of life. Findings included . During a joint observation on 12/12/2024 at 12:21 PM with Staff C, Dietary Manager and Staff D, Corporate Dietary Manager, showed a small white sink was observed in the kitchen with a white tube (approximately six feet long) taped with gray (duck) tape around the faucet fixture that held the tube to the faucet fixture. In an interview on 12/12/2024 at 12:24 PM Staff C, stated it was the only sink in the kitchen that had hot water to wash the pots, pans, and trays that held the plastic containers with meals for the residents. Staff C stated the dietary staff put the end of the white tube into a large pan, filled the pan with hot water and poured the hot water from the pan into the kitchen sink and used the hot water to wash pots, pans, and meal trays. Staff C stated that they used a lot of time doing this, going back and forth getting hot water from this small sink with large pots and going over to the larger sinks and pouring the water into the sinks to wash the pots and pans. We could not do this for all the dishes, it would take too much time, and we did not have enough staff to do that. Staff C further stated that it was the reason why they were using the plastic food containers to serve the residents' meals. In an interview on 12/12/2024 at 2:17 PM, Staff C stated that based on their handwriting on the dish machine form, they stopped getting hot water [because the boiler was not working] to use for the dishes right after lunch on 12/03/2024 and they notified the Administrator [Staff A] the same day. In an interview on 12/12/2024 at 2:21 PM with Staff D, stated, that they knew about the hot water not working on 12/06/2024, and stated, it was unfortunate because it affects the operations of the kitchen in their time and efficiency. Staff C stated that it affected the residents' meals. Staff C further stated that their expectation was that the hot water would be fixed and turned back on. In an interview on 12/12/2024 at 2:46 PM with Staff E, Maintenance, stated that the boiler stopped working on 12/03/2024, and it started working again around 12/08/2024 after a vendor came and worked on it, then went back out again. Staff E stated they were aware staff were filling up pots of hot water from the small sink, transporting it to the large sink to wash pots, pans and things like that. Staff E stated they were temping the hot water they use and was afraid for the amount they need, and it just might stop working. Staff E further stated that it should be replaced on 12/17/2024 and that residents would need to eat from the plastic meal containers until they could get it fixed. Review of a form titled, Dish Machine Log dated December of 2024, showed the log had not been used since 12/03/2024 at lunch and a handwritten note no hot water with lines drawn from 12/03/2024 downward. Review of an undated Summary Report form showed that on 12/03/2024 at 12:15 PM there were reports of an odd smell outside of the facility, the same day at 12:30 PM to 12:45 PM an investigation was conducted, and the city was called to investigate. At 1:50 PM, the city identified a leak and turned the boiler off, they put red tags on the boiler so that it could not be used. The summary report showed that on 12/04/2024 and on 12/05/2024, a repair technician was on site and quotes were submitted for replacement, and on 12/08/2024 the technician was called back for low temperature reports. Further review showed that on 12/09/2024 the boilers were shut down again until 12/18/2024 when they were installed. In an interview on 01/06/2025 at 5:34 PM Staff A, stated, this was not acceptable, it was not good. We needed to get it [boiler] fixed sooner. Reference: (WAC) 388-97-1100 (2) .

Feb 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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED ARE IN BOLD. Based on observation, interview, and record review, the facility failed to take timely action and/or document the reason for delayed dental treatment for 1 of 3 residents (Resident 1), reviewed for dental care services. The failure to provide timely dental care services placed the resident at risk for dental pain, decline in nutritional status, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set assessment (MDS - an assessment tool) dated 01/24/2024 showed the resident readmitted to the facility on [DATE]. The MDS assessment showed the resident had intact memory. On 02/06/2024 at 2:42 PM, Resident 1 stated, I don't have any teeth and when the food hits my gums it hurts, so I don't eat very much because I can't. I drink the milk shakes to keep from losing too much weight, it's not as bad as when I try to chew food. I just need some dentures, even soft foods hurt to chew. I was supposed to get dentures a long time ago. I don't know what happened. Observation on 02/06/2024 at 2:47 PM, showed Resident 1 had missing teeth in the front of their mouth and had dark brown teeth that were embedded in their gums in the back of their mouth. Observation on 02/28/2024 at 1: 41 PM, showed a meal tray that had a piece uncut meatloaf and white mashed potatoes. Resident 1 stated, I can't eat the meat loaf, but I tried to eat a little bit of the mashed potatoes. Review of a dental form dated 11/08/2023, showed Resident 1 was seen by a dentist in the facility. The form noted that Resident 1 had decayed (cavities) loose, missing, and broken teeth, and it documented that Resident 1 stated, their teeth hurt when they eat and would like dentures. Further review of the form showed a referral for x-rays (photographic images), evaluation, extraction of all upper and lower teeth, and for upper and lower dentures. Review of the weight record dated 11/02/2023, showed Resident 1's weight was 108.6 pounds; on 02/01/2024, the resident's weight was 100.4 pounds, and on 02/20/2024, the resident's weight was 99.6 pounds. Review of an Interdisciplinary Team (IDT) note dated 02/21/2024, showed Resident 1 had their food cut up at meals, usually consumed 25-50 percent of meals and received health shakes three times a day. The IDT note showed Resident 1 had a significant weight loss of 8.3 percent in the last two months, and usually drank 100 percent of supplements (health shakes). The IDT consisted of Staff B, Assistant Director of Nursing, Staff C, Resident Care Manager, and Staff D, Registered Dietician, when this note was documented in the electronic medical record on 02/21/2024. On 02/28/2024 at 4:26 PM, Staff B Registered Nurse, stated the dentist would give the completed referral form to nursing or to the social services department, and then the nursing or social services would follow-up on the referral, and make the necessary appointments. At that time, Staff B was not able to find documented follow-up or appointments for the referrals made by the dentist on 11/08/2023 for x-rays, evaluations, teeth extractions and/or dentures for Resident 1. On 02/28/2024 at 4:46 PM, Staff A, Administrator, stated the dentist would give the referral forms to the social services or the nursing department to follow up on, and the expectation was for the referrals to be followed up on and the information should be placed in the electronic medical record. Staff B further stated that the referral for Resident 1 should have been followed up on and placed in the electronic medical record. Reference: (WAC) 388-97-1060 (3)(vii) .

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide meals that accommodated resident food allergies and preferences for 1 of 2 residents (Resident 1), reviewed for food allergies/preferences. This failure placed the resident at risk for allergic reaction, dissatisfaction with food, weight loss, and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 08/28/2023 showed Resident 1 was cognitively intact and received therapeutic diet. Review of Resident 1's allergy record dated 08/22/2023 showed Resident 1 was allergic to egg white that could cause an anaphylactic reaction (or anaphylactic shock is a severe, potentially life-threatening allergic reaction that can develop rapidly, signs include itchy skin or a raised, red skin rash, swollen eyes, lips, hands, and feet). Review of the progress notes dated 10/11/2023 at 5:18 PM, showed Staff C, Registered Dietitian, stated that the resident could drink lactose free milk though preferred not to drink milk at all, and would have swelling and itchiness with intake of dairy and eggs. Further review of the progress notes showed Staff C reviewed common food items to be excluded such as cheese, mayo, cookies, and pudding, and the resident expressed understanding that those foods contained dairy and/or eggs. Staff C also noted that they confirmed with the resident that pasta did not contain eggs unless they were egg noodles and that they updated the meal tray ticket to reflect no dairy and no eggs. An interview on 10/10/2023 at 12:08 PM, Resident 1 stated they were allergic to egg white and dairy products. When asked about their food allergy, Resident 1 stated if they consumed egg white and dairy products, they would experience anaphylactic reaction. Resident 1 also stated that they told several dietary aides, and Certified Nursing Assistants (CNAs) about their food allergies and they continued to serve food like egg noodle, macaroni and cheese, milk, scrambled eggs, including cold cereal that they did not like. Review of Resident 1's meal tray tickets showed the following: - Breakfast meal dated 09/30/2023, showed scrambled eggs and an eight ounce (oz) of milk were served. - Breakfast meal dated 10/01/2023, showed an eight oz of milk was served, - Lunch meal dated 10/19/2023, showed buttered macaroni noodles was served. - Breakfast meal dated 10/20/2023, showed cold cereal was served. - Breakfast meal dated 10/25/2023, showed cold cereal was served. An interview on 10/10/2023 at 1:00 PM with Staff C, stated that Resident 1 should not be served foods they were allergic to. Joint record review of Resident 1's meal tray tickets showed milk and egg noodles were served to the resident. Staff C stated that it was a mistake, and that Resident 1 should not have been served dairy or eggs products due to their food allergies. An interview on 10/21/2023 at 1:12 PM, Staff D, Division Dietary Manager, was asked if butter macaroni noodles and scrambled eggs contained egg whites, Staff D stated yes. When asked about Resident 1 and the meals they were served, Staff D stated that food containing egg whites and dairy products should not have been served to Resident 1 because they were allergic to these foods. An interview on 10/21/2023 at 1:11 PM, Staff F, CNA, stated that when passing the breakfast meal tray that morning, Resident 1 stated they did not want cold cereals but preferred hot oatmeal, Staff F stated that they went and told the kitchen staff. An interview on 10/21/2023 at 2:30 PM with Staff B, Director of Nursing, stated that if the resident was allergic to certain food, they should not serve it. Staff B also stated that the resident should be served according to their food preferences, and if it was not available in the menu, a substitute meal should be offered. Joint record review of Resident 1's meal tray tickets showed Resident 1 were served dairy and food containing egg white. Staff B stated that it should not have happened because of the resident's food allergies. Reference: (WAC) 388-97- 1100 (1) .

Sept 2023 17 deficiencies

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure damaged wheelchair armrests were repaired and/or replaced for 1 of 1 Resident (Resident 17), reviewed for comfortable/safe equipment use. This failure placed the resident at risk for unsafe equipment, potential injury, and a diminished quality of life. Finding included . Resident 17 admitted to the facility on [DATE] with diagnosis that included dependence on wheelchair. Review of Resident 17's quarterly MDS (an assessment tool) dated 06/20/2023, showed Resident 17 was using a wheelchair as a mobility device. Observations on 09/10/2023 at 12:41 PM, and on 09/11/2023 at 12:46 PM, showed Resident 17 was sitting in their manual wheelchair. Further observation showed the wheelchair's protective cover for both arm rest were ripped/missing, and the sponges were exposed. On 09/11/2023 at 12:50 PM, Resident 17 stated their wheelchair arm rest protective cover had been ripped/broken for a while and that they would like to have their wheelchair arm rests repaired or replaced. On 09/12/2023 at 10:01 AM, Staff W, Director of Plant Operations, stated that maintenance staff oversaw maintaining and repairing manual wheelchairs. On 09/12/2023 at 11:10 AM, joint observation with Staff W, showed Resident 17's wheelchair arm rests' cover were both ripped/missing, and the sponges were exposed. Staff W stated they were not notified about the wheelchair's condition and stated that the wheelchair arm rests should have been replaced. On 09/13/2023 at 9:38 AM, Staff A, Administrator, stated the facility's maintenance personnel should maintain/repair residents' manual wheelchairs. Reference: (WAC) 388-97-0880 (1)(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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written transfer/discharge notices to the resident and/or the resident's representative and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents) describing the reason for transfer for 1 of 3 residents (Resident 42) reviewed for hospitalization. This failure placed the residents at risk of not having the opportunity to make informed decisions about transfers and access to an advocate who informed residents about options and resident rights. Findings included . Review of the facility's policy titled, Transfer or Discharge Notice revised in March 2021, showed that if an immediate transfer or discharge is required by the resident's urgent medical needs, the transfer or discharge notice is given to the resident and representative as soon as it is practicable but before the transfer or discharge. The policy also showed that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and their representative. Resident 42 admitted to the facility on [DATE]. Review of the electronic progress notes dated 05/15/2023 showed, Resident 42 transferred to the hospital for not feeling well. The Electronic Health Record (EHR) did not show documentation that a written notice of transfer and discharge was provided to Resident 42, their representative, and to the Office of the State Long-Term Care Ombudsman. Review of the electronic progress notes dated 07/11/2023 showed, Resident 42 transferred to the hospital for possible pneumonia (infection of the lungs). The EHR did not show documentation that a written notice of transfer and discharge was provided to Resident 42, their representative, and to the Office of the State Long-Term Care Ombudsman. Review of the electronic progress notes dated 08/23/2023 showed, Resident 42 transferred to the hospital due to pain and weakness. The EHR did not show documentation that a written notice of transfer and discharge was provided to Resident 42, their representative, and to the Office of the State Long-Term Care Ombudsman. Review of the electronic progress notes dated 08/28/2023 showed, Resident 42 transferred to the hospital due to shortness of breath. The EHR did not show documentation that a written notice of transfer and discharge was provided to Resident 42, their representative, and to the Office of the State Long-Term Care Ombudsman. On 09/13/2023 at 9:24 AM, Staff E, Social Services Director (SSD), stated they were responsible of sending copy of the notice to the Office of the State Long-Term Care Ombudsman. Staff E also stated that they were not sure if Residents 42's discharge notices were sent to the Office of the State Long-Term Care Ombudsman. On 09/13/2023 at 9:49 AM, Staff B, Assistant Director of Nursing, stated the notice of transfer and discharge was initiated by the nurse in charge of transferring the resident and the facility's admission Coordinator, and then the SSD would follow-up. On 09/13/2023 at 11:29 AM, Staff A, Administrator, stated that a written transfer/discharge notices should be provided at the time discharge/transfer and should be documented in the resident's record. Reference: (WAC) 388-97-0120 (2)(a)(b)(c) .

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 59 Resident 59 admitted to the facility on [DATE]. Review of the EHR showed, Resident 59 was sent to the hospital on [DATE] due to right shoulder bruising and swelling. Further review of the EHR showed, no indication that a written bed hold notification was provided to Resident 59 and/or their representative. On 09/13/2023 at 8:52 AM, Staff B stated, Notice of bed hold is being initiated by nursing and followed up by the Business Office Manager [BOM]. A joint record review with Staff B showed, no written bed hold notification was provided to Resident 59 and/or their representative at the time of transfer. On 09/13/2023 at 9:35 AM, Staff X, BOM, stated, Notice of bed hold should be given to the resident or their family at the time of discharge or transfer. And if they were not able to receive it at that time, we do follow up or send the letter to them. Staff X further stated that no follow up was done and no written bed hold notification was sent to Resident 59 and/or their representative. RESIDENT 86 Resident 86 admitted to the facility on [DATE]. Review of the EHR showed, Resident 86 was sent to the hospital on [DATE] for further evaluation related to a fall. Further review of the EHR showed, no indication that a written bed hold notification was provided to Resident 86 and/or their representative. On 09/13/2023 at 8:52 AM, Staff B stated, Notice of bed hold is being initiated by nursing and followed up by the BOM. A joint record review with Staff B showed, no written bed hold notification was provided to Resident 86 and/or their representative at the time of transfer. On 09/13/2023 at 9:35 AM, Staff X stated, Notice of bed hold should be given to the resident or their family at the time of discharge or transfer. And if they were not able to receive it at that time, we do follow up or send the letter to them. Staff X further stated that no follow up was done and no written bed hold notification was sent to Resident 86 or their representative. Reference: (WAC) 388-97-0120 (4)(a)(b)(c) Based on interview and record review, the facility failed to ensure bed hold notices were provided at the time of transfer for 3 of 3 residents (Residents 42, 59 and 86) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed-Holds and Returns, revised in March 2022, showed that all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours). RESIDENT 42 Resident 42 admitted to the facility on [DATE]. Review of Resident 42's electronic progress notes dated 07/11/2023, showed Resident 42 transferred to the hospital for possible pneumonia (infection of the lungs). The electronic Health Record (EHR) did not show documentation that a written bed hold notification was provided to Resident 42 and/or their representative. Further review of the progress notes dated 08/28/2023 showed, Resident 42 transferred to the hospital due to shortness of breath. The EHR did not show documentation that a written bed hold notification was provided to Resident 42 and/or their representative. On 09/13/2023 at 9:49 AM, Staff B, Assistant Director of Nursing, stated that bed hold notification was initiated by the nurse in charge of transferring the resident, the facility's admission Coordinator, and then the Social Services Director would follow-up. On 09/13/2023 at 11:29 AM, Staff A, Administrator, stated a written bed hold notification should be provided on discharge, and should be documented in the resident's record.

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

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 admission assessments were completed within 14 days of admission for 2 of 15 residents (Residents 86 & 199), reviewed for comprehensive assessments. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, revised October 2019, showed the RAI process stated that the MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the Care Area Assessments (CAAs) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than day 14. RESIDENT 86 Resident 86 admitted to the facility on [DATE]. Review of Resident 86's admission MDS dated [DATE], showed it was completed on 08/21/2023, four days late. The admission MDS should be completed within 14 days, as required. RESIDENT 199 Resident 199 admitted to the facility on [DATE]. Review of Resident 199's admission MDS dated [DATE], showed it was completed on 09/07/2023, three days late. The admission MDS should be completed within 14 days, as required. On 09/12/2023 at 3:20 PM, Staff C acknowledged that the admission MDS assessments for Resident 86 and Resident 199 were completed late and that they should have been completed within 14 days of admission. Reference: (WAC) 388-97-1000 (5)(a) .

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 interview and record review, the facility failed to ensure a Significant Change in Status Assessment was conducted after the determination that hospice (end of life care) services no longer required for 1 of 1 resident (Resident 38), reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, revised October 2019, showed that a significant change in status assessment is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The Assessment Reference Date must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. RESIDENT 38 Resident 38 admitted to the facility on [DATE]. Review of Resident 38's admission Minimum Data Set (MDS - an assessment tool) dated 06/22/2023, showed Resident 38 was receiving hospice services. On 09/10/2023 at 7:20 AM, Resident 38 stated they were taken off hospice services about one month ago. Review of Resident 38's clinical progress notes dated 08/24/2023, showed Resident 38 was discharged from hospice services on 08/24/2023. Review of Resident 38's MDS tracking list showed no significant change MDS assessment was completed within 14 days after the resident discharged from hospice services. On 09/12/2023 at 2:59 PM, Staff C, MDS Coordinator stated that a significant change MDS should have been completed after Resident 38 came off hospice services. Reference: (WAC) 388-97-1000 (3)(b) .

CONCERN (D)

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

MDS Data Transmission (Tag F0640)

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 complete and transmit resident assessment data according to the required timeframe for 1 of 3 residents (Resident 42), reviewed for timeliness in completing and transmitting discharge tracking records. This failure placed the resident at risk of unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, revised October 2019, showed Discharge Minimum Data Set (MDS) assessments must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500B + 14 days) to the database as required. Resident 42 admitted to the facility on [DATE]. Review of a progress note dated on 08/28/2023, showed Resident 42 discharged to the hospital. Review of Resident 42's MDS assessments, showed no discharge MDS was created and completed for the discharge date of 08/28/2023. On 09/13/2023 at 9:33 AM, joint record review and interview with Staff C, MDS Coordinator, showed Resident 42 discharged on 08/28/2023 and no discharge MDS was completed for it. Staff C stated the facility followed the RAI Manual as their policy for completion of MDS assessments. Staff B acknowledged that no discharge MDS was completed for Resident 42 and stated that it should have been completed. Reference: (WAC) 388-97-1000 (5)(a)(e)(iii) .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 3 of 24 residents (Residents 29, 38 & 77) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding participation of assessment/goal setting (Section Q) and Brief Interview for Mental Status (BIM - to assess cognitive patterns) placed the residents at risk for unidentified or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, showed Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). RESIDENT 29 Resident 29 admitted to the facility on [DATE]. Review of the annual MDS assessment dated [DATE], showed Resident 29's participated in their assessment. Further review of the annual MDS, showed the Brief Interview for Mental Status (BIMS) was not conducted during this assessment period. RESIDENT 38 Resident 38 admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE], showed Resident 38's participated in their assessment. Further review of the admission MDS showed Resident 38's did not have the BIMS completed during this assessment period. RESIDENT 77 Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's quarterly MDS dated [DATE], showed the resident did not have the BIMS completed during this assessment period. On 09/12/2023 at 2:59 PM, Staff C, MDS Coordinator, stated that Resident 29 and Resident 38 did not participate in their assessments [Section Q] and the section that addressed their cognitive status [Section C for Residents 29, 38 & 77] were not completed because there was no Social Services hired at that time. Staff C confirmed the assessments were inaccurate. Staff C stated they worked remotely and did not do a face-to-face assessment on each residents and that they relied on doctor notes, long-term care staff, nursing documents, and hospital records. Staff C further stated that MDS assessments needed to be accurate since the MDS directs the care of the residents. On 09/13/2023 at 9:59 AM, Staff B, Assistant Director of Nursing, stated they were not aware that the section for cognition were not completed, and that cognitive status interviews were to be completed by either Social Services or Speech Therapist. Staff B further stated that it was their expectation for the MDS to be accurate. Reference: (WAC) 388-97-1000 (1)(b) .

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

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 baseline care plan was completed within 48 hours of admission and ensure a summary of the baseline was provided to the resident and/or their representative for 1 of 15 residents (Resident 199), reviewed for baseline care plan. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Resident 199 admitted to the facility on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE], showed the resident was cognitively intact. Review of the Post admission Patient [resident]-Family Conference form dated 09/10/2023, showed Section E (copy given to resident and/or their representative) was not marked or checked. Further review of the clinical records showed no information that a written summary of the 48-hour baseline care plan was provided to Resident 199 and/or their representative. On 09/10/2023 at 11:46 AM, Resident 199 stated that the facility did not provide them a written summary of baseline care plan since the time of admission. On 09/12/2023 at 1:15 PM, an interview and a joint record review of Resident 199's clinical records with Staff B, Assistant Director of Nursing, and Staff G, Corporate Nurse, showed a written summary of the 48-hour baseline care plan was not provided to Resident 199. Staff G stated that a copy of the baseline care plan would be provided to the resident. Reference: (WAC) 388-97-1020 (3) .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were developed for 1 of 24 residents (Resident 199), reviewed for comprehensive care plans. The failure to develop care plans for skin conditions and use of a Continuous Positive Airway Pressure (CPAP, a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing) machine placed the resident at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Skin Integrity Management, dated 05/26/2021, showed develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. Review of the facility's policy titled, Care Planning-Interdisciplinary Team, dated 08/25/2021, showed that a comprehensive care plan for each resident is developed within seven (7) days of the completion of the comprehensive assessment. The care plan is based on the resident's comprehensive assessment and is developed by an Interdisciplinary Team which includes but is not necessarily limited to the following personnel. Resident 199 admitted to the facility on [DATE]. SKIN CONDITION Review of Resident 199's admission Minimum Data Set (MDS- an assessment tool), dated 08/28/2023, showed that Resident 199 had Moisture Associated Skin Damage (MASD - skin erosion caused by prolonged exposure to urine, feces, sweat, wound drainage, saliva, or mucus). Review of the Nursing Documentation Evaluation dated 08/22/2023, showed in Section P (Skin Integrity), Resident 199 had MASD to peri-area [surrounding the private areas] and upper thighs chafing [rubbing] from briefs/incontinence. 1x1 [1.0 x 1.0, did not document if it was centimeter or inches] blanchable [skin that losses redness with pressure] redness to coccyx [tail bone]. Denies discomfort. Dressing in place to prevent pressure from forming. Review of the Body Check dated 09/09/2023, showed Resident 199 has an open wound in between her thighs about the size of a nickel. No signs of bleeding or drainage. The area is cleaned and covered. Review of Resident 199's comprehensive care plan printed on 09/12/2023, showed no care plans were initiated for the upper thigh chafing, MASD to peri-area, and blanchable redness to coccyx. On 09/12/2023 at 9:26 AM, joint observation of Resident 199's left inner thigh/groin area, showed a white 1.0 x 1.0 (one-inch square diameter) gauze dressing. Resident 199 stated that one of the staff did their wound dressing. On 09/12/2023 at 9:28 AM, a joint record review and interview with Staff Y, Licensed Practical Nurse, showed Resident 199's had MASD, blanchable redness to coccyx and open wound to their thigh/groin area. Staff Y stated they were not care planned. CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Review of the August 2023 Treatment Administration Record showed Resident 199 had been using a CPAP machine since admission. Review of Resident 199's admission MDS assessment dated [DATE], showed use of the CPAP machine was coded. Review of Resident 199's comprehensive care plan printed on 09/12/2023, showed no care plan was initiated for the use of CPAP machine. On 09/12/2023 at 9:28 AM, a joint record review of Resident 199's clinical records with Staff Y, showed Resident 199's use of CPAP machine was not care planned. Staff Y stated it was not care planned. On 09/12/2023 at 10:38 AM, a joint record review and interview of Resident 199's clinical records with Staff B, Assistant Director of Nursing, showed Resident 199's skin conditions and use of CPAP machine were not care planned. Staff B acknowledged that Resident 199 had no care plans for their skin condition and use of CPAP. Reference: (WAC) 388-97-1020 (1)

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 interview and record review, the facility failed to ensure residents and/or their representatives were invited to participate in care plan meetings/care conferences for 3 of 6 residents (Residents 29, 45 and 50), reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plan Comprehensive, dated 08/25/2021, showed the . Interdisciplinary Team is responsible for evaluation and updating of care plans . At least quarterly .The resident has the right to refuse to participate in the development of [their] care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies . RESIDENT 29 Resident 29 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 29's was cognitively intact. On 09/10/2023 at 8:01 AM, Resident 29 stated they did not get invited to their care conferences on a quarterly basis. RESIDENT 45 Resident 45 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 45 was cognitively intact. On 09/10/2023 at 7:36 AM, Resident 45 stated they were not invited to their care conferences. RESIDENT 50 Resident 50 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 50 was cognitively intact. On 09/10/2023 at 6:50 AM, Resident 50 stated they were not sure if they were invited to their care conferences. On 09/11/2023 at 12:00 PM, Staff E, Social Services Director, stated that they typically invited family and residents to attend care conferences. On 09/12/2023 at 11:23 AM, Staff E acknowledged there was no documentation to support that the three residents [Residents 29, 45 & 50] and/or their representatives were invited to care conferences. Staff E stated there was no Social Services [in that position] during the residents' assessments. On 09/13/2023 at 9:59 AM, Staff B, Assistant Director of Nursing, stated their expectation would be that residents and/or their representatives would be invited to care conferences. Reference: (WAC) 388-97-1020 (2)(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

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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 showers/bathing were consistently provided for 2 of 4 residents (Residents 41 & 29), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident's Rights, revised in December 2021, showed Employees shall treat all residents with kindness, respect, and dignity . guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence .to be supported by the facility in exercising [their] rights . Review of the undated facility policy titled, Resident Self Determination and Participation, showed Our facility respects and promotes the right of each resident to exercise [their] autonomy regarding what the resident considers to be important facets of [their] life .Each resident is allowed to choose activities, and scheduled health care and healthcare providers, that are consistent with [their] interests, values, assessments, and plans of care, .exercise and bathing schedules. RESIDENT41 Resident 41 admitted to the facility on [DATE] with diagnosis that included right and left partial traumatic amputation (cut off a limb) at knee level. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 08/22/2023, showed Resident 41 was cognitively intact and extensive to total assist with activities of daily living (ADL) of one to two person. Review of the care plan initiated on 08/18/2023, showed Resident 41 was dependent for ADL care in bathing. Review of the shower log from 08/18/2023 until 09/12/2023, showed Resident 41 was scheduled for showers on Thursday. Further review of the shower log showed Resident 41 had not received a shower for the entire duration of their stay and had only received one bed-bath on 08/18/2023. Observation on 09/10/2023 at 6:40 AM, showed Resident 41 had visibly soiled [unwashed] hair. Interview with Resident 41 stated they had not received a shower the entire time they had been in the facility and had only received one bed-bath. Resident 41 further stated, I would love a shower, it will make me feel much better! Observation on 09/11/2023 at 8:58 AM, showed Resident 41 was wearing the same hospital gown from the previous day and had not been showered. On 09/11/2023 at 12:40 PM, Staff R, Certified Nursing Assistant (CNA), stated that all showers and bed baths were recorded in the Electronic Medical Record (EMR). Staff R further stated all residents were assigned a shower day. Staff R also stated that residents normally receive one shower per week but could request additional showers. On 09/11/2023 at 3:03 PM, Staff Q, Registered Nurse, stated that they were familiar with Resident 41 and that Resident 41 had no medical diagnosis or condition that would not allow them to receive showers. On 09/11/2023 at 3:07 PM, Staff F, CNA, stated that ADLs were documented in the EMR and that residents were showered at a minimum once per week. Staff F confirmed that residents were provided with scheduled showers unless they refused. Staff F was assigned to Resident 41 and could not confirm if they had been showered. On 09/11/2023 at 3:28 PM, Staff B, Assistant Director of Nursing, stated that the expectation of the facility staff was that all residents received assistance with their ADLs. Staff B also stated that Resident 41 had not received any showers per the EMR and as indicated by Resident 41. RESIDENT 29 Resident 29 admitted to the facility on [DATE] with a diagnosis of fracture of the sacrum (broken bone at the base of the spine). Review of the quarterly MDS dated [DATE], showed Resident 29 was cognitively intact. Review of the annual MDS dated [DATE], identified Resident 29's bathing, either in a tub, shower or a bed bath was very important to them. Additionally, the MDS showed the resident required two person extensive assist for bed mobility and was totally dependent on two staff for transfers. Review of Resident 29's care plan dated 06/23/2022, showed the resident required assistance for bathing. Review of Resident 29's undated [NAME] (CNA care plan that directs care for a resident) printed on 09/11/2023, showed the resident required extensive assistance of one staff member for bathing and their bath was to be completed each Monday and as needed. Review of Resident 29's EMR, showed a task for bathing dated 08/15/2023 through 09/08/2023, which showed the resident refused a bath/shower one time on 08/24/2023. The document showed the resident was not offered a bath/shower on the following Mondays: 08/21/2023, 08/28/2023, and 09/04/2023. On 09/10/2023 at 8:00 AM, Resident 29 stated there was no set schedule to receive a shower/bath and did not remember the last time they had been offered one. On 09/11/2023 at 3:28 PM, Staff B, Assistant Director of Nursing, stated that the expectation of the facility staff was that all residents received assistance with their ADLs. Reference: (WAC) 388-97-1060 (2)(c) .

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's policy titled, Skin Integrity Management, dated 05/26/2021, showed the facility will identify patient's [resident's] skin integrity status and need for prevention, intervention, or treatment modalities through review of all appropriate assessment information. Additionally, the policy showed the physician/advanced practice provider will be notified to obtain orders. RESIDENT 199 Resident 199 admitted to the facility on [DATE]. Review of Resident 199's Body Check assessment dated [DATE], showed the resident had an open wound in between their thighs about the size of a nickel. No signs of bleeding or drainage. The area is cleaned and covered. Review of Resident 199's comprehensive care plan printed on 09/12/2023, showed no care plans were initiated for the upper thigh chafing, MASD to peri-area, and blanchable redness to coccyx. On 09/10/2023 at 7:20 AM, Resident 199 stated, I have a wound on my left inner thigh. The staff placed dressing on it. Observation on 09/12/2023 at 9:26 AM, showed Resident 199 had a white 1.0 x 1.0 (one-inch square diameter) gauze dressing to their left inner thigh/groin area. Resident 199 stated that staff provided wound dressing treatment. On 09/12/2023 at 9:28 AM, an interview and joint record review of Resident 199's clinical records with Staff Y, Licensed Practical Nurse, showed no care plan, and no physician order for the left inner thigh wound. Staff Y stated they were not aware that Resident 199 had an open wound to their left inner thigh. On 09/12/2023 at 10:38 AM, a joint record review of Resident 199's clinical record, and an interview with Staff B, Assistant Director of Nursing, showed the physician was not notified to obtain orders for the left inner thigh wound. Staff B stated they expected staff to inform the physician to obtain orders for the wound, and care planned it. Reference: (WAC) 388-97-1060 (1)(3)(b)(h)(k) Based on interview and record review, the facility failed to ensure a nutritional recommendation for Vitamin D (or Cholecalciferol, a supplement) was implemented for 1 of 1 resident (Resident 50), reviewed for nutritional management. In addition, the facility failed to ensure necessary care/treatment in accordance with professional standards of practice was followed for 1 of 1 resident (Resident 199), reviewed for skin condition. These failures placed the residents at risk for decline in health status, medical complication, and a diminished quality of life. Findings included . Review of the facility's policy titled, Nutrition/Hydration Care and Services, revised on 02/01/2023, showed the facility will review the Dietitian (health professionals who are experts in diet and nutrition) recommendations and obtain orders per recommendations. Additionally, it showed that the facility will contact the physician/advanced practice provider to convey the recommendations. RESIDENT 50 Resident 50 admitted to the facility on [DATE] with a diagnosis of orthostatic hypotension (low blood pressure that happens when standing after sitting or lying down). Review of Resident 50's quarterly Minimum Data Set (MDS - an assessment tool) dated 08/15/2023, showed the resident was cognitively intact. Review of Resident 50's Activities of Daily Living (ADL) care plan dated 04/27/2023, showed Resident 50 was at risk for decreased ability to perform ADL. Resident 50's ADL care plan intervention included notifying the physician/mid-level practitioner of abnormal laboratory test results. Review of Resident 50's Vitamin D laboratory test dated (collection date) 05/01/2023, showed it was flagged/marked as low (may develop soft weak, or brittle bones). Review of Resident 50's Nutritional assessment dated [DATE], showed Staff J, Registered Dietician, recommended Cholecalciferol 2000 units daily due to low levels of Vitamin D. Review of Resident 50's May 2023 Medication Administration Record did not show an order for Vitamin D supplement. Review of Resident 50's Nutritional assessment dated [DATE], did not show Staff J's recommendation of a Vitamin D supplement to address resident's low Vitamin D level. On 09/12/2023 at 9:45 AM, Staff J stated that when they complete nutritional assessments, they interview the resident, review the resident's medical history including hospital records to decide if they would make recommendations. Staff J stated any recommendations that they made were then sent to the Director of Nursing or the Resident Care Manager, and they would go back to verify if the recommendations were put in place. Staff J checked and confirmed that Resident 50's recommendation to receive Vitamin D supplement was not carried forward. On 09/13/2023 at 8:46 AM, Staff T, Nurse Practitioner, confirmed receiving an email from Staff J on 05/09/2023 and did not respond to Staff J's initial recommendation for a Vitamin D supplement for Resident 50.

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 supervision was provided for a safe use of e-cigarette (electronic cigarette) 1 of 1 resident (Resident 30), reviewed for e-cigarette/smoking management. This failure placed the resident at risk for burns, and avoidable accidents or fire. Findings included . Review of the U.S. Food & Drug Administration (FDA), dated 09/17/2021, showed to charge the vape on a clean, flat surface, away from anything that can easily catch fire and someplace they can clearly see it-not a couch or pillow where it is more prone to overheating or get turned on accidentally. Protect the vape from extreme temperatures by not leaving it in direct sunlight or in your car on a freezing cold night. Review of the facility's policy titled, Smoking, dated 08/09/2022, showed .Electronic Nicotine Delivery Systems (e-cigarettes) are products shaped like cigarettes, cigars or pipes that are designed to deliver nicotine or other substances to a user in the form of a vapor that is inhaled .smoking by residents is allowed outside the facility in designated, marked smoking areas with the following measures readily available . Residents who choose to smoke shall be evaluated using the Safe Smoking Evaluation form .all residents determined to be safe or unsafe to smoke will be supervised by a smoking aide . The resident shall obtain [their] smoking materials from the smoking cart and proceed to the designated smoking area during designated smoking times with the smoking aide. The policy failed to address the use of rechargeable e-cigarettes, which poses a potential accident hazard. Resident 30 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of the left hand. Review of the annual Minimum Data Set (an assessment tool) dated 04/28/2023, showed Resident 30's was cognitively intact. Review of Resident 30's Smoking Care Plan dated 11/11/2022, showed that the resident had potential for injury from smoking, potential for cravings of nicotine, and the resident will smoke cigarettes or vape pens in the appropriate smoking area. Review of the Safe Smoking Evaluation dated 11/11/2022, showed Resident 30 was unsafe to smoke unsupervised. On 09/10/2023 at 10:04 AM, Resident 30 stated that staff were aware that they used their vape device while in their room. Resident 30 further stated that they use their computer to charge their vape. On 09/10/2023 at 10:16 AM, Resident 30 was observed vaping while lying in their bed. There were 10 to 15 used vaping cartridges on Resident 30's bedside table. On 09/11/2023 at 8:53 AM, Resident 30 was observed lying in their bed vaping. On 09/11/2023 at 9:13 AM, Staff O, Certified Nursing Assistant, stated residents were only allowed to smoke/vape in the designated smoking areas under supervision. On 09/11/2023 at 1:38 PM, Staff P, Registered Nurse (RN), stated residents could only smoke in designated smoking areas, during designated smoking times, and with a smoking aide present. Staff P further stated there was no smoking in the facility and all cigarettes and vapes were locked in the smoking cart. On 09/11/2023 at 2:06 PM, Staff Q, RN, stated that there was no smoking or vaping in the facility or in residents' room. Additionally, Staff Q stated that residents were to smoke in designated smoking areas during the designated smoking times. When asked about Resident 30 smoking in their room. Staff Q stated, We have to tell [Resident 30] every day [they] cannot vape in [their] room. On 09/11/2023 at 2:21 PM, Staff A, Administrator, stated that the facility was a non-smoking facility and that there were currently 14 residents who smoke. Staff A stated that residents who smoke were assessed at admission, quarterly, and when there was a significant change in status. Staff A also stated that all residents deemed safe or unsafe were supervised by the smoking aide and were only allowed to smoke during designated smoking times. Staff A further stated there was no smoking in the facility or in residents' room and that all smoking paraphernalia (equipment that is used in or necessary for smoking) was locked in the smoking cart. Staff A stated they were not aware that Resident 30 had been vaping in their room. Reference: (WAC) 388-97-1060 (3)(g) .

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** Based on observation, interview and record review, the facility failed to ensure weekly weights were conducted for the first four weeks of admission to determine a baseline weight and failed to ensure nutritional supplements (health shake) at each meal was served for 1 of 1 resident (Resident 50) reviewed for nutritional management. This failure placed the resident at risk for significant weight loss, medical complications, and a diminished quality of life. Findings included . Review of the facility policy titled, Weight Management dated 08/25/2021, showed . weights will be obtained weekly for 4 weeks after admission .Notification of attending physician by nursing staff. The dietetics professional (experts in diet and nutrition) will assess the resident, document the assessment, and make recommendations in the resident's medical record. Orders may be obtained for nutritional supplements or other interventions. Resident 50 admitted to the facility on [DATE] with a diagnosis of failure to thrive. Review of the physician orders dated 04/27/2023, indicated Resident 50 was ordered a nutritional health shake three times a day in addition to a regular diet. Review of Resident 50's care plan dated 05/09/2023 showed, nutritional risk with a diagnosis of failure to thrive. Review of the quarterly Minimum Data Set, dated [DATE], showed Resident 50 was cognitively intact. Review of the admission Dietary Assessment, dated 05/02/2023, showed Staff J, Registered Dietitian, stated Resident 50's admit height was 76 inches and the weight were 165.6 pounds (lbs.) Resident 50's Body Mass Index (BMI - measure of adequacy of weight to height)) was at 20.2, in normal range, no known food allergies. Staff J visited resident in room. Resident 50 has had a 40 lb. weight loss in the past eight to nine months. Resident 50 stated that they had been very constipated and did not want to eat solids until they had a bowel movement. Resident 50 was willing to consume health shake three times per day at meals (vanilla or strawberry flavor). Staff J encouraged by mouth (PO) and fluid intake with resident. Review of Resident 50's electronic health record showed the following weights on: - 04/27/2023 weighed 165.6 lbs. - 05/27/2023 weighed 163.4 lbs. - 06/05/2023 weighted 129.8 lbs. - 06/15/2023 weighed 157.2 lbs. - 06/27/2023 weighed 159.4 lbs. - 07/26/2023 weighed 158.6 lbs. - 08/2/2023 weighed 159.8 lbs. - 08/26/2023 weighed 159.4 lbs. - 09/01/2023 weighed 156.0 lbs. On 09/10/2023 at 6:53 AM, Resident 50 stated they had not received health shakes for the past month due to the facility being out. Observation on 09/10/2023 at 8:40 AM, showed Resident 50's breakfast tray had no carton of nutritional shake. Resident 50 then produced their meal ticket and it stated for the resident to have a nutritional shake to be served with each meal. At 1:33 PM, Resident 50 was observed again without a nutritional shake on their lunch tray. Observation on 09/11/2023 at 8:37 AM, showed Resident 50's breakfast tray was served without a nutritional shake. On 09/12/2023 at 9:45 AM, Staff J stated Resident 50 was at mild nutritional risk and confirmed that nursing did not weigh Resident 50 during the first four weeks of their stay. Staff J stated weekly weights for a new resident was to be done for the first four weeks to determine a baseline weight. On 09/12/2023 at 11:29 AM, Staff D, Dietary Manager, stated Resident 50 had frozen nutritional shakes in the kitchen freezer. On 09/13/2023 at 9:59 AM, Staff B, Assistant Director of Nursing, stated the kitchen was to provide Resident 50 with the nutritional shakes and it was their expectation that weekly weights were to be competed weekly for the first four weeks after an admission. Reference: (WAC) 388-97 1060 (3)(h) .

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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Based on interview and record review, the facility failed to ensure grievances were initiated, logged, addressed, and resolved timely in response to concerns for 4 of 6 residents (Residents 9, 33, 19 & 22), reviewed for grievances. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the undated facility policy titled, Resident Council, showed that the Resident council response form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of the July 2023 and August 2023 Resident Council Meeting Minutes, showed there were issues concerning not enough staff and delayed call light response. RESIDENT 9 On 09/11/2023 at 2:00 PM, Resident 9 stated that during the January 2023 monthly council meeting, there were concerns about call lights not being answered in a timely manner. Resident 9 further stated that Staff S, Activity Director, was at the meeting and would take any concerns to the Administrator. However, the council members never received a follow-up. RESIDENT 33 On 09/12/2023 at 11:43 AM, Resident 33 stated that during the January 2023 council meeting, there were concerns about call lights not being answered in a timely manner and the request for more Certified Nurse Assistants (CNAs) on all shifts. Resident 33 further stated that the council members never received a response. RESIDENT 19 On 09/12/2023 at 1:10 PM, Resident 19 stated that at the January 2023 council meeting, concerns were raised about call lights not being answered in a timely manner and the request for more CNAs on all shifts. Resident 19 further stated that the council members never received a response. RESIDENT 22 On 09/12/2023 at 2:10 PM, Resident 22 stated that in January 2023 council meeting, there were concerns about call lights not being answered in a timely manner and the request for more CNAs on all shifts. Resident 22 further stated that the council members never received a response. On 09/13/2023 at 10:21 AM, Staff S stated they were aware of the Resident Council policy and should have followed-up with the residents about their staffing and call lights issues in January 2023. Reference: (WAC) 388-97-0460 (2) .

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure food were served at proper temperature for 8 of 8 residents (Residents 58, 38, 83, 44, 73, 56, 74 & 54), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included . Review of the undated facility policy titled, Food Preparation and Service, showed the . Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food distribution and services. RESIDENT 58 On 09/10/2023 at 7:02 AM, Resident 58 stated the food was cold. Review of Resident 58's annual Minimum Data Set (MDS - an assessment tool) dated 07/04/2023, indicated the resident was cognitively intact. RESIDENT 38 On 09/10/2023 at 7:22 AM, Resident 38 stated the food was not hot when served. Review of Resident 38's admission MDS dated [DATE], indicated the resident was alert and oriented. RESIDENT 83 On 09/10/2023 at 9:56 AM, Resident 83 stated the food was cold when it was to be hot. Review of Resident 83's admission MDS dated [DATE], indicated the resident was cognitively intact. RESIDENT 44 On 09/10/2023 at 10:19 AM, Resident 44 stated the food was not hot when served. Review of Resident 44's admission MDS dated [DATE], indicated the resident was cognitively intact. RESIDENT 73 On 09/10/2023 at 11:49 AM, Resident 73 stated the food was cold and not served on time. Review of Resident 73's quarterly MDS dated [DATE], indicated the resident was cognitively intact. RESIDENT 56 On 09/10/2023 at 11:23 AM, Resident 56 stated the food was cold. Review of the quarterly MDS dated [DATE] indicated a Brief Interview for Mental Status score of 9 out of 15, indicating Resident 56's cognition was moderately impaired. RESIDENT 74 On 09/10/2023 at 12:37 PM, Resident 74 stated the food was cold. Review of Resident 74's quarterly MDS dated [DATE], indicated the resident was cognitively intact. RESIDENT 54 On 09/10/2023 at 12:39 PM, Resident 54 stated the trays were left in the hallway and the food ends up being cold after it was served. Review of Resident 54's quarterly MDS dated [DATE], indicated the resident was cognitively intact. On 09/12/2023 at 11:59 AM, Staff N, Director of Operations, Staff U, Regional Dietary Supervisor, and Staff D, Dietary Manager, observed the tray line food temperatures being taken. Staff K, Cook, obtained the food temperatures, the chicken enchilada casserole was at 199 degrees Fahrenheit (F) and the Mexican corn was at 200 degrees F. At 12:42 PM, the test tray was placed on the top of a metal insulated cart and pushed out of the kitchen by Staff M, Dietary Aide. The test meal was in a disposable container. Meals were being served in disposable containers due to a potential disrepair of the facility's dish machine. At 12:43 PM, the insulated metal cart was delivered by Staff M to 500 A unit. Staff V, Certified Nursing Assistant, picked up the first meal from the cart at 12:47 PM. At 1:00 PM, the test meal was taken off the metal insulated cart by Staff U and placed on the nursing station counter. Staff U then took a digital thermometer and tested the chicken enchilada casserole, which read 134.6 degrees F and the Mexican Corn read 104.9 degrees F. Staff U, Staff N, and the surveyor, tasted the meal, and all confirmed the meal was not warm. Staff N stated the meal tasted good, but the cheese needed to be hotter. Reference: (WAC) 388-97-1100 (2) .

CONCERN (F)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff D) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . Review of the facility's policy titled, Dietician, dated 10/2017, showed . A qualified, competent, and skilled Dietician [health professionals who are experts in diet and nutrition] will help oversee the food and nutrition services of the facility. A qualified Dietician or other clinically qualified nutrition professional will help oversee food and nutrition services provided by the residents. If a dietician is not employed full time (35 or more hours per week) a director of food served management will be designated. This individual will. be a certified dietary manager. have an associate's (or higher) degree in food service management or hospitality. Receive frequent scheduled consultations from a qualified dietician or qualified nutrition professional. Review of the undated employee record (resume) showed Staff D, Dietary Manager (DM) had two years prior working experience as a DM in a long-term care facility. On 09/12/2023 at 9:45 AM, Staff J, Registered Dietician, confirmed they did not supervise Staff D and was a consultant only. On 09/12/2023 at 11:29 AM, Staff D confirmed they were not a certified DM and had no formal education in dietary services. Staff D stated they had been in their position for the past two months. Reference: (WAC) 388-97-1160 (2)(3)(a)(b)(i) .

Jul 2022 8 deficiencies

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to inform 1 of 3 residents (Resident 45) in writing, of their potential liability for payment, related to Medicare services ending. The failure to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), placed the residents and/or the resident representatives at risk for not having adequate information to making financial decisions, related to a continued stay in the facility. Findings included . Review of the Notice of Medicare Non-Coverage (NOMNC) form showed Resident 45's Medicare (national insurance) skilled nursing services ended on 04/25/2022. Additional record review showed the SNF ABN (to inform the resident of potential financial liability) and/or the uniform (insurance) denial letters was not issued or provided to the resident, as required. The resident remained in the facility after Medicare benefits ended. On 07/29/2022 at 3:18 PM, Staff A, Administrator, was asked if the SNF ABN form was provided to the resident/or the resident representative after Medicare services ended, Staff A stated no and that it should have been issued. The failure to notify the resident and/or the resident representative about the potential financial liability, placed the resident and/or the resident representative at risk for not having adequate information to make financial decisions, related to a continued stay in the facility. Reference: (WAC) 388-97-0300 (4)(a)(b)(c) .

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

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 conduct a comprehensive assessment of resident needs, strengths, goals, history, and preferences by completing all portions of the required Minimum Data Set (MDS) Assessment. Sections of the MDS, including assessments of the resident's cognitive status and/or mood status were not completed for 2 of 20 residents (Residents 36 and 91) whose assessments were reviewed. Findings included . Review of the electronic medical record (EMR) under the Census tab revealed Resident 36 was admitted on [DATE] with diagnoses including delusions, depression, and Alzheimer's Disease (a neurological disorder that causes problems with memory, thinking and behavior). Review of the annual MDS assessment dated [DATE] in the EMR under the MDS tab revealed the facility failed to complete Section C, which was the comprehensive assessment of the resident's cognitive status. Review of the EMR for Resident 91, under the Census tab revealed an admission date of 09/05/2018 with diagnoses including anxiety and depression. Review of Resident 91's annual MDS dated [DATE], revealed that Section C and Section D (mood and behavior patterns) were blank, indicating no assessment of the resident's cognition and/or mood status. Interview with the Social Services Director, Staff F on 07/29/2022 at 3:19 PM, confirmed the resident's MDS assessments were not complete. Interview with the Administrator, Staff F on 07/30/2022 at 9:30 AM, revealed the facility's MDS Nurse Assessment Coordinator worked off-site and had not been in the building since the Administrator started working, which was before 07/01/2022. The Administrator stated that the facility went several months without a Social Services Director, and no one had been assigned to do these parts of the MDS (Sections C and/or D) during that time. Staff A stated the facility lacked policies and procedures for the completion of the MDS resident assessments. Staff A confirmed the facility failed to use the MDS 3.0 Resident Assessment Instrument Manual to direct the completion of each assessment and assure a complete assessment of the resident's status. Reference: (WAC) 388-97-1000 (2)(c)(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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure activities of daily living (ADL) were maintained for 1 of 2 residents (Resident 66) reviewed for ADL care. The facility failed to assist Resident 66 with grooming, including nail care and facial hygiene. The facility's deficient practice had the potential to negatively affect Resident 66's dignity, comfort, and a diminished quality of life. Findings included . Review of the facility-provided policy titled, Activities of Daily Living, with a revision date of 06/01/2021, revealed The Center [facility] must provide the necessary care and services to ensure that a patient's [resident's] activities of daily living activities are maintained. Further review of the facility-provided policy titled, Shaving, dated 12/01/2006, revealed Shaving will be provided on a routine and as needed basis .To promote facial hygiene, dignity, and comfort. Review of Resident 66's Electronic Medical Record (EMR) under her Profile tab revealed Resident 66 was admitted to the facility on [DATE] with multiple diagnoses that included hemiparesis (weakness or inability to move on one side of the body) and altered mental status. Review of Resident 66's admission Minimum Data Set (MDS- a required assessment) dated 06/21/2022 revealed Resident 66 required extensive assistance with personal hygiene and was totally dependent on staff for bathing. A Brief Interview for Mental Status (BIMS) was not performed by the facility and no assessment was made of her cognition. Review of Resident 66's care plan (CP) initiated on 05/15/2022, revealed staff were to Provide resident with extensive assistance for personal hygiene (grooming). The CP did not include specific interventions related to either nail care or the shaving of facial hair. Further review of records showed the Visual Bedside [NAME] (overview of resident care) Report under the [NAME] tab in the EMR revealed no directives regarding Resident 66's nail care or shaving of Resident 66's face. On 07/27/2022 at 2:15 PM, Resident 66 was on her bed in her room. Resident 66 had multiple white hairs on her chin area below her right lower lip and a moderate amount of brown hair under her chin covering her upper neck and chin area. Resident 66's chin hairs were the length of an ink pen top, her fingernails were long, the nail polish was chipped, and there was a brownish-black grainy substance under her nails. On 07/29/2022 at 11:12 AM, Resident 66 was again observed with multiple gray hairs under the right side of her lip and a moderate number of brown hairs on her upper neck and chin area. Resident 66's fingernails had red nail polish that was spotty (chipped) and did not cover the entire nails. Resident 66's fingernails were long and were not clean [had brown and yellowish particles under them]. On 07/29/2022 at 3:20 PM, a joint observation was made of Resident 66's long and unclean fingernails with brown/tan debris under all her nails. The Certified Nursing Assistant, Staff R, who was present during this observation confirmed Resident 66 had gray hair on her chin on the right side of her lower face as well as a moderate amount of brown hair on her chin. Staff R described Resident 66's fingernails as long, with moisture/dirt and food particles under some of them, the substances under Resident 66's nails were white and black in color and that Resident 66's nail polish was red and peeling off. Staff R confirmed there was a lot of hair under Resident 66's chin, and stated Resident 66 had a little hair on her upper lip also and that she did not know when Resident 66 was shaved last and was unsure why Resident 66 face was not shaved. On 07/29/2022 at 3:29 PM, Resident 66 was in her room on her bed. Registered Nurse, Staff Q, described Resident 66's fingernails as long, not clean, and with nail polish peeling off. Staff Q stated Resident 66's nails appeared to have dry food and/or something else (other dirt) under them, which was brown/black in color. Staff Q confirmed Resident 66's fingernails should be clean and that the CNA staff should clean and cut residents nails, adding that the CNAs should look at the residents every day but at least every other day to assess for cleanliness. An interview was conducted on 07/28/2022 at 11:48 AM with Resident 66's Family Member (FM66) in the day room at the facility. FM66 stated she did not like Resident 66's facial hair. FM66 stated she had not asked anyone at this facility about shaving Resident 66's face and was unsure what the facility's policy was regarding shaving. FM66 stated she asked someone at the facility twice about having Resident 66's toenails and fingernails cut. FM66 stated she was unsure who she asked the first time about cutting Resident 66's finger and toenails but had also asked the young lady from activities about having her fingernails and toenails cut. FM66 stated she made this request on 07/25/2022, however, Resident 66's fingernails and toenails had not yet been cut that day. An interview was conducted on 07/29/2022 at 3:00 PM with Staff R, who confirmed the shower aides or CNAs were responsible for shaving residents at the facility. Staff R stated residents were shaved twice a week during their shower time, so it depended on the residents' shower schedule. However, Staff R added, staff did not shave female residents unless the resident asked for this service. Staff R stated some female residents want to be shaved under their arms or have their chin shaved. Staff R stated if residents were confused, she would talk to them about being shaved. Staff R stated she did not think the facility had a policy about shaving residents. Staff R stated she and other staff cut or cleaned residents' fingernails when they noticed residents' nails were dirty or if the nails were long, she would cut them if the resident was not diabetic (a metabolic disorder with high sugar levels in the body). Staff R stated the facility did not have a shower aide now and the CNA staff were providing the residents with showers. An interview was conducted on 07/30/2022 at 11:01 AM with the Recreation Assistant, Staff X, who confirmed she had a conversation with Resident 66's FM (Family Member), who requested that Resident 66 have her nails cleaned and trimmed. Staff X stated she told the FM that she would let the nursing staff know, because that was not her department's responsibility. Staff X stated that although she told her supervisor about the request, she did not inform nursing staff of the FM's request for Resident 66 to receive nail care. Staff X stated she was unsure of the date she had the conversation with Resident 66's FM regarding nail care. An interview was conducted on 07/30/2022 at 11:34 AM with the Recreation Director, Staff N, who confirmed Resident 66's FM requested nail care for Resident 66's fingers and toes. Staff N stated the Interdisciplinary Department Team (IDT) discussed nail care for Resident 66 at one of their stand-up meetings after she reported Resident 66's FM request. Staff N stated she did not remember what date she received the request for Resident 66, but that this happened in the month of June 2022. After being asked about this, Staff N, looked, and stated the information was no longer on the communication form that she had completed at the time of the request, adding that sometimes the information got deleted after it was done. Staff N stated nursing staff would be responsible for cleaning and trimming Resident 66's nails. Staff N confirmed the IDT team consisted of the Director of Nursing (DNS), Resident Care Manager, Staff T, and Social Services. Staff N stated Resident 66's nail care was assigned to Staff T. Staff N stated she was unsure if staff cleaned or trimmed Resident 66's nails after this request. Staff N stated she had not heard any information about Resident 66's facial hair at the IDT meetings that were held on weekdays at between 9 or 9:30 [AM] at the facility. An interview was conducted on 07/30/2022 at 11:49 AM with Staff T, who confirmed he was aware of Resident 66's FM request to clean and trim the resident's nails. Staff T stated he could not remember when the request from Resident 66's FM for nail care was made, or when it was discussed by the IDT. Staff T confirmed the facility did not provide nail care as requested for Resident 66 until 07/20/2022, after surveyor intervention. Staff T stated he just forgot to follow through with the task after the discussion with IDT meeting. Staff T confirmed CNA staff were responsible for nail care for non-diabetic residents. Staff T stated he was unsure of the frequency of nail care requirement per the facility's policy; however, resident's nails should be cleaned as needed and daily and whenever they were dirty. Staff T stated nail care cleaning and trimming and shaving provided by the facility should be included on resident's [NAME] used by CNA staff. Staff T stated shaving residents was also a CNA's task. Staff T confirmed and verified Resident 66's [NAME] did not contain information regarding nail care or shaving. Staff T confirmed Resident 66 had facial hair at times, and the facial hair should be shaved as needed. Staff T confirmed Resident 66 was not capable of requesting her facial hair to be shaved because of impaired cognition. An interview was conducted on 07/30/2022 at 12:18 PM with the Administrator, Staff A, who confirmed the FM's request for nail care for Resident 66 was discussed in the IDT morning meeting, adding that he was aware of the request on 07/17/2022. Staff A stated the information was deleted from the system and he had no documentation to provide to regarding the IDT discussion for that date. Staff A stated the IDT discussed Resident 66's nail care at their meeting on 07/28/2022 as a follow up but was unsure of the details discussed at the IDT meeting. An interview was conducted on 07/30/2022 at 6:29 PM with the DNS, Staff B. Staff B confirmed Resident 66's hands and nails should be cleaned every day. Staff B stated she was aware in stand-up meeting that Resident 66's FM requested for Resident 66 to have nail care provided by the facility, including cleaning her nails. Staff B stated she was not sure why staff at the facility did not shave Resident 66's face and that the facility's expectation for CNA staff was that they would provide ADL care for residents including shaving female and male residents and caring for their nails. Reference: (WAC) 399-97-1060 (2)(c) .

CONCERN (D)

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

Deficiency F0678 (Tag F0678)

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 each resident's electronic medical record (EMR) accurately and consistently reflected the resident's code status. One resident (Resident 72) of 20 sampled residents had conflicting documents that could delay or prevent the resident from receiving care in accordance with the resident and/or the guardian's decision-making. Findings included . Review of the facility policy titled, OPS117 Health Care Decision Making dated [DATE], revealed 2. Throughout the stay, advance care planning conversations will be conducted as part of the care plan process and with significant change in condition to identify, clarify, and review existing advance directives and/or portable medical orders and determine whether the patient wishes to change or continue these instructions. Review of Resident 72's Clinical dashboard tab in the EMR revealed Resident 72 was re-admitted to the facility on [DATE]. Resident 72's code status was listed as Full Code [if a resident's heart stopped or they stopped breathing, all resuscitation procedure will be provided to keep them alive] on the dashboard. Review of Resident 72's 5-day assessment Minimum Data Set (MDS - a required assessment) dated [DATE] under the MDS tab revealed Resident 72 had a Brief Interview Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Review of the electronic face sheet located on the main page of the resident's electronic record revealed the resident was a Full Code status. Review of the electronic physician's orders for 07/2022 located in the Orders tab also revealed the resident was a Full Code status. Review of the electronic care plan located in the care plan tab dated [DATE] also revealed the resident has an established Advanced Directive: Full Code. Identified rep [representative]: Guardian of Person and Estate. Effective until: [DATE]. Although each of the above documents documented that the resident was a Full Code (and should therefore receive cardiopulmonary resuscitation (CPR) if needed), review of the electronic Physician Orders for Life Sustaining Treatment (POLST) form, dated [DATE] and located in the Miscellaneous tab, revealed the resident was listed as a DNR (do not resuscitate) status. An interview on [DATE] at 2:18 PM, with Registered Nurse, Staff L, revealed the staff identifies a resident's code status from the POLST forms which were held in a binder at the nurses' station. An interview on [DATE] at 3:03 PM with the Director of Nursing, Staff B, revealed the resident's code status had been updated and verified as a Full Code Status. She stated the medical records personnel was behind in scanning updated documents. Further interview with Staff B revealed that staff had updated a copy of the POLST in the binder, which was located at the nurse's station, indicating the resident was a Full Code status. An interview was conducted on [DATE] at 3:51 PM with Social Services (SS), Staff F, and SS, Staff E, who stated the resident had an updated POLST form, which indicates the resident was a Full Code. Further interview with Staff F revealed that although the resident was, per the MDS, cognitively intact, Resident 72 had a guardian and deemed incapacitated by the State of [NAME]. Additional interview on [DATE] at 4:01 PM, with Staff E revealed the resident's code status was going to be changed to reflect the DNR status, due to the facility not having a current POLST form, which showed the resident was to be a Full Code. Additional interview on [DATE] at 4:16 PM, with Staff B revealed the resident's code status was now changed to reflect the POLST form dated 2020. Staff B stated she did not speak with the resident or resident's guardian prior to changing the resident's status to DNR. Staff B explained the reason they did not speak with the resident prior to changing the code status was because the court had deemed the resident incapacitated and the facility cannot overrule the courts. During an additional interview on [DATE] at 4:30 PM, Staff B stated she called the guardian, who stated the resident was a Full Code. Staff B stated the facility was in the process of getting an updated POLST with the guardian's signature. She further stated she spoke with the physician as well about the conversation with the guardian regarding the resident being a Full Code. Staff B stated her expectations was for all residents' code status to match their POLST forms, and the POLST forms were used as physician's orders. An additional interview was conducted on [DATE] at 5:21 PM with Staff B and Staff E. Staff E stated she spoke with Resident 72, who stated he would like to be a Full Code, and when Staff E spoke with the guardian, she stated she was going with the resident's wishes of wanting to be a Full Code. Staff B stated she was doing an immediate care plan meeting, including the guardian resident, and medical director, to resolve the code status issue. Reference (WAC): 388-97-1060 (1) .

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

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, record review, the facility failed to ensure 1 of 9 residents (Resident 9) reviewed for medication administration, was free of significant medication errors. The failure to follow physician's orders to hold an Insulin (medication used to treat high blood sugar [BS]) dose for BS level results that were outside the set parameters on multiple occasions, had the potential to significantly drop the resident's BS level below the specified limit and could result in Hypoglycemia (irregular/fast heartbeat, pale skin, numbness of lips, tongue, cheek, and sweating) and other related medical complications. Findings included . Review of a facility-provided policy titled, Medication Administration: General, dated 05/01/2021, revealed A licensed nurse .per state regulations, will administer medications to patients [residents]. Accepted standards of practice will be followed .To provide safe, effective medication administration process. Review of an additional facility-provided policy titled, Medication Administration: Injectable (IM [intramuscular], Sub-Q [subcutaneous], dated 06/01/2021, revealed staff were to Prepare for administration of medication .verify medication order on Medication Administration Record (MAR) .Correct .special instructions. Review of Resident 9's undated admission Record revealed Resident 9 was admitted to the facility on [DATE]. Resident 9's Diagnosis Information revealed Resident 9 had multiple diagnoses including diabetes (a disorder in which the body has high blood sugar levels for prolonged periods of time) and dependance of renal dialysis (procedure that performs the function of the kidneys by removing unwanted substances and extra water). Review of Resident 9's physician's orders under the Orders tab in the Electronic Medical Record (EMR) revealed an order for Insulin Glargine Solution 100 Units/ML [milliliters]/ Inject 10 units subcutaneously two times a day for diabetes hold if BS less than 150, dated 05/17/2022. a. Review of Resident 9's Blood Sugar Summary in the Wt [weight]/Vitals tab in the EMR revealed the following information: 07/29/2022 at 9:02 AM - 128 was entered for the BS level. An observation of medication pass was conducted on 07/29/2022 at 9:13 AM, Licensed Practical Nurse, Staff P, prepared medications from Cart 2, on Hall 400 for Resident 9. Review of Resident 9's MAR was conducted on Staff P's computer, and it included orders for Insulin Lispro Solution 100 Unit/ML give per sliding scale Inject SQ [subcutaneous] before meals. At this time, Staff P reported Resident 9's BS was 128 per fingerstick and no dose of sliding scale insulin was required. The MAR also included an order for Insulin Glargine Solution 100 unit/ml inject 10 units sq twice a day (Hold if BS less than 150). Observation revealed that after obtaining the resident's medications, Staff P entered Resident 9's room and approached Resident 9's bedside. Staff P first applied a Lidocaine patch (medication for pain) as ordered to Resident 9's lower back. Staff P then changed (donned and doffed) gloves. Staff P set the prepared insulin at bedside prior to cleansing Resident 9's right arm with alcohol in preparation for injection of the Insulin Glargine Solution. As Staff P then prepared to inject the insulin, the survey team intervened and asked Staff P to return to the medication cart in the hallway prior to administering Resident 9's insulin. Staff P returned to the medication cart in the hallway. At this time, Staff P confirmed they were ready to administer the dose, with the belief that it was in accordance with the physician's orders. The survey team then requested Staff P to review Resident 9's MAR. After a review of the computer on the medication cart, Staff P confirmed that Resident 9's insulin order was to hold the insulin order for a BS of less than 150. Staff P then stated that based on Resident 9's BS, she should have held the insulin dose and not attempted to administer it to Resident 9. Staff P stated that based on the resident's BS, insulin administration could cause Resident 9 to become hypoglycemic. Staff P confirmed her intent and was going to administer Resident 9's insulin dose, until surveyor intervention, which was considered a drug error. b. Review of Resident 9's MAR dated 07/01/2022-07/31/2022 revealed additional instances when Insulin was given when the resident's BS was less than 150. The section on the MAR for Insulin Glargine Solution 100 UNITS/ML Inject 10 unit subcutaneously two times a day for diabetes hold if BS< [less than]150 included Chart Codes .'check' = [equals] Administered. The following information was documented regarding the insulin administration: 07/07/2022 0700 [AM] BS 80. A check mark was entered with the staff's initials, indicating the dose was not held (although the BS was less than150) and the insulin was administered by facility staff. 07/21/2022 0700 BS 147. A check mark was entered with the staff's initials, indicating the dose was not held (although the BS was less than 150) and the insulin administered by facility staff. 07/27/2022 0700 BS 140. A check mark was entered with the staff's initials, indicating the dose was not held (although the BS was less than 150) and the insulin was administered by facility staff. Review of Resident 9's Notes tab revealed no information regarding notifying the physician of a medication error for the above dates and times. An interview was conducted on 07/30/2022 at 5:04 PM with the Director of Nursing, Staff B, who confirmed Staff P should have held Resident 9's insulin dose and documented Resident 9's BS level on Resident 9's MAR. Staff B stated that Staff P should have informed/notified the physician of Resident 9's BS level results of less than 150 per fingerstick, instead of attempting to administer the insulin. Staff B stated the potential harm for Resident 9 if Staff P incorrectly administered the insulin dose was Hypoglycemia. Staff B confirmed her expectation for nursing staff was to read the MAR carefully prior to administering medication to residents. In addition to the significant error, which was prevented by the survey team, Staff B confirmed that facility staff documented administration of Resident 9's dose of insulin three other times during the month of 07/2022 when Resident 9's BS level results were below 150 and the physician's orders were not followed. Reference: (WAC) 388-97 1060 (3)(k)(iii) .

CONCERN (D)

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

Infection Control (Tag F0880)

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, record review, the facility failed to ensure an effective infection control program designed to prevent the spread of infection, Licensed Practical Nurse, Staff P, failed to perform hand hygiene or clean the hub of a peripherally inserted central catheter (PICC line - a thin flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the heart called super vena cava) prior to accessing it with a syringe for one of three residents (Resident 52) reviewed for intravenous (IV) therapy. This failure has the potential to increase the risk of a systemic infection and related complications. Findings included . Review of a facility-provided policy titled Medication Administration, dated 06/21/2021, revealed To provide a safe, effective medication administration process .Maintain Standard Precautions [a set of infection control practices used to prevent transmission of disease that can be acquired by blood, body fluids, non-intact skin .and mucous membranes.] Review of Mosby's Pocket Guide to Nursing Skills and Procedures, 9th Edition-E-Book revealed Complications associated with PICC lines can include .systemic infection that may be caused by contamination of the catheter from .poor infection-prevention practices during .care, and maintenance ([NAME] et al,.2014) .Scrub catheter hub with antiseptic swab for at least 15 seconds and allow to dry completely. Review of a facility-provided policy titled Administering Intravenous Push Medications, dated 06/01/2021, revealed Licensing nurses caring for patients receiving infusion therapies must adhere to Aseptic Non-Touch Technique (ANTT) for all infusion -related procedures as a critical aspect of infection prevention. Review of Resident 52's Profile tab in the Electronic Medical Record (EMR) revealed Resident 52 was readmitted (re-entry) to the facility on [DATE]. Review of Resident 52's Med Diag [diagnosis] tab revealed multiple diagnoses, including infection and inflammatory reaction due to internal right knee prosthesis (artificial device to replace/augment a missing body part) and erosion (gradual destruction) of other implanted mesh organ or tissue. Review of Resident 52's physician's orders under the Order tab revealed Normal Saline Flush Solution .Use 10 ml [milliliters] intravenously one time a day for IV Flush IV line before and after medication administration, dated 07/12/2022. Review of Resident 52's Medication Administration Record (MAR) dated 07/01/2022-07/31/2022 revealed an order for Normal Saline Flush Solution 0.5 % (Sodium Chloride Flush) Use 10 ml intravenously one time a day for IV Flush IV line before and after medication, dated 07/13/2022. Observation on 07/29/2022 at 8:51 AM, revealed Staff P, Licensed Practical Nurse, entered Resident 52's room. No hand hygiene was performed. Staff P then donned gloves, doffed gloves, exited Resident 52's room, returned to the medication cart in the 400 hallway, retrieved a syringe containing saline flush from the medication cart drawer, and returned to Resident 52's room. No hand hygiene was performed, and Staff P donned gloves. Staff P then disconnected the IV tubing from the PICC line hub in Resident 52's right upper arm, touching the PICC line hub, IV tubing line, and IV pole. Staff P wrapped the IV tubing around the pole next to Resident 52's bed. Staff P then removed the plastic package from the saline syringe, picked up the PICC line hub and held it in one gloved hand and connected the syringe (containing saline flush) to Resident 52's PICC line hub; then with the other hand injected the saline flush. Staff P did not clean the PICC line hub prior to connecting the saline syringe. Interview with Staff P confirmed she did not perform hand hygiene or clean Resident 52's PICC line hub. An interview was conducted on 07/30/2022 at 5:36 PM with Staff B, Director of Nursing, confirmed the expectations for nursing staff to clean the PICC line hub prior to inserting a saline flush syringe. Staff B stated the process of cleaning the PICC line hub was to kill any germs outside of the hub and avoid infections. Staff B confirmed infections in Resident 52's PICC line or blood vessels could be life threatening for Resident 52. Staff B stated she believed her facility had three residents with IVs, including central lines and PICC lines. Reference: (WAC) 388-97-1320 (1)(c)(5)(c) .

CONCERN (E)

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

Respiratory Care (Tag F0695)

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, record review, the facility failed to ensure necessary respiratory care and services were provided in accordance with professional standards of practice, physician orders, and resident's care plan for 4 of 4 residents (Residents 66, 29, 42 and 91) reviewed for respiratory care. Specifically, oxygen equipment was not maintained to include cleaning the oxygen concentrator filter, changing oxygen tubing, and changing water bottles (humidifier). Additional respiratory equipment such as a bilevel positive airway pressure (BIPAP) machine was not cleaned as ordered. Physician's orders for oxygen flow rate were not followed for Residents 66, 29 and 42. The facility's deficient practice had the potential to affect each resident's respiratory status, including the potential for exposure to respiratory complications and respiratory infections. Findings included . Review of a facility-provided policy titled Oxygen Concentrator dated 12/01/2006 revealed the equipment was To provide a non-renewable source of oxygen for residents. The policy further stated, Maintenance will be done. However, there was no specific information regarding cleaning the oxygen concentrator filter. Review of a facility-provided titled Oxygen Therapy via Nasal Cannula [NC] with an effective date of 12/01/2006 revealed Oxygen therapy via nasal cannula will be administered as ordered by a physician and will include correct flow rate .Verify physician's order .Assist the resident to place cannula prongs into nose .replace entire set-up every seven days and date. RESIDENT 66 Review of Resident 66's electronic medical record (EMR) under the Profile tab revealed Resident 66 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and atrial fibrillation (irregular and often faster heartbeat). Review of Resident 66's admission Minimum Data Set (MDS - a required assessment) with an Assessment Reference Date (ARD) of 06/21/2022 under the MDS tab revealed Resident 66's Brief Interview Mental Status (BIMS) was not performed by the facility and no score was entered for her cognition. Resident 66's Special Treatments as assessed by the facility revealed oxygen was administered to Resident 66 during the assessment period. a. Failure to provide oxygen at rate ordered by physician: Review of Resident 66's physician's orders under the Order tab revealed on order that Patient [resident] can use oxygen at 2 liters [L] to keep oxygen saturation above 88% or for comfort every day and night shift for comfort may use anytime around the clock, dated 07/07/2022. Review of Resident 66's Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated for 07/01/2022-07/31/2022 revealed no information for Resident 66's oxygen administration including flow rate. Review of Resident 66's care plan under the Care Plan tab revealed O2 as ordered via nasal cannula, with the Date Initiated: 06/29/2022. An observation was conducted on 07/27/2022 at 2:13 PM of Resident 66 laying on her bed without oxygen administration. Resident 66 had a NC/oxygen tubing lying on her chest. Resident 66's oxygen concentrator was at her bedside and set on flow rate of 2.5 L. An additional observation on 07/29/2022 at 3:38 PM, revealed Resident 66 was receiving oxygen via NC at a flow rate of 2.5 L. Registered Nurse (RN), Staff Q, was present in Resident 66's room at this time and confirmed Resident 66 had oxygen administered to her via NC at a flow rate of 2.5 L (rather than 2 L as ordered). b. Failure to maintain respiratory equipment: Further review of Resident 66's physician's orders under the Order tab revealed there was no physician's order for maintenance of oxygen equipment including changing oxygen tubing and cleaning the oxygen concentrator filter. Review of Resident 66's TAR and MAR dated for 07/01/2022-07/31/2022 revealed no information regarding maintenance for Resident 66's oxygen equipment, including the oxygen tubing or oxygen concentrator filter. Review of Resident 66's care plan under the Care Plan tab revealed no interventions for maintaining oxygen equipment was initiated, including changing oxygen tubing or cleaning oxygen concentrator filter on her care plan. An observation was conducted on 07/27/2022 at 2:13 PM of Resident 66's oxygen equipment. Resident 66 had a NC oxygen tubing lying on her chest. Resident 66's NC oxygen tubing was not labeled with a date of change on it. The filter on Resident 66's oxygen concentrator, which was at her bedside, had a plastic vent cover over it and was not clean and had dust particles on it. A second observation was conducted on 07/29/2022 at 11:05 AM with Resident 66 laying on her bed with oxygen administered via NC. Resident 66's NC oxygen tubing was now labeled with a date of change of 07/08 (2022). Resident 66's oxygen concentrator filter on the back of the oxygen concentrator machine had a plastic cover over it, the cover was not clean and had dust particles on it. A third observation and interview on 07/29/2022 at 3:38 PM with Staff Q in Resident 66's room confirmed Resident 66's oxygen tubing had a label with the date of change on it. At this time, Staff Q stated Resident 66's oxygen tube label was unreadable and difficult to tell the date of change for Resident 66's oxygen tubing. Staff Q stated he was unsure where Resident 66's oxygen concentrator filter was on the machine. Staff Q confirmed there was a vent cover on the back of Resident 66's oxygen concentrator and the equipment was not clean and covered with moderate amount of dust particles. Staff Q, who was the Unit Manager stated nursing staff was supposed to change the equipment as a task that was included on the resident's TAR. An interview was conducted on 07/30/2022 at 6:24 PM with the Director of Nursing, Staff B, who stated Resident 66's oxygen tubing should be labeled with a date of change readable within the weekly time frame. Staff B confirmed Resident 66's oxygen concentrator filter should be cleaned weekly, and Resident 66's EMR should include a physician's order to clean the oxygen concentrator filter. RESIDENT 29 Review of Resident 29's undated admission Record under his Profile tab revealed Resident 29 was admitted to the facility on [DATE] with diagnoses that included respiratory failure and chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs with symptoms to include difficulty of breathing and/or cough). Review of Resident 29's admission MDS with an ARD of 05/08/2022 under the MDS tab revealed Resident 66's Special Treatments included oxygen was administered to Resident 29 during the assessment period. a. Failure to provide oxygen at rate ordered by physician: Review of Resident 29's physician's order under the Orders tab revealed Oxygen 3 L/M [liters per minute], Continuous via NC dated 05/08/2022. Review of Resident 29's MAR dated 07/01/2022-07/31/2022 also revealed an order for Oxygen at 3 L via NC. Review of Resident 29's care plan under the Care Plan tab also revealed oxygen via NC at 3 L/M continuous . Administer Oxygen as ordered/indicated. An observation was conducted on 07/27/2022 at 11:00 AM with Resident 29 receiving oxygen administration via NC. Resident 29 was sitting on his bed; his oxygen concentrator was set at 3.5 L flow rate. Resident 29's had a water bottle connecting the oxygen concentrator with NC tubing, the water bottle was empty and had a handwritten date of 07/20/2022. An interview was conducted on 07/30/2022 at 6:03 PM with Staff B, who verified Resident 29 had a physician's order for oxygen administration at 3 L/M. Staff B confirmed Resident 29's physician's order should be followed by the facility staff for his oxygen flow rate. Staff B verified Resident 29 had a diagnosis of COPD and stated Resident 29's health risk with having a flow rate higher than the physician order could cause him to have too much carbon dioxide [which could be harmful to the resident]. b. Failure to maintain respiratory equipment: Review of Resident 29's physician's order under the Orders tab revealed no order to clean the oxygen concentrator filter, store the oxygen nasal cannula in a bag when not in use, or to change the oxygen water bottle. Review of Resident 29's TAR dated 07/01/2022-07/31/2022 revealed staff were to Change and label oxygen tubing Q [every] Sunday. There were no directives/orders to clean the oxygen concentrator filter or change the water bottle on either the TAR or of 07/01/2022 - 07/31/2022 MAR. Review of Resident 29's care plan under the Care Plan tab revealed no interventions for maintaining oxygen equipment including changing the oxygen tubing, changing the water bottle, or cleaning the oxygen concentrator filter. An observation was conducted on 07/27/2022 at 11:00 AM of Resident 29 with oxygen administration via NC. Resident 29's NC oxygen tubing was labeled (handwritten) with date of change on the label dated 07/20/2022. Resident 29 had a water bottle connecting the oxygen concentrator with a NC tubing, the water bottle was empty and had a handwritten date of 07/20/2022. The oxygen concentrator filter on the side of his machine was not clean and was covered with dust particles. Resident 29 had a second source of oxygen supply in his room, an oxygen tank, which was in a tank stand with wheels. Resident 29's had NC oxygen tubing connected to the oxygen tank in the stand, the oxygen NC tubing was not stored in a bag and was wrapped around of his walker handle, labeled with a date of change of 07/20/2022. A second observation was conducted on 07/29/2022 at 10:54 AM of Resident 29 receiving oxygen administration via NC from the oxygen concentrator. Resident 29's oxygen concentrator filter was on the right side of the equipment and was not clean and covered with dust particles. Resident 29's water bottle was less than half full of water and dated 07/25/2022. Resident 29's oxygen tubing was labeled with date of change of 07/25. Resident 29 had two more oxygen supplies in his room, the second supply was an oxygen tank in his room in a tank stand and the third was a portable oxygen machine. Resident 29's portable oxygen machine had NC tubing connected to it, the NC tubing (connected to his portable tank) was laying across his walker, was not stored in a bag, and had a label with date of change of 07/20. A third observation was conducted on 07/29/2022 at 3:46 PM in Resident 29's room. Staff Q, who was present at this time, confirmed Resident 29's NC oxygen tubing was laying on his bed and was not stored in a bag. Staff Q confirmed the oxygen concentrator filter was not clean and had a moderate amount of dust particles on it. An interview was conducted on 07/30/2022 at 6:03 PM with Staff B, who verified Resident 29 had a physician's order to change his oxygen tubing weekly but no physician's order for cleaning his oxygen concentrator filter. Staff B confirmed Resident 29 should had a physician's order for cleaning his oxygen concentrator filter. Staff B stated the harm with not cleaning the filter was Resident 29 may not be getting the correct quality of air and possible exposure to germs. Staff B confirmed Resident 29's NC tubing should be stored in a bag when not in use. RESIDENT 42 Review of Resident 42's EMR under his Profile tab revealed he was readmitted to the facility on [DATE] with multiple diagnoses to include COPD. a. Failure to provide oxygen at rate ordered by physician: Review of Resident 42's physician's orders under the Orders tab revealed Oxygen at 2L/min via Nasal Cannula continuously dated 03/29/2022. Review of Resident 42's MAR and TAR dated 07/01/2022-07/31/2022 also revealed Oxygen at 2L/min via Nasal Cannula continuously. Observation on 07/29/2022 at 3:42 PM, revealed Resident 42's oxygen concentrator flow rate was set at 2.5 L. Staff Q, who was present during this observation, confirmed Resident 42's oxygen concentrator flow rate was 2.5 L. An interview was conducted on 07/30/2022 at 6:18 PM with Staff B. Staff B verified Resident 42 had a diagnosis of COPD and confirmed Resident 42 had a physician's order for oxygen at a flow rate of 2 L in his EMR. Staff B stated Resident 42's oxygen flow rate set on the concentrator at 2.5 L was too high and the facility was not following Resident 42's physician's orders. b. Failure to maintain respiratory equipment: Review of Resident 42's physician's orders under the Orders tab also revealed orders to clean filter on oxygen concentrator weekly, dated 03/27/2022 and Oxygen tubing change weekly. Label each component with date and initials. Review of Resident 42's MAR and TAR dated 07/01/2022-07/31/2022 also revealed Clean filter on oxygen concentrator weekly .Oxygen tubing change weekly. Label each component with date and initials. The MAR and TAR contained no information regarding storing oxygen tubing in a bag. An observation was conducted on 07/27/2022 at 10:28 AM of Resident 42 with oxygen administration via NC. Resident 42's oxygen tubing did not have a date of change label on it. Resident 42's oxygen concentrator filter on the right side of his machine and was not clean and was covered with dust particles. A second observation was conducted on 07/29/2022 at 11:01 AM of Resident 42 laying on his bed, in his room. Resident 42's NC oxygen tubing was now labeled with a date of 07/27. Resident 42's oxygen concentrator filter was on the right side of his oxygen concentrator and was not clean and had moderate amount of dust particles. A third observation on 07/29/2022 at 3:42 PM, revealed Resident 42's oxygen concentrator filter was not clean. Staff Q, who was present during this observation, described Resident 42's oxygen concentrator filter as moderately dirty with dust particles. Further interview with Staff Q revealed the night shift nurse was responsible for oxygen maintenance. RESIDENT 91 Review of the Census tab in the EMR for Resident 91 revealed an admission date of 09/05/2018 with diagnoses including cerebral vascular accident (stroke), anxiety, and sleep apnea (a sleep disorder characterized by loud snoring and episodes of stop breathing). Review of the physician's orders under the Orders tab in the EMR revealed a BIPAP (bilevel positive airway pressure) machine was ordered on 01/25/2021 to be used nightly. Review of the MAR under the Orders tab of the EMR revealed the facility was to clean and dry the BIPAP water reservoir each day, between uses. Further review of the MAR for 07/28/2022 and 07/29/2022 revealed Registered Nurse, Staff I, had documented the daily cleaning of the BIPAP machine as complete. Interview with Staff I on 07/30/2022 at 10:13 AM, revealed Staff I was unable to describe how the daily cleaning of the BIPAP was to be completed. Staff I then stated that despite documenting the BIPAP daily care was completed, he had not actually performed the cleaning in more than a week and did not provide the care on 07/28/2022 and 07/29/2022. Interview with Staff B on 07/30/2022 at 10:30 AM, confirmed that care should only be documented in the medical record, including the MAR, if it was completed. Additional interview with Staff B on 07/30/2022 at 2:49 PM, revealed the facility lacked policies and procedures for the care of the BIPAP machine, including the changing of filters and tubing. Reference: (WAC) 388-97-1060 (3)(j)(vi) .

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, record review, the facility failed to ensure medications were stored in a safe and secure storage for 2 of 4 medication carts (Cart One & Cart Two) and for 1 of 2 medication rooms (Station Two Medication Room). Medications were stored loosely and without labels in a medication cup in the drawers. Discontinued controlled substances were stored in a narcotic locked box with non-discontinued medications on two of four medication carts. Discontinued medication (Insulin - medication used to treat high blood sugar) was stored with non-discontinued medication. The Station Two Medication Storage Room had expired/discontinued medications and medical supplies stored together. The medication refrigerator temperature was not monitored/recorded for correct temperature for storage of refrigerated required medications (vaccines) and contained a discontinued vaccine vial. The facility deficient practice had the potential to allow medication errors to occur and diversion of controlled substances. Findings included . CART ONE Review of a facility-provided policy titled, Medication Administration: Oral, reviewed 06/01/2021, revealed Prepare medication for one patient at a time. An observation was conducted on 07/30/2022 at 8:44 AM, on the 200 hallway was one of the facility's medication carts (Cart One) with Registered Nurse (RN), Staff L. The medication cart top drawer had multiple un-labeled loose pills in four small clear medication cups. There was no label on the clear medication cups and no resident's names to identify to whom the medications belonged. Staff L stated the residents were not ready to take their medication when she attempted to administer them, so she put the cups containing the medications in the top drawer of the medication cart to administer later. Staff L stated she would go back to those residents later with the same unlabeled medication cups and administer the medications. Staff L stated Vitamin B12 (a supplement), and Percocet (a controlled substance [narcotic medication for pain]) were in one of the cups. Staff L stated she prepared the medication in the cup 20 minutes prior and confirmed the narcotic medication was not stored in the narcotic locked box. An interview was conducted on 07/30/2022 at 10:37 AM with the Director of Nursing, Staff B, who stated the facility did not have a policy regarding Medication Cart Storage. An additional interview was conducted on 07/30/2022 at 5:04 PM with Staff B, who confirmed the facility's expectation for the nursing staff after preparing the medication was to administer it to the resident. Staff B stated that Staff L should have discarded the medications and not stored medication loosely in the medication cart drawer. Staff B confirmed that nursing staff should not store multiple cups of loose pills on the medication cart. Staff B stated pre-pouring medication was not okay, adding to a pre-poured medication was not okay, and especially leaving a narcotic un-labeled and pre-poured in a cup in an unlocked drawer on the medication cart was not okay. Staff B confirmed pre-pouring medication and storing it loosely on the medication cart was not a proper nursing practice and had the potential to create a medication error. Review of a facility-provided policy titled, Disposal/Destruction of Expired or Discontinued Medication, revised 01/01/2022, revealed Facility staff should destroy and dispose of medications .Once an order to discontinue a medication is received, facility staff should remove this medication from the resident's medication supply .Facility should place all discontinued or out-of (sic) dated (sic) medications in a designated, secure location which is solely for discontinued medication .Facility should destroy non-controlled medications in the presence of a registered nurse and witnessed by one other nurse .Facility should destroy controlled substances. Review of Resident 73's Medication Administration Record in the Electronic Medical Record (EMR) under the Orders tab revealed the resident had an order for Clonazepam (an antianxiety medication) Tablet 0.5 MG [milligram] which was DC [discontinued] Date 07/11/2022 at 11:30. During the observation on 7/30/2022 at 8:54 AM of Medication Cart One on Hallway 200 with Staff L, the narcotic locked box was observed to contain discontinued controlled substances stored in with other residents non-discontinued and non-expired medication. Resident 73 had two cards containing Clonazepam 0.5mg tablet. 1-2 tabs hours as needed of mouth every 12 hours. One card had 10 tablets remaining, and the second card had 30 tablets remaining. The count of Resident 73's Clonazepam medication cards was verified and confirmed from the narcotic book with Staff L. Staff L then confirmed Resident 73's Clonazepam 0.5mg tablet medication was discontinued two days ago. Staff L stated the facility does not destroy medications right away because sometimes the residents start the medication back. Staff L confirmed Resident 73's discontinued medications (Clonazepam) was stored in the active narcotic drawer for Resident 73. CART TWO An observation and interview on 07/30/2022 at 9:18 AM were conducted with Licensed Practical Nurse (LPN), Staff P, of Medication Cart Two on Hallway 400. The top drawer contained Resident 12's Levemir FlexTouch 100u/ml (units/milliliter) insulin, stored with facility's residents non-discontinued medications. The label on Resident 12's medication (insulin) pen did not have a date opened or date expiration on it. During this interview, Staff P stated Resident 12's insulin had been discontinued. Staff P was unsure if Resident 12's medication was opened. The clear bag that contained Resident 12's medication had a sticker that read, should be kept in the refrigerator if unopened. Staff P confirmed Resident 12's discontinued or expired medication should not be kept on the medication cart. Staff P also said the reason the insulin was kept in the medication cart was because multiple nurses were using the cart. Observation on 07/30/2022 at 9:18 AM, the narcotic locked box of Cart Two contained Resident 342's-controlled substance (Morphine [a narcotic pain medication] 20mg/1ml) with 15.5ml remaining in the bottle, which was stored with non-discontinued controlled medications. Staff P confirmed Resident 342's medication should not be stored in the narcotic box on the medication cart because Resident 342's Morphine had expired in 05/2022, and the medication should have been destroyed. Staff P stated the facility's policy for medication destruction required an LPN and an to destroy discontinued or expired medications and it was difficult to find an RN to destroy the medications. An interview was conducted on 07/30/2022 at 10:37 AM with Staff B, who stated the facility did not have a policy regarding Medication Storage Rooms. STATION TWO MEDICATION ROOM An observation was conducted on 07/30/2022 at 1:52 PM of Station Two Medication Room with the Resident Care Manager, Staff T. The Medical supplies and medications were in a plastic bin in a plastic wash basin labeled PICC Line Desg (sic) in a top cabinet on the right side of the medication storage room, stored with un-expired medical supplies. The following expired medical supplies and medications were in the cabinet: a. Six-Heparin (a blood thinner) 10 units/1ml syringe with an expiration date of 04/30/2022. b. Three- female Luer lock caps with an expiration date of 03/16/2020. c. Two- female Luer lock caps with an expiration date of 07/11/2020. d. Three- female Luer lock caps with an expiration date of 09/2019. e. One- female Luer lock caps with an expiration date of 01/22/2022. f. One- filter straw with an expiration date of 07/2017. g. One- filter straw with an expiration date of 11/2018. h. Six-Ondansetron (medication for nausea and vomiting) 4 mg tabs with no patient label with an expiration date of 05/31/2022. Six tablets remained in the medication card. Interview during the tour conducted on 07/30/2022 at 1:52 PM with Staff T confirmed and verified the above medical supplies were expired and should be discarded. In addition, the following supplies were noted: i. Three Continu-Flo solution set tubing (used to administer fluids to residents). Unable to determine an expiration date. Tubing was not clear and was discolored. j. Two Non-Dehp solution set tubing. Unable to determine an expiration date. The drip chamber was not clear and was discolored. An interview during the tour conducted on 07/30/2022 at 1:52 PM with Staff T revealed he was unsure of the expiration date of the IV tubing. In addition, a drawer on the right side of the room contained the following medical supplies: a. Three specimen collection kits with an expiration date of 09/2021. b. Five Safety lock blood collection kits 23g with an expiration date of 07/31/2020. c. Five Safety lock blood collection kits 21g with an expiration date of 07/31/2020. All the above medical supplies were stored with un-expired lab supplies. A white cabinet contained facility's residents' un-expired medications, which were stored with two boxes of Resident 54's medication Lonhala Magnair (an anticholinergic that works by relaxing muscles in the airways to improve breathing). Thirty pouches were in each box, with an expiration date of 2/28/2021. The medication storage refrigerator contained three vaccines bottles of pneumovax pneumococcal (vaccine to prevent Pneumonia [lung infection] on a shelf on the interior door. A document titled, Vaccine Storage Temperature Log, dated July 2022, was on the exterior door of the medication refrigerator. Review of the document revealed twenty-four missing entries, indicating the task was not performed to ensure medication was stored at correct temperature. During the tour on 07/30/2022, Staff T exited the medication storage room at 2:05 PM and RN, Staff I, entered the medication storage room. Staff I confirmed and verified the three vials of vaccines were stored in the medication refrigerator whose temperature log had missing entries and was not complete to verify the medication was stored at the correct temperature. Staff I stated one vial of the vaccine medication was discontinued because Resident 343 had expired and was no longer at the facility and the medication should not be stored with un-expired or un-discontinued medications. An interview was conducted on 07/30/2022 at 5:51 PM with Staff B, who stated expired and discontinued medications were to be stored in a box on the counter and were destroyed or sent back to the pharmacy. Staff B confirmed expired medical supplies should not be stored with un-expired medical supplies. Staff B stated the expired medical supplies should be thrown away. Staff B also confirmed the staff should document the medication refrigerator log temperature log twice a day when vaccines were stored, and if no vaccines were stored it should be documented once a day. Staff B confirmed and verified the facility's refrigerator temperature log had missing entries, indicating the staff did not perform the task of ensuring medications were stored at the correct temperature. Review of a facility-provided policy titled, Medication and Vaccine Refrigerator/Freezer Temperatures, with a revision date of 11/15/2020, revealed Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures .To ensure medications and vaccines are maintained at a safe temperature .Document internal temperature on the Medication/Vaccine Refrigerator Temperature Log .Completed Medication/Vaccine Temperature Logs are maintained for three years. Review of a facility-provided policy titled, Vaccine Storage and Handling, revised 04/01/2022, revealed Vaccines will be stored and maintained properly from the time they are received at the Center [facility] until they are administered . Check and record vaccine/medication refrigerator .temperature .Do not use compromised vaccines. Reference: (WAC) 388-97-1300 (2) & 2340 (2)(a)(i) .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Washington facilities.

Concerns

• 53 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade C (50/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.

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About This Facility

What is Ballard Center's CMS Rating?

CMS assigns BALLARD CENTER 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 Ballard Center Staffed?

CMS rates BALLARD CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 49%, compared to the Washington average of 46%.

What Have Inspectors Found at Ballard Center?

State health inspectors documented 53 deficiencies at BALLARD CENTER during 2022 to 2025. These included: 52 with potential for harm and 1 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Ballard Center?

BALLARD CENTER 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 GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 142 certified beds and approximately 103 residents (about 73% occupancy), it is a mid-sized facility located in SEATTLE, Washington.

How Does Ballard Center Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, BALLARD CENTER's overall rating (2 stars) is below the state average of 3.2, staff turnover (49%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Ballard Center?

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

Is Ballard Center Safe?

Based on CMS inspection data, BALLARD CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Ballard Center Stick Around?

BALLARD CENTER has a staff turnover rate of 49%, 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 Ballard Center Ever Fined?

BALLARD CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Ballard Center on Any Federal Watch List?

BALLARD CENTER 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: 142
Avg. Residents: 103
Occupancy: 72.9%
Ownership: For profit - Limited Liability company
Chain: GENESIS HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
53 Deficiencies: -10
Final Score: 50/100

Nearby Alternatives

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

View all in SEATTLE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505042