Based on observation, interview, and record review the facility failed to ensure residents were provided care and services in a dignified manner for 7 (Residents 106, 12, 144, 123, 45, 123, & 156) of 36 sample residents reviewed. The failure to: provide dignified toileting assistance (Residents 106, 12, & 144), ensure staff sat when feeding residents (Resident 45), provide bodily privacy when transporting residents to and from the shower room (Resident 123), and ensure catheter bags (bags that collect urine from tubing placed in the body to assist with urinary drainage) were covered to obscure their contents (Resident 156) placed residents at risk for undignified care and a diminished sense of self-worth. Findings included . <Policy> According to the facility's undated General Rights policy, all residents had a right to a dignified existence, self-determination, and access to services inside the facility. The policy showed facility staff would treat each resident with respect and dignity and care for each in a manner that would promote maintenance or enhancement of their quality of life and would recognize each resident's individuality. The policy showed each resident had the right to be free from interference, and coercion when exercising their rights and the facility would support them in exercising their rights. <Resident 106> According to the 09/26/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 106 had a diagnosis of blindness. The MDS showed Resident 106 was dependent on staff for toileting hygiene. The assessment showed the facility did not attempt a trial toileting program since Resident 106 admitted to the facility. Review of the revised 10/03/2024 resident has an ADL [Activities of Daily - hygiene and other daily routines] self-care performance deficit . Care Plan (CP), Resident 106 needed two-person assistance for toileting hygiene at bed level. This CP showed Resident 106 required the use of a mechanical lift as needed for transfers. Review of a 10/03/2024 bowel and bladder evaluation showed Resident 106 always voided appropriately without any incontinence. The evaluation showed Resident 106 could be incontinent due to their limited mobility. The evaluation showed Resident 106 required assistance from two staff with transfers to the toilet. The evaluation showed Resident 106 was sometimes aware of their need to use the toilet. The evaluation showed the facility would provide toileting before and after meals, bedtime, and every three hours during the night while awake. In an observation and interview on 11/14/2024 at 8:22 AM Resident 106 pressed their call light to use the toilet. Staff M (Certified Nursing Assistant - CNA) and Staff G (CNA) answered Resident 106's call light. Resident 106 requested to be assisted to the toilet so they could urinate. Staff M reviewed the sign in Resident 106's room directing them to toilet Resident 106 with two-staff assistance. At that time, Staff M stated they would consult with Staff N (Primary Registered Nurse - RN) because they did not transfer Resident 106 before and wanted to ensure safety for the resident. Staff M returned to Resident 106's room with Staff N after less than one minute, Staff N asked Resident 106 if they could urinate in their bed and they would clean them up. Resident 106 replied no they could not go in their bed. Staff N told Resident 106 the therapy department had told them it was unsafe for staff to take them to the bathroom and then directed Staff M and Staff G to clean Resident 106 and exited the room. Staff N stated they directed residents to go in their bed and then staff would clean them up when they were done. Staff N stated therapy was in charge of updating the signs in the residents' rooms and they needed to check why it directed staff to toilet Resident 106 with two-person assistance. Staff N stated they should not tell residents to go in their pants so the resident could remain continent and for the resident's respect and dignity. In an interview on 11/19/2024 at 9:10 AM Staff B (Director of Nursing) stated they expected staff to follow the resident's individualized CPs and CP signs in rooms. Staff B stated it was important to provide residents with toileting assistance as requested and care planned to maintain their ADLs and for the resident's dignity. <Resident 12> According to a 10/03/2024 Quarterly MDS, Resident 12 was dependent on staff for transfers on and off the toilet and for toileting hygiene. The MDS showed Resident 12 was frequently incontinent of bowel and bladder. The assessment showed the facility did not attempt a toileting program with Resident 12. Review of a 10/18/2024 bowel and bladder evaluation showed Resident 12 was usually aware of the need to use the toilet. The evaluation showed Resident 12 required assistance from two staff using a mechanical sit-to-stand lift for transferring on and off the toilet. The evaluation showed staff would offer and provide toileting assistance to Resident 12 before and after meals, before bedtime, and as needed. Review of the revised 04/10/2024 ADL CP Resident 12 required assistance from two staff using a mechanical sit-to-stand lift for transferring on and off the toilet. The CP showed staff would assist Resident 12 with toileting before and after meals, before bedtime, and as needed. In an interview on 11/13/2024 at 11:36 AM Resident 12 stated when they asked staff to assist them to the toilet, the staff directed them to go in their brief. <Resident 144> According to a 08/09/2024 Quarterly MDS, Resident 144 required substantial assistance from staff for toilet transfers and was dependent on staff for toileting hygiene. The assessment showed the facility did not attempt a trial toileting program since Resident 144 admitted to the facility. Review of a 11/12/2024 bowel and bladder evaluation showed Resident 144 was incontinent due to limited mobility and required the assistance of one staff for toileting. The evaluation showed Resident 144 was mostly continent of bowel and was sometimes aware of need to use the toilet. Review of a revised 08/15/2024 ADL CP showed Resident 144 was dependent on the assistance of one staff for toileting hygiene. The CP showed Resident 144 required toileting assistance as requested by the resident. In an in interview on 11/13/2024 at 10:01 AM Resident 144 stated when they requested assistance with the toilet, staff would instruct them to go in their brief. Resident 144 stated they would use a urinal, but staff did not offer them one. <Resident 45> Observation on 11/14/2024 at 8:38 AM and 9:16 AM showed Staff Q (CNA) in Resident 45's room standing next to the resident while assisting them with breakfast. In an interview on 11/20/2024 at 12:57 PM, Staff E (Charge Nurse RN) stated it was their expectation staff sat while providing feeding assistance to residents. Staff E stated standing while feeding could feel intimidating to the resident. <Resident 123> Observations on 11/19/2204 at 10:21 AM showed Staff R (CNA) transporting Resident 123 in a shower chair through a hallway, past the nurse's station and a resident sitting area, to a shower room on another hall. Resident 124 was covered with a blanket that wrapped around them from the front but exposed their left lower backside and upper bottom to others in the area. At the time of the observation, there were other residents in the hallway, staff seated at the nurse's station, and three residents in the sitting area. In an interview on 11/20/2024 at 12:57 PM, Staff E stated it was their expectation staff did not expose residents when bringing them through the hallways for showers and indicated Resident 123's backside should be covered for privacy and dignity reasons. <Resident 156> Observations on 11/15/2024 at 10:50 AM showed Resident 156 in a shower chair in the hallway being transported by staff back to their room. Resident 156's catheter bag partially filled with urine could be seen hanging on the front of the chair. The catheter bag was not covered with a dignity bag (a covering for a catheter bag that obscures its contents from view). At the time of the observation staff, visitors, and other residents were present in the hallway. In an interview on 11/20/2024 at 12:57 PM, Staff E stated all catheter bags should be covered to promote privacy and dignity for the resident. REFERENCE: WAC 388-97-0180(1-4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <<Resident 115> According to the 10/21/2024 Significant Change MDS, Resident 115 had fractures, needed substantial assistance with upper and lower dressing, and had impairment on one side of their lower extremity. The MDS showed Resident 115 used a walker and wheelchair for their mobility. The MDS did not show Resident 115 used hearing aids. A 10/18/2024 Functional CP showed Resident 115 had a decrease in function related to impaired physical mobility and a decrease in cognition and had self-care deficits. Hearing aids were not addressed on the CP. In an interview on 11/14/2024 at 9:23 AM, Resident 115 stated they lost their hearing aid while at the facility and staff did not find them yet and stated they could not hear that well. Observation on 11/15/2024 at 9:05 AM showed Resident 115 telling Staff V (RN) they could not hear them because their hearing aid was missing. The white communication board in Resident 115's room listed care instructions for staff to follow. This communication board showed Resident 115 needed assistance with a right hearing aid. Observation on 11/19/2024 at 8:23 AM showed Resident 115 had a personal amplifier to facilitate better hearing behind their bed. Resident 115 stated their hearing aid was missing but their family did not report it to staff, but staff were supposed to help them with hearing aids. In an interview with Staff P (Assistant Director, RN) stated Resident 115 should have a hearing aid and the hearing aid should have been included on the CP but was not. Staff P stated they were not aware that Resident 115's hearing was missing and stated staff should have reported hearing aid was missing. Staff P stated Resident 115's hearing aid was important so the resident could communicate and receive communications clearly. According to an 11/04/2024 CAA (Care Area Worksheet) Resident 115 had impaired mobility, impaired strength, and balance issues related to a hip fracture and pain. This CAA showed Resident 115 had falls and was at risk for injury. According to 10/24/2024 Injury potential CP showed Resident 115 was a fall risk. This CP included interventions to provide assistance with all transfers, for staff to keep the bed in its lowest position, to provide frequent visual checks when Resident 115 was in their room, and to review safety measures as needed. A fall mat was not listed on CP as an intervention. Review of the [NAME] (care directions for staff) on 11/18/2024 did not show instructions to care staff that Resident 115 was a fall risk, when to keep the fall mat off the floor during the day, or when to put it down at bedtime. Observation on 11/15/2024 at 9:12 AM showed Resident 115 had a fall mat standing on the side of wall away from Resident 115's bed. In an interview on 11/20/2024 1:33 and 3:21 PM, Staff P stated Resident 115's fall mat was not on Resident' 115's CP. In an interview with Staff B (Director of Nursing) on 11/20/2024 at 3:30 PM, Staff B stated the fall mats should be addressed in the resident's care plan. <Resident 159> According to the 08/12/2024 Significant Change MDS, Resident 159 had depression and an anxiety disorder. According to the 08/07/2024 CAA worksheet Resident 159 had delirium, mood decline, and took psychoactive medications. Review of the 11/11/2024 Mood and Behavior CP showed Resident 159 had an alteration in mood and behavior related to their depression and anxiety. This CP included a goal for Resident 159's mental status to remain stable and included interventions to assess for changed or new medications, provide emotional support and reassurance, provide a regular routine, reapproach if agitated, and try to anticipate the resident's needs. The term stable was not defined in the CP in a way to allow the goal to be measurable. In an interview on 11/19/2024 at 11:51 AM Staff E (Charge Nurse, RN) stated Resident 159 had a mood disorder. Staff E stated the term stable meant the resident's physical mobility and mood was stable, and the permanent staff already knew what the term stable meant. Staff E stated if another person covered on the unit or did not know Resident 159, there needed to be more details on the CP for them to know what stable meant for Resident 159. <Resident 429> According to the 11/10/2024 admission MDS, Resident 429 admitted to the facility on [DATE] and had diagnoses including a non-traumatic brain dysfunction and unspecified dementia. Review of the 11/04/2024 Activity deficit and social isolation CP showed Resident 429 had brain disorder and dementia. The CP included a goal for Resident 429's activity engagement to remain person-centered and included interventions for staff to provide monitoring for satisfaction through verbal check-ins and vocalizations, and to provide verbal social conversation when providing care. Review of the 11/11/2024 mood and behavior CP showed Resident 429 had dementia and short-term memory loss and included interventions to encourage Resident 429 to express their feelings and provide emotional support and reassurance as needed. There was no CP addressing Resident 429's speech or communication needs. Review of physician's progress notes dated 11/08/2024, 11/11/2024, 11/13/2024, and 11/14/2024 showed Resident 429 had a previous stroke and had mild aphasia (difficulty with communication of speech and comprehension due to brain injury) and had a mild right facial droop. Review on 11/19/2024 of the [NAME] showed staff should encourage Resident 429 to discuss their feelings and concerns but did not identify Resident 429 had difficulty with communication, speech, or comprehension. Observation on 11/12/2024 at 10:52 AM showed Resident 429 sitting in bed, not responding to questions asked of her. Observation on 11/14/2024 at 10:16 AM showed Resident 429 was able to speak some English, but did not use many words during conversation. In an interview on 11/20/24 at 1:01 PM Staff P stated for residents with impaired cognition and communications needs, care staff should inform the charge nurse if the resident had difficulty or discomfort with communications so the facility could discuss changes needed in the MDS or CP. Staff P stated the facility should ensure Resident 429's CP was individualized so services met the resident's needs. REFERENCE: WAC 388-97-1020(1), (2)(a)(b). <Resident 81> According to a 10/11/2024 admission MDS, Resident 81 admitted on [DATE] and was cognitively impaired. The MDS showed Resident 81 had no natural teeth and no difficulty with chewing during the assessment period. Review of Resident 81's CPs showed no directions for staff regarding what kind of oral care and assistance Resident 81 required. Observations on 11/14/2024 at 1:13 PM, on 11/15/2024 at 9:11 AM, on 11/18/2024 at 9:08 AM showed Resident 81 eating meals with no dentures in their mouth. In an interview on 11/20/2024 at 2:49 PM, Staff O (Charge Nurse, Infection Preventionist) stated they were not aware if Resident 81 had dentures or not. Staff O reviewed Resident 81's record and stated there was no CP developed to instruct staff about Resident 81's dental care. Staff O stated there should be a dental CP but there was not. <Resident 119> According to a 09/17/20 24 Quarterly MDS, Resident 119 admitted on [DATE], was cognitively impaired, and required two-person assistance from staff with transfers and toileting needs. The MDS showed Resident 119 was at risk of developing pressure wounds during the assessment period. Review of the 11/09/2021 Skin Integrity impaired CP instructed staff to encourage and assist Resident 119 to change position every two hours and to have heel protector boots on when in bed. Observations on 11/14/2024 at 11:44 AM and 2:01 PM showed Resident 119 sitting in their wheelchair in the dining area. On 11/15/2024 at 9:31 AM, 11:08 AM, and 1:13 PM Resident 119 was still sitting in their wheelchair in the dining area in the same position with no staff offering to change the resident's position. Observation on 11/15/2025 at 1:43 PM, and on 11/18/2024 at 8:01 AM showed Resident 119 was lying in bed with no heel protector boots on. In an interview on 11/18/2024 at 11:56 AM, Staff D (Assistant Director of Nursing, RN) stated they expected staff to follow the CPs.<Resident 83> According to a 10/01/2024 Significant Change MDS, Resident 83 had multiple medically complex diagnoses including depression and required the use of antidepressant medications during the assessment period. Observations on 11/13/2024 at 8:28 AM & 10:31 AM, on 11/15/2024 at 8:46 AM, and on 11/18/2024 at 9:01 AM showed Resident 83 lying in bed. Review of Resident 83's November 2024 Medication Administration Records (MAR) showed staff administered an antidepressant medication daily. This MAR showed Resident 83 was monitored by staff for behaviors of self-isolation, statements of leaving earth, and wanting to sleep and never wake up. Staff documented Resident 83 had no episodes of these behaviors in November 2024. Review of Resident 83's revised 01/12/2024 mood and behavior CP showed staff identified goals for the resident's mental status and mood to remain stable. These goals did not include measurable objectives for staff to know when or if the resident was meeting their goals. In an interview on 11/20/2024 at 2:33 PM, Staff B (Director of Nursing) stated having measurable goals was important in order for staff to evaluate if a resident was improving or declining, if the interventions in place were adequate, and/or if the goals needed to be adjusted. Staff B stated their expectation was all CPs have measurable goals. Based on observation, interview, and record review the facility failed to develop and/or implement comprehensive Care Plans (CPs) for 7 (Residents 88, 83, 81, 119, 115, 159, & 429) of 36 sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, in appropriate care, and frustration. Findings included . <Facility Policy> According to the facility's reviewed January 2024 Care Plans - Comprehensive Person Centered policy showed the facility would develop a comprehensive, person-centered CP to address each resident's physical, psychosocial and functional needs . <Resident 88> According to the 09/13/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 88 was assessed with a severe memory impairment. The MDS showed Resident 88 depended on staff assistance to move in bed, was at risk for developing pressure ulcers and used a pressure reducing device on their bed. The MDS showed Resident 88 was rarely/never understood and rarely/never understood others in conversation. Review of Resident 88's vital statistics records showed on 11/11/2024, Resident 88 weighed 107 pounds (Lbs.). The Potential for Impaired Skin Integrity . CP showed Resident 88 was at risk for pressure ulcers due to decreased mobility, weakness, deconditioning, fragile skin, and incontinence. This CP showed nursing staff should adjust the knob on the mattress pump for comfort, preferable in the middle every shift. Observation on 11/15/2024 at 8:25 AM showed Resident 88 was asleep in bed. The pump for Resident 88's air mattress was located at the foot of the bed. The pump had a dial to adjust the pressure, which was set at the firmest setting, rather than in the middle as the CP instructed. Resident 88's air mattress was also observed to be at the firmest setting on 11/15/2024 at 10:00 AM, 11/15/2024 at 12:52 PM, 11/18/2024 at 10:11 AM, 11/18/2024 at 1:53 PM, and 11/20/2024 at 2:13 PM. In an interview and observation on 11/20/2024 at 3:07 PM Staff W (Charge Nurse, License Practical Nurse- LPN) stated the mattress should be set according to the resident's weight with the firmer setting being appropriate for heavier residents. Staff W looked at the mattress pump and stated firm was not the right setting for Resident 88. Staff W stated it was important to have the mattress at the correct setting to ensure the right amount of pressure was offloaded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 106> According to a 09/26/2024 admission MDS, Resident 106 admitted to the facility on [DATE]. The MDS showed Resident 106 had diagnoses of, but not limited to, Alzheimer's Disease, Non-Alzheimer's Dementia, and was legally blind. Review of a 10/23/2024 incident report showed a post fall/injury huddle report conducted immediately after Resident 106 fell showing fall mats needed to be in place. Review of a revised 11/14/2024 at risk for fall and injury CP showed staff would maintain Resident 106's room and pathways free of clutter and ensure adequate lighting. Resident 106's CP showed no interventions of fall mats. Observation on 11/15/2024 at 9:31 AM showed Resident 106 with their bed in the lowest position and a fall mat on the floor next to the right side of their bed. In an interview on 11/14/2024 at 11:48 AM Resident 106 stated they had at least three falls since being at the facility. In an interview on 11/18/2024 at 10:07 AM Staff D (Assistant Director RN) stated when fall mats were utilized for a resident they should be listed on the resident's CP. Staff D reviewed Resident 106's records and stated the fall mats were not on their CP but should be. <Resident 169> According to a 10/07/2024 admission MDS Resident 169 admitted [DATE]. The MDS showed it was very important to Resident 169 to be choose between a bath, bed bath, or shower. The assessment showed Resident 169 did not have behaviors of rejection of care. The assessment showed Resident 169 required maximal assistance from staff for showers/bathing. Review of a revised 10/22/2024 Activities of Daily Living (ADL) CP showed Resident 169 was dependent on one staff for showers. Record review of an October 2024 documentation survey report showed Resident 169's bathing preference as specify, and was not completed/individualized. Review of Resident 169's November 2024 documentation survey report showed the same for bathing preferences as the October 2024 report. In an interview on 11/19/2024 at 8:29 AM Resident 169 stated they reported to staff they could not take shower's due to childhood trauma. Resident 169 stated they told staff they would agree to a bed bath as long as staff told them what they were going to do before they started. In an interview on 11/18/2024 at 1:36 PM Staff B stated they expected staff to ask resident's their bathing preferences and document in the resident's CP. Staff B stated if the resident changed their mind and preferred something different, staff was expected to update the CP. <Care Conferences> <Resident 134> According to a 10/11/2024 admission MDS Resident 134 admitted to the facility on [DATE]. The assessment showed Resident 134 had no memory impairment and was cognitively intact. Review of a 10/15/2024 Alteration in Health Maintenance related to Nursing Home Placement CP showed the facility would invite Resident 134's family to participate in the resident's care conferences. In an interview on 11/14/2024 at 10:19 AM Resident 134 stated they did not have a care conference since admitting to the facility. Resident 134 stated they were at the facility for about four weeks. Record review on 11/17/2024 showed no documentation in Resident 134's records of a care conference occuring. In an interview on 11/18/2024 at 8:44 AM Staff K (Social Worker) stated Resident 134 admitted not too long ago on 10/05/2024 and they did not have a care conference yet. <Resident 17> According to a 10/25/2024 Quarterly MDS Resident 17 admitted to the facility on [DATE]. The MDS showed Resident 17 wanted staff to discuss discharge plan preferences with them with each comprehensive assessment. In an interview on 11/13/2024 at 1:44 PM Resident 17 stated staff did not conduct a care conference with them since they admitted to the facility. Review of Resident 17's records on 11/17/2024 showed no documentation in their records of a care conference being conducted. In an interview on 11/18/2024 at 8:46 AM Staff L (Social Service Director) stated they oversaw the Social [NAME] department and expected residents to be offered a care conference upon admit, quarterly, and as needed or requested by the resident or resident representative. In an interview on 11/18/2024 at 9:14 AM Staff K stated they did not offer Resident 17 a care conference yet. Staff K stated Resident 17 was only at the facility for six months. Staff K stated Resident 17 preferred to discuss discharge annually. Staff K stated discharge was not the only topic they were expected to discuss at a care conference. Staff K stated Resident 17 knew they could request a care conference if they wanted one. REFERENCE: WAC 388-97-1020(2)(c)(d). Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated as needed to reflect changes in resident's care needs for 5 (Residents 45, 83, 156, 106, 169) of 36 sample residents whose CPs were reviewed and failed to provide care conferences as required for 2 (Residents 134 & 17) of 36 sample residents whose CPs were reviewed. The failure to update CPs with changes in residents' health status placed residents at risk for unmet care needs, unnecessary care, and frustration. Findings included . <Facility Policy> According to the facility's January 2024 Care plans - Comprehensive person centered policy, CPs would be revised as information about the residents and the residents' conditions change. <CP Revision> <Resident 45> According to a 10/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 45 had minimal difficulty with hearing while using a hearing appliance, had no wandering behaviors, and was assessed to be dependent on staff for transfers from the bed to a chair. Review of a revised 07/15/2023 communication Care Plan (CP) showed directions to staff to ensure Resident 45's pocket talker/amplifier (a handheld device that amplifies sound through earphones) was within reach and working. Observations on 11/13/2024 at 8:35 AM & 1:55 PM, 11/14/2024 at 11:27 AM, and 11/15/2024 at 8:44 AM & 1:28 PM showed Resident 45 sitting up in a wheelchair near the nurse's station with no pocket talker or amplifier nearby. Review of a revised 06/17/2023 elopement risk/wanderer CP showed an intervention giving directions to staff to distract Resident 45 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books and stated, Resident prefers but identified no preferences. Review of a revised 06/28/2024 self-care performance CP showed directions to staff to bring Resident 45 to the gym for their restorative program at 10:30 AM on Monday, Wednesday, and Fridays. Observations on 11/13/2024 at 10:28 AM showed Resident 45 sitting in a wheelchair nearby the nurse's station watching television. In an interview on 11/20/2024 at 12:57 PM, Staff E (Charge Nurse - Registered Nurse) stated Resident 45 no longer used a pocket talker or amplifier and indicated the resident only used a white board for communication with others. Staff E stated Resident 45 no longer had any elopement or wandering behaviors. Staff E stated Resident 45 was on end-of-life services and no longer went to the gym for their restorative program. Staff E stated Resident 45's CP needed to be revised to reflect the resident's current conditions. <Resident 83> According to a 10/01/2024 Significant Change MDS, Resident 83 was assessed with no broken or loosely fitting full or partial dentures. This MDS showed Resident 83 had no active infection identified and did not receive antibiotic medications during the assessment period. Observations on 11/13/2024 at 10:34 AM showed Resident 83's upper denture moving up and down when the resident was talking. In an interview at this time, Resident 83 stated they usually use denture adhesive but did not always, get around to it. Similar observations of Resident 83's upper denture moving up and down were noted on and 11/15/2024 at 8:46 AM. Review of a revised 07/18/2024 oral/dental health CP showed Resident 83 had a partial upper denture. In an interview on 11/20/2024 at 12:57 PM, Staff E stated Resident 83 no longer had an upper partial. Staff E stated Resident 83 had a full upper denture now and indicated staff should have updated and revised the resident's CP. Review of a revised 09/11/2024 antibiotic therapy CP showed directions to staff to administer an antibiotic medication and to monitor and document for any side effects and effectiveness every shift. Review of Resident 83's September 2024 Medication Administration Record (MAR) showed Resident 83 started an antibiotic for an infection on 09/11/2024, continued for five days, and received their last dose on 09/16/2024. <Resident 156> According to a 10/17/2024 admission MDS, Resident 156 had clear speech, was understood, and able to understand others. This MDS showed Resident 156 was dependent on staff to roll from side to side in bed and it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. In an interview on 11/14/2024 at 10:31 AM, Resident 156 stated they received assistance with bathing one time weekly but preferred bathing more often. Review of Resident 156's bedside [NAME] (directions to staff regarding how to provide care) as of 11/12/2024 showed, Bathing (Prefers: SPECIFY) This [NAME] did not specify what Resident 156's bathing preferences were. In an interview on 11/20/2024 at 12:57 PM, Staff E stated Resident 156's CP should be updated to include their bathing preferences. In an interview on 11/20/2024 at 2:33 PM, Staff B (Director of Nursing) stated CPs were important and were used to coordinate a resident's care with all other staff. Staff B stated it was their expectation CPs be updated and revised daily and based on any changes that occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 144> According to an 11/08/2024 Quarterly MDS, Resident 144 admitted on [DATE] with a diagnosis of, but not limited to, cancer. The MDS showed Resident 144 received pain medications during the assessment period but did not receive any non-medication interventions for pain. Review of a revised 11/08/2024 Care Plan (CP) showed Resident 144 was at risk for malnutrition with an intervention to monitor for signs of pain affecting their appetite. The CP showed Resident 144 had potential for pain due to a tumor under their left armpit and the resident would verbalize adequate relief of pain. In an interview on 11/15/2024 at 8:58 AM Resident 144 stated their left shoulder was always in pain. Resident 144 stated they had talked to the doctor about the constant pain in their left shoulder but did not receive a change in their pain medications. Review of Resident 144's September, October, and November 2024 MARs showed a physician's order to monitor pain three times a day (every shift). The physician's order included directions to document Resident 144's pain level, what non-medication interventions were administered, and if the non-medication interventions were effective or not. The MARs showed NA=Not Applicable documented for Resident 144's pain assessment on 223 out of 231 required assessments without explanation or further notes regarding their pain. Resident 144's September, October, and November MARs showed physician's orders for one as-needed narcotic pain medication and two as-needed, non-narcotic pain medications for pain. The three pain medication orders did not have parameters directing staff which pain medication to administer to Resident 144 for what level of pain. In an interview on 11/20/2024 at 10:08 AM Staff B stated they expected staff to include parameters for pain medications within the physician order, to document the pain level on a scale of 0-10 on pain assessments, and to document if non-medication interventions were administered and their effectiveness. Staff B stated parameters for different pain medications were important to ensure the facility was not administering unnecessary doses when not needed. Staff B stated the orders should have parameters, and gave examples of pain levels of 3-5/10 administer the lower dose pain medication, and for the narcotic/stronger pain medication, administer for pain levels of 6-10/10. <Medication Timeliness> <Facility Policy> According to the facility's revised 08/26/2024 Medication Administration policy, the facility would ensure medications were administered by licensed nurses or other staff who are legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice. The policy showed staff would on the MAR the resident's name and the correct name, form, dose, route of administration, and time of the medication. The facility policy showed staff would administer medications to residents within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. <Facility Process> On 11/20/2024 at 11:52 AM Staff B stated the facility's process was for medications to be administered within one hour before or after the scheduled time. <Resident 432> Observation of medication pass on 11/15/2024 at 9:47 AM, showed Staff T (Medication Tech) enter Resident 432's room to administer the resident's morning medications. Review of November 2024 MAR on 11/15/2024 showed Resident 432's medications were ordered to be administered at 8:00 AM, or within an hour before or after 8:00 AM. In an interview on 11/15/2024 at 9:53 AM, Staff T stated they should have administered the medications to Resident 432 that were due at 8:00 AM between 7:00 AM and 9:00 AM. Staff T stated medications should be administered an hour before or an hour after the scheduled time. In an interview on 11/20/2024 at 12:57 PM, Staff B stated they expected staff to administer medications within the allotted time window of one hour before or after the scheduled time as facility policy. Staff B stated the 8:00 AM medications should have been administered between 7:00-9:00 AM and if staff was unable to administered within that timeframe, they were to notify the provider and update the order. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). Based on observation, interview, and record review the facility failed to ensure physician's orders were clarified for 2 of 36 sampled residents reviewed (Residents 88 & 144), and failed to ensure medications were administered timely for 1 of 5 sample residents (Resident 432) observed during medication pass. These failures placed residents at risk for ineffective treatments, inappropriate medications, and delayed treatment. Findings included . <Clarifying Orders> <Resident 88> According to the 09/13/2024 Quarterly Minimum Data Set, Resident 88 was assessed to have a severe memory impairment, and diagnoses including anxiety and depression. The MDS showed Resident 88 took an antidepressant medication. Review of the November 2024 Medication Administration Record (MAR) showed Resident 88 had a 07/31/2019 physician's order for an antidepressant medication, give 1 tablet once a day for depression/anxiety. In an interview on 11/21/2024 at 10:48 AM, Staff B (Director of Nursing) reviewed Resident 88's antidepressant order and stated it needed clarification. Staff B stated psychotropic medication should only be prescribed to treat one specific diagnosis or condition. Staff B stated the order should not show it was prescribed for both anxiety and depression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL) related to toileting, cleanliness, and grooming for 2 (Residents 106 & 119) of 7 sample residents reviewed for ADLs. The failure to provide residents who were dependent on staff assistance the toileting, dressing, and shaving assistance they required placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life. Findings included . <Facility Policy> According to the facility's undated Activities of Daily Livings policy, the facility would provide ADLs in accordance with residents' comprehensive assessment, Care Plan (CP), and resident preferences to ensure residents' ADL abilities did not diminish unless a decline in function was unavoidable. <Toileting> <Resident 106> According to a 09/26/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 106 was dependent on staff for toileting hygiene. The MDS showed Resident 106 was frequently incontinent of urine. The assessment showed the facility did not conduct a toileting program to manage Resident 106's incontinence. The MDS showed Resident 106 had diagnoses including blindness. Review of a 09/24/2024 blindness CP showed staff would provide Resident 106 supervision with ambulating with a walker. Review of a revised 11/02/2024 impaired skin integrity CP showed staff would provide toileting before and after each meal, at bedtime, and every three hours at night while awake. Review of an 11/14/2024 alteration in urinary elimination CP showed staff would provide toileting assistance before and after meals, at bedtime, and every three hours at night while awake. Review of an 11/14/2024 at risk for falls CP showed staff would assist Resident 106 with toileting every two hours when awake, before and after meals, at bedtime, and at routine intervals during the night. The fall CP showed staff would maintain Resident 106's room and pathways clear of clutter and ensure adequate lighting. Review of a 09/26/2024 bowel and bladder evaluation showed Resident 106 always voided appropriately without incontinence. The evaluation showed Resident 106 had incontinence due to their limited mobility and required toileting assistance from staff. The evaluation showed Resident 106 was sometimes aware of the need to use the toilet. The evaluation showed Resident 106 required two-person assistance with toileting hygiene and staff would provide toileting before and after each meal, at bedtime, and every three hours during night when awake. In an observation and interview on 11/14/2024 at 8:22 AM Resident 106 used their call light to request assistance to get up to use the toilet. Staff M (Certified Nursing Assistant - CNA) and Staff G (CNA) answered Resident 106's call light. Staff M reviewed the care directive sign in Resident 106's room showing two-person assistance with toileting. Staff M stated they did not work with Resident 106 previously and wanted to check with the charge nurse before transferring Resident 106. Staff M returned to Resident 106's room with Staff N (Primary Registered Nurse- RN). Staff N asked Resident 106 if they could go to the bathroom in your bed, and have staff assist with clean up. Resident 106 stated they could not go in their bed. Staff N instructed Resident 106 they needed to go to the bathroom in their bed because therapy said it was not safe to transfer them. Staff N stated therapy updated the care directive signs in residents' rooms and they were unsure why the sign for Resident 106 showed to use two-person assistance. Staff N stated they told residents to void in their beds and instructed them staff would clean them up when they were done. Staff N stated they should not instruct residents to go in their pants for the residents to maintain their ability to stay continent and for the resident's dignity and respect. In an interview on 11/19/2024 at 9:10 AM Staff B (Director of Nursing) stated they expected staff to follow the residents CP for toileting. Staff B stated staff were not to instruct a resident to go to the bathroom in their pants when they called for assistance to use the toilet. Staff B stated it was important for staff to provide assistance to residents requesting toilet assistance and according to the residents CP in order to maintain their ADL abilities and for the resident's dignity. <Dressing/Shaving> <Resident 119> According to a 09/17/2024 Quarterly MDS, Resident 119 admitted on [DATE], was cognitively impaired and required total assistance from staff with personal hygiene and dressing. The MDS showed Resident 119 demonstrated a behavior of rejecting care one-to-three times during the assessment's look back period. According to the 03/10/2023 ADL self-care performance deficit revised Care Plan, Resident 119 was dependent on staff for personal hygiene including dressing and shaving. Observation on 11/14/2024 at 11:44 AM and 11/15/2024 at 9:31 AM showed Resident 119 seated in their wheelchair in the dining area, wearing the same blue sweatshirt on both days. Observation on 11/18/2024 at 9:51 AM showed Resident 119 was again seated in their wheelchair in the dining area wearing the same blue sweatshirt now with food stains. Observation at this time showed Resident 119 was not shaved. In an interview on 11/20/2024 at 11:17 AM, Staff D (Assistant Director RN) and Staff S (Charge Nurse, Licensed Practical Nurse - LPN) stated they expected staff to check all residents' preferences related to ADLs and to provide assistance every morning. Staff D stated staff should have changed Resident 119's clothes every morning and as needed, and shaved Resident 119 as they allowed. Staff D stated if the resident refused, staff should document the refusals, but they did not. REFERENCE: WAC 388-97-1060(2)(C). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 2 of 2 sampled residents (Resident 106 & 142) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Policy> According to a facility policy titled, Activity Policy and Procedures, revised 08/2018, showed staff would provide meaningful activities to residents to address their physical, mental, and psychosocial well-being. The policy showed activities would be offered in a variety of formats, various times of day, and each day of the week taking into consideration each individual's abilities, needs, and preferences. The policy showed activity staff would document residents' attendance in activities in the residents health records under a progress note. The policy showed residents would receive assistance needed to participate in activities such as staff escort to/from activity, and staff would remind residents of their stated activities of interest when they were scheduled. <Resident 106> According to a 09/26/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 106 admitted to the facility on [DATE]. The MDS showed staff did not conduct an activities preference interview with Resident 106 because they were rarely/never understood. The MDS also showed Resident 106 was sometimes able to understand others and make themselves understood. The assessment showed staff completed an assessment of Resident 106's activity preference and found Resident 106 preferred participating in their favorite activities and religious activities. Review of a 10/20/2024 Activity Deficit and Social Isolation CP Resident 106 would receive visits from a Rabbi. The CP showed the Rabbi requested staff to message them when Resident 106 wanted a visit. The CP showed staff would invite Resident 106 to live music opportunities. The CP showed staff would monitor Resident 106's satisfaction with activities through verbal check ins. Review of a 10/20/2024 Alteration in Mood and Behavior related to Dementia and Depression CP staff would escort and encourage Resident 106 to activities of choice/preference. In an interview on 11/14/2024 at 8:20 AM Resident 106 stated they don't have any activities for them. Resident 106 stated staff did not bring them any activities to do or invite them to any activities so they would just sit in bed all day. In an interview on 11/20/2024 at 1:27 PM Staff K (Social Worker) stated they did not currently have an activities coordinator for the long-term care and hospice units. Staff K stated Staff Y (Assistant Director of Life Enrichment) oversaw activities and they documented the activities provided to residents in the resident's progress notes in their health records. In an interview on 11/20/2024 at 1:33 PM Staff Y reviewed Resident 106's health records and stated no activities were documented as offered or refused since the resident had admitted on [DATE]. <Resident 142> According to a 08/30/2024 Quarterly MDS Resident 142 admitted [DATE] and only spoke and understood the Bosnian language. The MDS showed it was somewhat important for Resident 142 to listen to music, have books, newspaper, and magazines to read, be around animals, and participate in religious activities. Review of Resident 142's CP showed a 08/30/2024 Activity CP with an intervention staff would provide a weekly activity calendar. Review of an 11/04/2024 Alteration in Mood and Behavior CP showed staff would escort Resident 142 to activities. Observations on 11/12/2024 at 9:13 AM, 11/13/2024 at 2:21 PM, 11/14/2024 at 11:08 AM, 11/15/2024 at 12:22 PM, 11/18/2024 at 1:11 PM, and 11/20/2024 at 10:43 AM showed Resident 142 lying in their bed with their lights off. In an interview on 11/13/2024 at 7:28 PM Resident 142's family member stated the resident mostly stayed in their room since admission to the facility. In an interview on 11/20/2024 at 1:33 PM Staff Y stated they oversaw the activities department because they did not currently have a Director of Activities. Staff Y stated activities that were offered or refused by a resident were documented in the resident's health records under progress notes as an activity note. Staff Y reviewed Resident 106's health records and stated no activities were documented as offered or refused since the resident had admitted on [DATE]. Staff Y stated the activities staff member for the hospice and long-term care unit had moved on a few months ago and that Staff K oversaw activities on those units. Staff Y reviewed Resident 142's health records and stated there were no activities documented since their admission except that the resident enjoyed visits from family. In an interview on 11/20/2024 at 1:33 PM Staff Y reviewed Resident 142's health records and stated there were no activities documented since this admission except that the resident enjoyed visits from family. REFERENCE: WAC 388-97-0940 (1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 429> According to an 11/10/2024 admission MDS, Resident 429 admitted to the facility on [DATE] and had diagnoses of dementia and Diabetes. The Diabetes condition included physician orders for injectable anti-diabetic medication to treat Resident 429's condition. Review of the Diabetes CP dated 11/04/2024, showed Resident 429 had Diabetes. Goals listed on the CP showed Resident 429 would be free from any signs and symptoms of hyperglycemia. Interventions listed on the CP showed the staff were to monitor and document side effects and effectiveness, educate as needed on medications and the importance of compliance, and to have the resident verbally state an understanding. No other interventions were provided for signs or symptoms to watch for if the resident had hyperglycemia. Review of Medication Administration Record (MAR) for November 2024, showed an 11/04/2024 order directing staff to administer the injectable anti-diabetic medication per sliding scale according to Resident 429 blood sugar results. Nurses were to check blood sugar results before meals and at bedtime. If blood sugar results were higher than 350 milligrams/deciliter the nurse would call the provider. No signs or symptoms were listed on the MAR to watch for if the resident had hyperglycemia. Observation on 11/12/2024 at 11:16 AM Staff I (Medication Tech) performed a blood sugar check on Resident 429 and the blood sugar reading result was 401. Staff I stated this blood sugar reading was high for this resident and notified the nurse. Review of the November Treatment Administration Record (TAR) showed eight times between November 8th and November 15th, Resident 429's blood sugar results were over 350. No signs or symptoms were listed on the TAR directing staff on what to watch for or what to do for hyperglycemia. Review of the November 2024 [NAME] (caregiver information sheet) for Resident 429 did not show instructions on symptoms to watch for if resident had hyperglycemia. Review of the November 2024 caregiver task list for Resident 429, did not show symptoms to observe for hyperglycemia and did not show what to do if hyperglycemia symptoms were observed. In an interview on 11/18/2024 at 10:23 AM Staff D stated staff should be documenting for signs and symptoms of low or high blood glucose levels. Staff D stated it was important to monitor for signs of low or high blood glucose levels in residents with Diabetes, so the resident did not become unconscious. REFERENCE: WAC 388-97-1060(1),(3)(c)(j). Based on observation, interview, and record review the facility failed to ensure 3 of 36 sampled residents (Residents 429, 142, & 169) reviewed for care and services, received the necessary care and services they required in accordance with professional standards of practice. The facility failed to monitor resident's hypo/hyperglycemia (high and low blood sugar levels) symptoms and follow bowel management protocols that placed residents at risk for delays in treatment, potential decline in health, and other negative health outcomes. <Facility Policy> According to the facility's undated, Principals and Practices Glycemic Management in Diabetic Residents policy, the licensed nurse would identify signs and symptoms of hypo/hyperglycemia, respond promptly in providing appropriate interventions to restore the resident's blood sugar level, prevent reoccurrences of hypo/hyperglycemia, and prevent complications. The policy showed the Care Plan (CP) would establish measurable goals for the resolution for the problem, develop an individualized plan to treat the condition, observe and monitor resident's response to treatment, preventative and safety measures. The CP would also include observations and reporting of complications, and provide all nursing care necessary to care for resident's conditions, to prevent complications. According to a facility policy titled Bowel Management, dated 10/2024, the staff would implement the facility's bowel protocol if the resident did not have a Bowel Movement (BM) after two days. The policy showed the bowel protocol as follows; if no BM for two days, staff would administer a powdered laxative (medication that treats constipation) mixed in water on day three, if no BM for eight hours, staff would administer a pill form laxative, if no BM after eight additional hours, staff would administer a rectal suppository laxative, then if no BM after these laxative medications, staff would perform an assessment of the resident to rule out a bowel blockage and notify the physician for further instructions. <Resident 142> According to an 08/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 142 had diagnoses of Diabetes (unstable blood glucose levels) and constipation. The MDS showed Resident 142 received injectable medication daily to assist in managing their blood glucose level. The MDS showed Resident 142 was frequently incontinent of bowels. Review of Resident 142's CP showed a 07/15/2024 revised Diabetes CP directing staff to monitor and document signs of low or high blood glucose levels for Resident 142. The CP showed a revised 08/07/2024 constipation CP directing staff to follow the facility bowel protocol for bowel management. Review of Resident 142's records showed no documentation of staff monitoring for signs and symptoms of hypo/hyperglycemia. Resident 142's records showed no BM on 10/30/2024, 10/31/2024, or 11/01/2024. These records showed the facility's bowel protocol was not initiated for Resident 142. In an interview on 11/18/2024 at 10:23 AM Staff D (Assistant Director RN) stated staff should be documenting signs and symptoms of hypo/hyperglycemia for Resident 142, but they were not. Staff D stated it was important to monitor for signs of hypo/hyperglycemia in residents with Diabetes, so the resident did not go unconscious. Staff D stated staff did not implement the facility's bowel protocol for Resident 142 but should have on 11/01/2024. <Resident 169> According to a 10/07/2024 admission MDS, Resident 169 had diagnoses including constipation. The MDS showed Resident 169 was dependent on staff for toileting hygiene. The assessment showed resident 169 was always continent of bowels. Review of Resident 169's CP showed a 10/03/2024 potential for altered bowel function/constipation CP, directing staff to administer bowel medications as ordered. The CP listed a goal for Resident 169 to have a BM every two days. Review of Resident 169's records showed no BM on 10/24/2024, 10/25/2024, or 10/26/2024 and no BM on 11/03/2024, 11/04/2024, or 11/05/2024. These records showed the facility's bowel protocol was not initiated for Resident 169. In an interview on 11/18/2024 at 10:23 AM Staff D stated Resident 169 did not have a BM on 10/24/2024, 10/25/2024, or 10/26/2024 and did not have a BM on 11/03/2024, 11/04/2024, or 11/05/2024. Staff D stated staff did not implement the facility's bowel protocol at these times but should have. Staff D stated it was important to administer the bowel protocol per facility policy after no bowel movement for two days because the resident could end up with a blockage in their intestines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 134> According to a 10/11/2024 admission MDS Resident 134 admitted [DATE]. The MDS showed Resident 134 did not receive restorative exercises during the assessment period. Review of a 10/10/2024 Restorative CP Resident 134 was to receive RNP 15 minutes 3-5 times a week. Review of RNP November 2024 documentation showed Resident 134 was only offered their restorative program two times for the week of the 10th to the 16th. In an interview on 11/14/2024 at 10:33 AM Resident 134 stated staff was supposed to offer them their exercise program three times a week. Resident 134 stated they were not always offered their RNP three times a week. <Resident 144> According to 08/09/2024 Quarterly MDS Resident 144 admitted to the facility on [DATE]. The MDS showed Resident 144 received one day of ROM restorative exercises during the seven-day assessment period. Review of Resident 144's health records showed a 02/29/2024 physician order for a RNP three times a week. Review of a 05/09/2024 Restorative CP showed Resident 144 was to receive upper extremity weightlifting exercises and lower body weight exercises 2-3 times a week. Review of RNP November 2024 documentation showed Resident 144 was only offered their restorative program one time for the week of the 10th to the 16th. In an interview on 11/13/2024 at 9:58 AM Resident 144 stated staff sometimes did exercises with them, but not very often. In an interview on 11/20/2024 at 10:08 AM Staff B (Director of Nursing) stated they expected the restorative aide to document the RNP per physician order and CP in the resident's health records per their individual program. Staff B stated if the resident refused or if staff documented not applicable, they expected the restorative aide to document the refusal or an explanation for the not applicable documentation. REFERENCE: WAC 388-97-1060(3)(d). Based on observation, interview, and record review the facility failed to provide Restorative Nursing Program (RNP), rehabilitative treatment/services and to follow the physician orders for 3 of 5 residents (Residents 27, 134, & 144) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Resident 27> According to a 09/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 27 had limited ROM to both arms and legs. Resident 27 required total assistance from staff with personal hygiene, bed mobility, transfers, dressing, and toileting. The MDS showed Resident 27 had no rejection of care during the assessment period. Review of Resident 27's November 2024 physician orders directed staff to apply a palm protector to Resident 27's right hand contracture and keep the palm protector on at all times. This order directed staff to remove the palm protector every morning to clean the resident's hand and check their skin every shift. Review of the 06/20/2023 Activities of Daily Living (ADL) revised Care Plan (CP) showed Resident 27 was dependent on staff for all ADLs. The CP instructed staff to apply the palm protector to Resident 27's right hand contracture and leave the palm protector on at all times. This CP directed staff to remove the palm protector one time daily in the morning to wash Resident 27's right hand and check skin every shift. Observations on 11/14/2024 at 10:25 AM, on 11/15/2024 at 9:00 AM and 10:55 AM showed Resident 27 with no palm protector on their right hand. The palm protector was observed sitting on the nightstand in Resident 27's room. In an interview on 11/15/2024 at 11:34 AM, Staff F (Med Tech) reviewed Resident 27's POs and stated the palm protector should be on Resident 27's right hand at all the times but it was not on. In an interview on 11/19/2024 at 9:38 AM, Staff D (Assistant Director RN) stated staff should follow the physician orders to apply the palm protector on Resident 27's right hand. Staff D stated if the resident refused to wear the brace, staff should document the refusal and notify the charge nurse but they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 169> According to a 10/07/2024 admission MDS Resident 169 admitted to the facility on [DATE]. The MDS showed Resident 169 was not up to date on their pneumococcal vaccine. Review of Resident 169's health records showed a 10/01/2024 pneumococcal vaccine consent form stated the resident already received the pneumococcal vaccine. Resident 169's health records did not contain documentation to support the resident received a pneumococcal vaccine while at the facility or outside of the facility. In an interview and record review on 11/19/2024 at 10:54 AM Staff O stated they did not check the Washington State Immunization Information System (WAIIS) yet to confirm the resident was up to date on their pneumococcal vaccine. Staff O pulled up Resident 169's immunization records in WAIIS at this time and stated they were not up to date on their pneumococcal vaccine. REFERENCE: WAC 388-97-1340(1)(2). Based on interview and record review, the facility failed to ensure 2 (Resident 45 & 169) of 5 sampled residents, reviewed for vaccinations, were up to date on the current recommendations from the Center for Disease and Control and Prevention (CDC) related to pneumococcal vaccinations. This failure placed residents at risk for contracting pneumonia, with their associated complications of infection. Findings included . <Facility Policy> According to the facility's revised 09/06/2024 Resident Vaccination Program policy, all newly admitted residents would be assessed for eligibility for the pneumonia vaccine. The policy showed residents would be educated about the benefits of the vaccine and the appropriate pneumonia vaccine would be offered. <Resident 45> According to a 10/3/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 was admitted to the facility on [DATE] and was up to date with their Pneumococcal vaccinations. Review of Resident 45's records showed two historical entries under the immunization section showing the resident received the following prior to admission: a Pneumovax Dose 1 on 10/26/1999; and a Pneumovax Dose 2 on 02/18/2016. These records did not indicate which form of Pneumovax doses Resident 45 received therefore the facility was unable to be determined if the resident was up to date with their Pneumococcal vaccinations. Review of the current October 26, 2024, CDC Pneumococcal Vaccine Recommendations showed, if a Pneumococcal Conjugate Vaccine 13 (PCV13) was not previously administered or if it was unknown if the PCV13 was administered, adults 50 years or older, should receive a PCV15, PCV20, or PCV21. In an interview on 11/20/2024 at 3:45 PM, Staff O (Charge Nurse/Infection Preventionist) stated they had recently been covering the infection control nurse position while that staff member was on leave from work. Staff O stated the electronic records software was updated, about a month ago and that function removed what actual Pneumovax doses Resident 45 received. At this time, Staff O reviewed Resident 45's state immunization registry which showed the resident received an unspecified formulation of a pneumococcal on 10/26/1999 and a Pneumococcal Polysaccharide Vaccine (PPSV23) on 02/18/2016. Staff O stated it was important for a resident to be up to date with their pneumococcal vaccinations because the variants change, and it help prevents a resident from spreading and getting respiratory diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> According to a 08/13/2024 Discharge Return Anticipated MDS Resident 17 was transferred to an acute care hospital on [DATE]. Review of an 08/13/2024 Hospital Transfer Form showed Resident 17 was transferred to an acute care hospital for evaluation and treatment of a viral infection. Resident 17's records included a census report which showed the resident transferred out to a hospital on [DATE] and returned to the facility on [DATE]. Resident 17's records showed no documentation that a written transfer notification was provided to the resident or their representative. <Resident 142> According to a 06/07/2024 Discharge Return Anticipated MDS Resident 142 was transferred to an acute care hospital on [DATE]. Review of an 06/07/2024 Hospital Transfer Form Resident 142 was transferred to an acute care hospital for evaluation and treatment of respiratory distress. Review of Resident 142's records showed a census report which showed they transferred to a hospital on [DATE] and returned to the facility on [DATE]. Resident 142's records showed no documentation that a written transfer notification was provided to the resident or their representative. In an interview on 11/20/2024 at 10:08 AM Staff B stated they were unable to locate documentation showing a written transfer notification was provided to Resident 17, Resident 142, or their representatives. Staff B stated they would talk to the charge nurse and provide further documentation if located. Staff B did not provide any further documentation for Resident 17's or Resident 142's written transfer notifications. REFERENCE: WAC 388-97-0120(2)(a-c). Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 (Residents 133, 17, & 142) of 6 residents reviewed for hospitalizations. Failure to ensure written notification was provided to the resident and/or the resident's representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . <Facility Policy> According to the facility's undated Transferor Discharge policy, for residents transferring/discharging emergently, notice of the transfer would be provided in writing to the resident or their representative as soon as practicable. The policy showed this notice would include contact information for the Long-Term Care Ombudsman. <Resident 133> Review of Resident 133's 05/29/2024 and 08/09/2024 Discharge Minimum Data Sets (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE] and 08/09/2024, with their return anticipated. Record review showed no documentation staff completed a transfer/discharge notice when Resident 133 was transferred to the hospital on [DATE]. A Transfer/Discharge notice from the 08/09/2024 hospitalization was completed by staff, but did not include any documentation the form was provided to Resident 133 and/or their representative as required. In an interview on 11/20/2024 at 12:57 PM, Staff E (Charge Nurse, Registered Nurse - RN) stated they were the usual charge nurse for the unit and were responsible for completing the transfer/discharge form when a resident was sent out to the hospital. Once the form was completed, Staff E stated they faxed a copy to the State Long-Term Care Ombudsman (an advocacy group for individuals residing in nursing homes). Staff E stated they did not provide a copy to the resident and/or their representatives. In an interview on 11/20/2024 at 2:33 PM, Staff B (Director of Nursing) stated it was their expectation the resident and/or the resident's representative be provided the notice which included their appeal rights. Staff B reviewed Resident 133's records and was unable to locate a transfer/discharge notice was completed by staff for the 05/29/2024 transfer to the hospital and was unable to find documentation the 08/09/2024 transfer/discharge notice was provided to Resident 133.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 115> According to the PASRR section of the 10/21/2024 Significant change MDS, Resident 115 was not considered by the state level II process to have a SMI or related condition. The MDS showed Resident 115 had a psychiatric/mood disorder. According to the 11/04/2024 Care Area Assessment (CAA) Resident 115 had a changing cognitive status and a mood decline, received psychoactive medications, had mental errors, and had psychological/mood problems. According to the 09/28/2024 Mood CP, Resident 115 had alterations in mood and behavior related to their psychiatric/mood disorder. Interventions listed on the mood CP showed that staff were to redirect Resident 115's behavior if they became aggressive, agitated, or restless. According to the 09/28/2024 PASSR CP, Resident 115's PASRR status was negative for a Level II evaluation. The CP included a goal for Resident 115 to remain stable. The CP showed the social worker would reassess Resident 115's PASSR status annually and upon a significant change. Record review showed a PASSR Level I was completed on 10/15/2024 showing Resident 115 had a mood disorder. The Level I form showed no Level II evaluation was indicated as the resident did not show a SMI indicator. Observation on 11/15/2024 at 10:24 AM showed Resident 113 began talking about a missing hearing aid, then switched conversation to talk about when they went to the hospital and had a fall, and then returned to talking about their missing hearing aid again. Resident 113 looked around their room and stated they saw flying bugs in the bedsheets and around them. No observations of flying bugs were shared by this surveyor. Review of an 11/15/2024 physician progress note showed staff reported Resident 115 appeared more confused, had fluctuating mentation and was fixated on finding French Street where there was a brown church. Resident 115 was not sure where they currently were. In an interview on 11/20/2024 at 3:01 PM, Staff C stated they did not seek a Level II PASRR referral as indicated because they did not know the process for PASRR II evaluations. REFERENCE: WAC 388-97-1915(1)(2)(a-c). <Resident 169> According to a 10/07/2024 admission MDS Resident 169 admitted to the facility on [DATE]. The assessment showed Resident 169 had diagnoses including an anxiety disorder and depression. Review of a 10/01/2024 Level I PASRR showed Resident 169 had a mood disorder and anxiety disorder listed as SMIs. The PASRR Level I for Resident 169 was marked no level II evaluation indicated. In an interview on 11/20/2024 at 2:39 PM Staff C stated Resident 169 should have been referred for a level II PASRR evaluation but were not.<Resident 27> According to a 09/06/2024 Quarterly MDS Resident 27 had diagnoses including non-Alzheimer's dementia, Psychotic disorder, and depression. The MDS showed Resident 27 received antidepressant medications during the assessment period. Observations on 11/14/2024 at 11:21 AM, on 11/15/2024 at 1:23 PM, and on 11/18/2024 at 11:43 AM showed Resident 27 was crying and staff were unable to redirect the resident. Review of Resident 27's records showed a 09/09/2024 physician's order for an antidepressant medication to be administered daily. Record review showed a Level I PASRR for Resident 27 was completed on 08/21/2024. The Level I PASRR listed depression as an SMI indicator. The PASRR I was marked as no level II evaluation indicated. In an interview on 11/18/2024 at 11:47 AM Staff C reviewed Resident 27's record and stated the Level I PASRR was inaccurate. Staff C stated the facility should have listed the psychotic disorder on the PASRR and should have referred Resident 27 for a Level II PASRR evaluation but did not. <Resident 48> According to a 09/04/2024 admission MDS, Resident 48 had diagnoses including an anxiety disorder, depression, and Post-Traumatic Stress Disorder (PTSD - a mental condition caused by an extremely stressful or traumatizing event). The MDS showed Resident 48 received antidepressant medications during the assessment period. Review of Resident 48's November 2024 Medication Administration Record (MAR) showed Resident 48 received two different antidepressant medications daily as ordered by the physician. Record review showed a Level I PASRR for Resident 48 was updated on 09/03/2024. The PASRR was marked no level II evaluation indicated. In an interview on 11/18/2024 at 11:47 AM Staff C stated they were not aware of new regulations requiring a referral for any resident with a mental health issue to the state authority for a PASRR Level II evaluation and determination. Based on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the resident's mental health condition and refer the residents to the appropriate state authority for Level II evaluation and determination for 5 of 9 (Resident 159, 27, 48, 169, & 115) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and /or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 159> According to an 08/12/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 159 had multiple medically complex diagnoses including an anxiety disorder and depression which required the use of psychotropic medications during the assessment period. Review of Resident 159's August 2024 Medication Administration Records (MAR) showed the resident received antidepressant and antianxiety medications. Review of a 05/16/2024 PASRR Care Plan (CP) identified an intervention for the social worker to reassess Resident 159's PASRR status annually and upon significant change. Review of Resident 159's records showed a 05/13/2024 PASRR identifying Resident 159 with Serious Mental Illness (SMI) indicators of a mood disorder and anxiety. Staff documented no PASRR Level II was indicated at that time. There was no updated PASRR in Resident 159's records following the Significant Change identified by staff in August 2024, at which time a PASRR Level II would be indicated as Resident 159 continued to have SMI indicators. In a joint interview with Staff B (Director of Nursing) and Staff C (Assistant Social Services Director), Staff B reviewed Resident 159's records and was unable to find an updated PASRR after 05/13/2024. Staff C confirmed Resident 159 had a Significant Change MDS completed on 08/12/2024, and stated if the change was not temporary, a new PASRR should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 3 of 5 residents (Resident 159, 142, & 45) reviewed for unnecessary medications were free from unnecessary psychotropic medications and monitored for behaviors. Failure to discontinue as needed psychotropic medications after 14 days and to identify/monitor target behaviors for as needed antipsychotic medications placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects. Findings included . <Facility Policy> According to the Psychoactive Medication Program policy revised March 2024, showed as needed psychotropic drugs would be used only if the medication was necessary to treat a specific, diagnosed condition that was documented in the clinical record, and for a limited duration of 14 days. The policy showed the facility would document nonpharmacological interventions and target behavior monitoring for each resident on psychotropic medications. <Resident 159> According to an 11/02/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 159 admitted on [DATE] with diagnoses of depression and anxiety. The MDS showed Resident 159 received antidepressant and antianxiety medications during the assessment period. Review of Resident 159's records on 11/20/2024 showed a 10/31/2024 physician order instructing staff to administer an antianxiety medication every eight hours as needed for anxiety. Resident 159's November Medication Administration Record (MAR) showed the as needed antianxiety medication was past the 14-day requirement to discontinue the medication. In an interview on 11/20/2024 at 10:08 AM Staff B (Director of Nursing) stated if a resident was receiving a psychotropic medication, they expected staff to obtain a physician order to monitor target behaviors every shift and include a stop date after 14 days for an as needed psychotropic medication. <Resident 142> According to a 06/13/2024 Quarterly MDS, Resident 142 admitted to the facility on [DATE] with a diagnosis of major depressive disorder. The MDS showed Resident 142 was receiving a routine antipsychotic medication during the assessment period. Review of Resident 142's physician orders showed an antipsychotic medication was initiated on 06/13/2024 and staff were to administer the medication to Resident 142 every day at bedtime. Review of a 07/15/2024 antipsychotic use Care Plan (CP) showed Resident 142 had agitated unsafe behaviors. The CP showed Resident 142's target behaviors were agitation and restlessness. Review of a 09/19/2024 pharmacy medication review record showed the pharmacist was unable to locate documentation of target behaviors or individualized behavioral interventions in Resident 142's health records. The medication review showed the pharmacist recommended nursing updated Resident 142's health records to include monitoring the residents specific target behaviors, documentation of frequency and impact of behaviors, nonpharmacological interventions, and overall goals of therapy. The medication review was signed by the physician on 09/26/2024 but not by facility nursing staff. Review of a 10/20/2024 pharmacy medication review record showed the pharmacist was unable to locate documentation of target behaviors or individualized behavioral interventions in Resident 142's health records. The medication review showed the pharmacist recommended a physician order to monitor specific target behaviors for Resident 142 to include documentation of frequency and impact of behaviors, nonpharmacological interventions, and overall goals of therapy. The pharmacy medication review was signed by the physician and Staff D (Assistant Director Registered Nurse- RN) on 10/23/2024. In an interview on 11/18/2024 at 10:23 AM Staff D stated Resident 142 did not have documentation of monitoring their specific behaviors for the antipsychotic mediation but should. Staff D stated they reviewed and signed off on the pharmacy recommendations for Resident 142 to implement the specific behavior monitoring and then handed the recommendation to the charge nurse. In an interview on 11/20/2024 at 10:08 AM Staff B stated if a resident was receiving a psychiatric medication, they expected staff to obtain a physician order to monitor target behaviors every shift and include a stop date after 14 days for an as needed psychiatric mediation. Staff B stated the order should include what the specific behaviors were for the resident, if the resident had any behaviors for that shift, and nonpharmacological interventions. Staff B stated they expected the staff who reviewed and noted the pharmacy medication review to input the pharmacy recommendations into the resident's health records. <Resident 45> According to a 10/03/2024 Quarterly MDS, Resident 45 had multiple medically complex diagnoses including dementia, depression, and an anxiety disorder, and required the use of antipsychotic and antidepressant medications during the assessment period. This MDS showed staff assessed Resident 45 had no wandering behaviors, was unable to walk at least 10 feet, or propel their wheelchair at least 50 feet due to their medical condition or safety concerns. Review of Resident 45's November 2024 MAR showed staff were administering the antipsychotic medication for anxiety/agitation and monitoring for the identified Target Behaviors (TB) of combative behavior towards staff or exit seeking. This MAR showed staff were administering the antidepressant medication for a mood disorder and monitoring for the identified TB of exit seeking behaviors after seeing or speaking with their spouse, self-isolation, or declining activities or to leave their room. Staff documented Resident 45 had no episodes of TBs in November 2024. Observations on 11/13/2024 at 8:35 AM & 1:55 PM, 11/14/2024 at 11:27 AM, and 11/15/2024 at 8:44 AM & 1:28 PM showed Resident 45 sitting up in a wheelchair near the nurse's station. Observations on 11/18/2024 at 8:35 AM showed staff using a mechanical lift to transfer Resident 45 to a wheelchair, staff then assisted the resident with morning care, then pushed Resident 45 in their wheelchair to an area next to the nurse's station. In an interview on 11/20/2024 at 12:57 PM, Staff E (Charge Nurse - Registered Nurse) reviewed Resident 45's identified TBs regarding exit seeking behavior, and stated the resident was not ambulating or observed self-propelling their wheelchair for over six months. Staff E stated Resident 45's TB behaviors needed to be updated and revised. REFERENCE: WAC 388-97-1060 (3)(k)(i). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement an effective Infection Control Program for 4 of 5 units (Units 300 East, 300 North, 300 South, & 100 East) The failure to: ensure facility staff sanitized glucometers (a blood sugar monitoring device); ensure food and drinks were handled in accordance with infection control standards when being distributed on the unit; ensure staff used Personal Protective Equipment (PPE) when required for residents with infectious diseases; perform hand hygiene as required; use appropriate infection control standards during incontinence care and wound care (Residents 156 & 119); and ensure resident rooms were free from staff property; placed residents at risk for exposure to infectious materials, communicable diseases, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 09/06/2024 Infection Control Manual, an effective Infection Control Program required the cooperation of all staff, and any break from technique or policy could lead to exposure for residents or staff. The policy showed staff should use PPE including gloves, eye protection, and masks or respirators as indicated during resident care to minimize exposure to blood, bodily fluids, or aerosolized droplets (moisture from exhalation that could contain respiratory materials). <Shared Glucometer Sanitation> Observation on 11/12/2024 at 11:16 AM showed Staff I (Medication Tech) used a facility glucometer to check Resident 429's blood sugar reading. Staff I completed the blood sugar testing and left Resident 429's room without washing their hands and did not sanitize the glucometer upon exiting. Observation on 11/12/2024 at 11:21 AM showed Staff I completed a blood sugar check for Resident 433 using the same facility glucometer used for Resident 429. After checking Resident 433's blood sugar, Staff I removed their gloves and left the resident's room and did sanitize the glucometer. Observation on 11/12/2024 at 11:24 AM showed Staff I entered Resident 229's room to conduct a blood sugar test. Staff I stated there were no more gloves in the resident's room. Staff I left to get another box of gloves and when they returned, they did not wash their hands before putting on new gloves. Staff I used the same unsanitized glucometer used for Resident 429 and Resident 433 to test Resident 229's blood sugar. In an interview on 11/12/2024 at 12:28 PM, Staff I stated they should have performed hand hygiene before they went into the resident rooms and sanitized when they left but did not. Staff I stated, they should have sanitized the glucometer but did not. Staff I stated both hand hygiene and glucometer sanitizing were important to stop the spread of germs between patients. In an interview on 11/13/2024 at 8:40 AM, Staff J (Primary Registered Nurse - RN) stated staff should sanitize glucometers after every use and should wash their hands before entering a resident's room, when putting gloves on, sanitizing glucometers, and taking off gloves. Staff J stated after glove removal staff should sanitize their hands again. In an interview on 11/13/2024 at 8:45 AM, Staff P (Assistant Director Nursing - RN) stated they did not know Staff I did not sanitize the facility's glucometers. Staff P stated staff should perform hand hygiene first, sanitize the glucometer and provide hand hygiene afterwards. When they go room to room, they should be performing the same thing over again. Staff P stated their staff needed to protect residents from infections by washing hands and sanitizing glucometers. Staff P stated facility trainer would be notified to provide training to the team on glucometer cleaning and hand hygiene. <Uncovered Foods> Observations on 11/12/2024 at 11:47 AM showed staff passing out lunch trays on the 300 North unit from a meal tray cart. Staff pulled a meal tray out of the cart, with an uncovered dessert, and carried the tray past four other rooms to deliver to a resident. Similar observations were made of uncovered fruit and pie being carried in the hallway past several rooms on 11/12/2024 at 11:56 AM. Observations on 11/13/2024 at 11:50 AM showed staff passing out lunch trays on the 300 East unit from a meal tray cart parked next to room [ROOM NUMBER]. Staff pulled a meal tray out of the cart, with an uncovered dessert, and carried the tray past three other rooms to deliver to a room. Similar observations were made of meal trays with uncovered fortune cookies on 11/13/2024 at 11:54 AM. Observations on the hospice unit on 300 East on 11/15/2024 at 8:34 AM, 11/18/2024 at 8:31 AM, and 11/19/2024 at 8:18 AM showed a coffee/water cart with an uncovered container of lemon slices and an uncovered container with ice and tongs in it. Observations on the long-term care unit on 11/18/2024 at 8:40 AM and 11/19/2024 at 9:01 AM showed a coffee/water cart with an uncovered container of lemon slices and an uncovered container with ice and tongs in it. Observation of lunch service on the 300 East unit on 11/18/2024 at 11:50 AM showed an unidentified aide walk the length of the hall with an uncovered salad, past rooms 326 - 337 before delivering a tray to a resident in the unit's day area. Another aide carried a tray with an uncovered cookie past several doors before delivering to a resident's room. At 11:55 AM an aide was seen carrying a tray with uncovered cut melon that also had an uncovered cookie. At 11:57 AM an aide was observed pouring a coffee from a beverage cart near the end of the unit. The aide did not cover the coffee before placing it on a tray. The aide then took the tray with the uncovered coffee tray past room [ROOM NUMBER], a therapy gym, a salon, an elevator, the Director of Nursing's office and rooms 334 - 337 before delivering the tray to a resident. The beverage cart did not have lids available at that time. Observations on 11/18/2024 at 12:07 PM showed staff push a meal tray cart from room [ROOM NUMBER] all the way through the hallway and placed it at the nurse's station near room [ROOM NUMBER]. Staff then removed a meal tray with an uncovered muffin from the cart and carried the tray back past five rooms to deliver to room [ROOM NUMBER]. Staff was then observed to remove another tray from the cart to carry past other residents, staff, and all the rooms in the hallway, to deliver to room [ROOM NUMBER], near where the cart was originally located. Similar observations of uncovered salad, fruit, and desserts continued as staff finished passing the meal trays for this meal. In an interview on 11/20/2204 at 1:35 PM, Staff EE (Director of Culinary Services) stated it was their expectation staff do not carry uncovered food through the hallways. Staff EE stated staff should be moving the meal tray cart through the hallway while delivering trays so that no more than two rooms are passed with uncovered foods. <Water Pitcher> In an observation and interview on 11/12/2024 at 8:25 AM Staff II (Dietary Aide) went from room to room with a cart of water pitchers, swapping residents' old water pitchers for new ones. At this time Staff II was observed to place a dirty water on the cart next to the clean water pitchers. Staff II stated they were expected to keep the clean pitchers on the top shelf of the cart and place the dirty water pitchers on the bottom shelf, away from the clean ones. Staff II stated they placed the dirty pitchers with the clean ones because the bottom shelf was full. Observation showed the bottom shelf only half full. Staff II stated they should have put the dirty water pitchers on the bottom shelf and not with the clean ones. In an observation and interview on 11/15/2024 at 9:25 AM Staff JJ (Dietary Aide) went from room to room with a cart of water pitchers, swapping residents' old water pitchers for new ones. At this time Staff JJ was observed placing dirty water pitchers on the same level of the cart next to the clean water pitchers. Staff JJ stated they did not let the dirty pitchers touch the clean water pitchers. When asked how they remembered which were the clean water pitchers and which were the dirty water pitchers as they continued passing to other residents, Staff JJ stated because they had a gap between them, so they did not touch. In an interview on 11/19/2024 at 10:51 AM Staff O (Charge Nurse/Infection Preventionist) stated they expected the dietary staff to keep the dirty water pitchers separate from the clean water pitchers. Staff O stated the dietary aides were educated on infection prevention measures when passing clean water pitchers and collecting dirty water pitchers. <PPE > Observations on 11/13/2024 at 2:22 PM showed Staff U (Occupational Therapist) on the COVID (COVID-19 - an infectious, respiratory disease) unit where fit-tested respirators was required to be worn. Staff U was sitting in a chair across from a resident, with their knees almost touching each other as they assisted the resident with exercises. Staff U wore a surgical mask positioned on their chin with their mouth visible. Once observed, Staff U moved the mask to cover their nose and mouth. Staff U was not wearing a fit-tested respirator mask as required. In an observation and interview on 11/13/2024 at 2:33 PM Staff LL (Certified Nursing Assistant - CNA) was observed to walk past the table outside of the entrance to the COVID unit with a sign instructing all who entered the unit to wear a respirator mask along with a box of respirator masks on the table. At this time Staff LL was observed to walk down the hall to the nurse's station without a mask/respirator on. Staff LL stated they were expected to wear a respirator before entering the COVID unit and should continue to wear one the whole time they were on the unit. Observations on 11/18/2024 at 1:45 PM showed Staff BB (Laundry Services Aide) wearing a surgical mask underneath a fit-tested respirator mask while emptying laundry from bins in the hallway on the COVID unit. At this time, Staff CC (Social Worker) was observed with no mask on while helping a resident in a wheelchair to their room in the COVID unit. In an observation and interview on 11/18/2024 at 2:25 PM Staff KK (Laundry Services) was observed on the COVID unit with a surgical mask below their nose going room to room collecting dirty linen. In an interview at this time Staff KK stated they did not know what the PPE requirements were for the COVID unit. Observation at this time showed a table outside of the entrance to the COVID unit with a sign instructing all who entered the unit to wear a respirator mask along with a box of respirator masks on the table. In an interview on 11/19/2024 at 10:51 AM Staff O stated they expected all staff who entered the COVID unit to follow the instructions at the door directing them to wear a respirator mask on the unit and if they were to enter a residents room that had COVID, they were to follow the signs posted outside of the residents room instructing them to wear a respirator mask, gown, gloves, and a face shield. Staff O stated the signs outside of the COVID rooms also instructed to remove all PPE before exiting the room and perform hand hygiene, then place a new respirator mask on which was available right outside of the room. In an interview on 11/20/2024 at 3:45 PM, Staff O stated there were signs posted at the entrances to the East 300 unit showing staff were required to wear a fit-tested respirator mask when entering the unit to help contain and prevent the spread of COVID infections. Staff O stated it was their expectation staff follow the posted requirements when on the unit. <Hand Hygiene> <Resident 45> Observations on 11/18/2024 at 8:06 AM showed Staff G (CNA) assisting Resident 45 to put their pants on. Staff G, while wearing gloves, picked up Resident 45's urine catheter bag and was moving the tubing while assisting the resident. Staff G, while wearing the same soiled gloves, touched the mechanical lift used to assist Resident 45 to the toilet. After assisting Resident 45 to the toilet, Staff G removed their gloves, washed their hands, then touched the soiled area on the lift while moving it to the hallway. <Resident 156> <Wound Care> According to a 10/17/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 156 had multiple pressure ulcers and required skin treatments during the assessment period. Observations on 11/15/2024 at 11:08 AM showed Staff V (RN) providing wound care for Resident 156. Staff V wore gloves and cleaned a pressure wound on Resident 156's bottom using gauze and a wound cleansing solution. Staff V then removed their gloves, and without performing hand hygiene, put on a new pair of gloves to apply a cream to the perimeter of the wound using a finger on their right hand. Staff V then removed the glove from their right hand, and without performing hand hygiene, put on a new glove. For each remaining step of the care to this wound, Staff V replaced their gloves without performing hand hygiene. Staff V did not perform hand hygiene until they began preparing for treatment of a second open area. Similar observations of Staff V not performing hand hygiene with glove changes occurred during the remainder of the wound care provided to the second and the third pressure wounds. <Incontinence Care> Observations on 11/15/2024 at 11:23 AM showed Staff AA (CNA) providing incontinence care for Resident 156. Staff AA wore gloves and used a wet cloth to assist with clean up after the resident had a bowel movement. Staff AA then removed their gloves, and without performing hand hygiene, put on a new pair of gloves and continued to provide care. Staff AA then touched Resident 156's leg and catheter tubing, and while wearing the same soiled gloves, touched the bed remote and call light, before removing their gloves and performing hand hygiene. In an interview on 11/20/2024 at 3:45 PM, Staff O stated it was their expectation staff perform hand hygiene before and after delivering care, when transitioning from dirty to clean areas, and after removing gloves prior to putting on new gloves. Staff O stated proper hand hygiene was important, and it was key to breaking the infection chain to prevent the spread of infection. <Resident 119> Observation on 11/15/2024 at 1:35 PM showed Resident 119 sitting in a wheelchair in the dining area. Staff G (CNA) brought Resident 119 to their room to change them. Staff G and Staff H (CNA) transferred Resident 119 from their wheelchair to their bed with a mechanical lift. Observation on 11/15/2024 at 1:57 PM showed Resident 119 had a bowel movement. Staff G and Staff H wore gloves on both hands and talked with Resident 119 about their incontinence care. Staff H held Resident 119 on their side while Staff G provided incontinence care to the resident in their bed. Staff G removed the soiled brief and cleaned the resident. Staff G took a clean brief without removing their soiled gloves or washing their hands. Staff G applied the clean brief to the resident while wearing the contaminated gloves. Staff G fixed Resident 119's clean bedding with the contaminated gloves and put the dirty linens in a bag before removing their gloves and washing their hands. Staff H also assisted Staff G with the incontinence care, put the dirty linen in a bag and without changing their gloves, also touched Resident 119's clean bedding and fixed their blanket before removing their gloves. In an interview on 11/15/2024 at 2:04 PM, Staff G and Staff H stated they should have removed their dirty gloves and washed their hands between dirty to clean care and before they touched the clean linens but forgot to do so. In an interview on 11/20/2024 at 2:16 PM, Staff B (Director of Nursing) stated they expected staff to perform hand hygiene before entering a room or exiting a room, between dirty and clean cares, and before and after glove change. <Personal Belongings> In an observation and interview on 11/13/2024 at 2:23 PM Staff MM (CNA) was observed to enter the long-term care unit carrying their purse. Staff MM was observed to enter room [ROOM NUMBER] and place their purse on the resident's cabinet inside their room before proceeding to the nursing station. In an interview at this time Staff MM stated they were not supposed to store their personal belongings in the resident rooms. In an interview on 11/15/2024 at 9:51 AM, Staff B stated they expected staff to store their personal belongings in a locker assigned to them. Staff B stated staff were not to store any personal belongings in the resident's rooms. Staff B stated it was important to not place personal belongings in resident rooms for infection control and out of respect for the resident's space. In an interview on 11/19/2024 at 10:54 AM, Staff O stated they expected staff to store their personal belongings in their assigned staff lockers. Staff O stated it was important for staff to not store their personal belongings in the residents' rooms as part of infection control in the facility. REFERENCE: WAC 388-97-1320 (1)(a), -1320 (1)(c), -1320 (3). .

<Resident 104> The 07/05/2023 admission MDS showed Resident 104 was assessed to make themselves understood and had the ability to understand others despite being cognitively impaired. Resident 104 had diagnoses of dementia, seizure disorder, and a hip fracture. In an interview on 08/01/2023 at 2:15 PM, Resident 104 stated they had a fall while at the facility. Resident 104 stated they hurt their hip during the fall and had to go to the emergency room. Review of the 06/23/2023 Facility Incident Report showed the root cause of the fall was related to Resident 104 falling out of bed while trying to pick something up from the floor. Further review of the incident report did not show how the facility identified root cause. Review of the 06/15/2023 fall CP showed no new interventions to prevent Resident 104 from future falls. An observation on 08/01/2023 at 2:15 PM showed no grabber was available for Resident 104's use. Similar observations were made on 08/02/2023 at 10:30 AM, 08/03/2023 at 9:30 AM, and 08/04/2023 at 8:52 AM. <Resident 27> The 05/23/2023 admission MDS showed Resident 27 was assessed to make themselves understood and had the ability to understand others despite being cognitive impaired. Resident 27 had diagnosis of septicemia, muscle weakness, and thyroid disorder. An interview on 08/01/2023 at 2:50 PM, Resident 27 stated they fell while at the facility. They stated they were sitting in their wheelchair, bent forward to pick something up off the ground, and fell forward onto the floor. They stated they received several injuries to their face because of the fall. Review of the 07/10/2023 facility incident report showed a grabber was added to Resident 27's CP to provide Resident 27 the means to pick up items from the floor. Review of the 05/16/2023 fall CP showed the CP was not updated with new interventions after the 07/10/2023 fall. There were no interventions to prevent Resident 27 from a repeated fall out of their wheelchair. An observation on 08/01/2023 at 2:58 PM showed no grabber was available to Resident 27 so they could safely pick things up off the floor. Observations were made on 08/02/2023 at 10:30 AM, and 08/03/2023 at 10:17 AM that showed Resident 27 did not have a grabber within reach. In an interview on 08/04/2023 at 11:00 AM, Staff B (Director of Nursing) stated there was a daily morning meeting with various departments in attendance. In the meeting falls were reviewed and interventions were discussed. Staff B stated nursing staff was expected to implement specific interventions on the CP related to the root cause of the fall. Staff B stated new interventions were important to prevent recurrent falls. REFERENCE: WAC 388-97-1060(3)(g). Based on observation, interview, and record review the facility failed to ensure resident safety from accidents and hazards for 3 of 4 (Residents 149, 27 & 104) residents reviewed for falls. The failure to determine the basic factors that caused resident falls and implement interventions related to the identified cause, placed residents at risk for further falls, significant injuries, and diminished quality of life. Findings included . <Resident 149> The 05/02/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 149 was admitted for a fall with pelvic fractures. Resident 149 was assessed to have memory impairment, difficulty making decisions, inattention, disorganized thinking, and worsening behaviors impacting their personal safety. Resident 149 was assessed with moderately impaired vision (not able to see newspaper headings but can identify objects). Review of the 01/04/2023 Fall Risk Care Plan (CP) showed Resident 149 was at increased risk of falls related to decreased functional mobility, weakness, and poor balance. The 01/04/2023 fall CP interventions directed nursing staff to offer use of the toilet before and after meals, at bedtime and as needed, frequent visual checks when resident was in their room and keep curtains open for easy visualization. A 01/16/2023 CP for transfers and walking showed Resident 149 required supervision/stand by assistance with a walker. The 01/16/2023 CP for toileting showed Resident 149 was independent using a walker when using the toilet and used a bedside commode at night. A 05/23/2032 CP for dressing showed Resident 149 required set up (staff placed clothing near resident) to get dressed independently. Review of the facility incident logs from March 2023 to July 2023 showed Resident 149 had nine falls in 18 weeks. A 03/15/2023 12:30 PM incident report showed Resident 149 fell when looking for a washcloth to give themself a bed bath. The intervention implemented was monitor and report acute changes and signs of infection. The facility collected a urine sample to rule out an infection. There was no intervention that addressed the resident's desire for a bath in the middle of the day or why the resident was not dressed at 12:30 in the afternoon. A 03/17/2023 7:00 PM incident report showed Resident 149 fell when trying to put on a gown and slipped. The intervention implemented was bed low and locked at all times when the resident was in bed, place a sign at doorway to notify staff of fall risk, and remind the resident to use call light for assistance. The intervention to keep the bed low and locked did not address the cause of the fall related to changing the resident's gown. A 04/11/2023 1:00 AM incident report showed Resident 149 fell when attempting to pick up the TV remote from the floor. The report stated staff noted a grabber device (a tool used to pick up objects from distant surfaces) in the room, but Resident 149 asked staff to leave the grabber in the windowsill and they would use it as they wanted. The intervention implemented on the report showed obtain a grabber and encourage its use and encourage use of the call light. There were no interventions to address Resident 149's refusal to use the grabber or to place the TV remote where Resident 149 could reach or prevent dropping the remote. A 05/18/2023 1:55 PM incident report showed Resident 149 fell when trying to come back from the bathroom. The caregiver statement showed Resident 149 was assisted into the bathroom by staff and staff left Resident 149. The witness statement showed Resident 149 fell to the floor, hit their head, obtained an abrasion on their arm, and yelled for help. The intervention implemented was offer routine assistance with toileting before and after meals, bedtime and routine intervals at night, continue frequent visual checks and encourage resident to use the call light for assistance. There was no documentation showing why staff did not assist Resident 149 out of the bathroom. There were no new interventions identified for prevention of falls. A 05/30/2023 12:15 AM incident report showed Resident 149 was trying to go to the restroom without using the call light, lost their balance and fell. The witness statement showed the resident had the walker over their legs and was last seen by the prior shift. There was no information in the investigation that the prior shift was interviewed. The investigation showed Resident 149 was non-compliant with using the call light, refused care, and remained at high risk for falls and injury. The interventions implemented were a fall/injury assessment, continue frequent visual checks, encourage use of call light for assistance and a medication review by the pharmacist. The investigation did not conclude the findings of the pharmacist medication review. There were no new interventions identified or instructions provided to staff to prevent Resident 149 from falling. A 06/21/2023 1:30 PM incident report showed Resident 149 was lying on the floor crying and yelling for help. Resident 149 stated they fell and hit their head while trying to get clothing out of the drawer. The witness statement showed the walker was lying on the resident, resident was not wearing any footwear, and was holding their glasses in one hand. The report showed Resident 149 had increased confusion and increased behaviors before the fall. The interventions implemented included check if resident is wearing appropriate footwear, encourage resident to use call light for assistance and medication review by the pharmacist. There was no documentation to support the staff considered Resident 149 needed incontinence assistance. The investigation did not conclude the findings of the pharmacist medication review, after the prior fall and second pharmacist request. A 07/02/2023 2:00 PM incident report showed Resident 149 was sitting on the floor next to the bed, stated they were looking through some papers, fell, hit their head, and complained of back pain. The report showed Resident 149 was non-compliant with using the call light, had frequent refusals of care, and remained high risk for fall and injury. The interventions implemented were a fall/injury assessment, continue frequent visual checks and first aid to a skin tear. There was no documentation to support how standing and looking at papers caused the fall and no interventions to prevent a future fall. A 07/05/2023 6:00 AM incident report showed Resident 149 was sitting on the floor screaming and stated they were trying to pick up a flower from the floor. There was no flower seen on the floor and the report showed Resident 149 hallucinated. The report showed Resident 149 was non-compliant with use of the call light, frequently refused care and remained a high risk for falls and injury. The interventions implemented were a fall/injury assessment, continued frequent visual checks and continue to encourage use of the call light. There were no new interventions identified to prevent future falls. There was no documentation in the report that showed the staff assessed Resident 149 for hallucinations or new interventions implemented related to monitoring or intervening with hallucinations. A 07/29/2023 4:34 PM fall/injury assessment showed Resident 149 sustained a fall, hit the right side of their head, and obtained a head contusion with pain. The cause of the fall was not identified in the fall assessment. The facility transferred Resident 149 to the emergency room for evaluation on 07/30/2023. In an interview on 08/04/2023 at 12:00 PM, Staff L (Resident Care Manager) reviewed Resident 149's nine fall incident reports and stated there was missing information in the investigations because it was not documented. Staff L stated most of the fall investigations did not identify the root cause of the incident. Staff L stated new interventions were expected to be implemented after every fall to prevent future falls. Staff L stated the new interventions must be related to the cause of the fall and the CP should be updated for fall prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheter (a tube to empty the bladder) care met infection control standards for 1 of 4 residents (Resident 12) reviewed for catheters. The failure to 1) review the risks and benefits of placing the catheter bag on the floor per Resident 12's preference, 2) update the care plan and 3) implement interventions to prevent contamination and Urinary Tract Infections (UTI), placed Resident 12 at risk for continued UTIs, sepsis (a blood infection) and a diminished quality of life. Findings included . <Facility Policy> The undated policy titled Indwelling Catheter Care and Maintenance, directed staff to perform routine maintenance and continued monitoring of residents with indwelling catheters and to ensure that residents received appropriate catheter care. The policy showed if a resident's preference went against infection control policies, it was important to prioritize the safety and well-being of the resident and prevent the spread of infection and conversation and education regarding infection control practices would be provided to the resident. The policy showed the care, management, and monitoring of the indwelling catheter should be addressed in the resident's Care Plan (CP). Review of the 06/11/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 12 was assessed with multiple complex diagnoses and required the use of an indwelling urinary catheter. Resident 12 was assessed as cognitively intact, able to make their own decisions and their needs and preferences known. Review of a 12/20/2022 CP showed instructions on how to manage Resident 12's catheter. The instructions included keep the catheter bag and tubing below the level of the bladder. There were no instructions to keep the catheter bag on the floor and under the bed. Review of an undated [NAME] (care instructions to the nursing assistants) directed staff to keep the catheter bag and tubing below the level of Resident 12's bladder. There were no directions to place the resident's catheter bag on the floor under the bed. Review of a 02/15/2023 Practitioner Encounter Note showed Resident 12 was hospitalized due to sepsis related to a complicated UTI. The note showed the UTI was caused by two different bacteria and was related to the chronic use of an indwelling urinary catheter. Review of a 03/03/2023 Hospital History and Physical Assessment showed Resident 12 was re-admitted to the hospital due sepsis related to UTI. The document showed the first hospitalization was 02/13/2023 (two weeks earlier). The document showed this was a second admission for another UTI with sepsis and chronic catheter use. In an observation on 08/01/2023 at 9:15 AM, Resident 12 was lying in bed with their eyes closed. Under the resident's bed was a urine collection bag, inside a privacy bag, and on top of a pad on the floor. On 08/01/2023 at 1:38 PM, Resident 12 did not want to be interviewed. An observation showed the catheter bag that contained urine was inside a privacy bag, placed on top of a pad, and on the floor. Observation on 08/02/2023 at 8:24 AM, showed Resident 12 in bed with the catheter bag in a privacy bag on the floor. During an interview on 08/02/2023 at 3:15 PM, Staff D (Nursing Assistant) confirmed Resident 12's catheter bag was on the floor. Staff D stated Resident 12 preferred the catheter bag on the floor. Staff D stated catheter bags were supposed to be hung on the bed so the urine would flow better to the collection bag. During an interview on 08/02/2023 at 3:20 PM, Staff C (Registered Nurse) confirmed Resident 12 preferred to have the catheter bag on the floor and not hang on the bed. Staff C stated there was a potential that the urine could backflow into the resident's bladder. A backflow of urine could cause an infection in the urinary tract. During an interview on 08/02/2023 at 3:45 PM, Staff E (Infection Control Preventionist) stated the facility tracks catheter use as part of the infection control surveillance. Staff E stated they were not alerted to Resident 12's preference to have their catheter bag on the floor and not hang on the bed per standard practices. Staff E stated this information should have been included in the infection control surveillance documents and was not considered during evaluation of Resident 12's past urinary infections. During an interview on 08/03/2023 at 9:09 AM, Staff A (Director of Nursing) confirmed there were no directions on the CP regarding Resident 12's preference to place the catheter bag on the floor. Staff B confirmed the facility practice was to hang the catheter bag from the bed, not the floor. Staff B stated Resident 12 was concerned about proper draining of her catheter and had wanted it on the floor. Staff B confirmed there was no documentation of the resident's preferences, the facility evaluation, or the discussion of infection risks of keeping the catheter bag on the floor in the clinical record. Staff B stated the facility should have documented discussions and updated the CP to prevent infections for Resident 12. REFERENCE: WAC 388-97-1060(3)(c). .

Based on observation and interview, the facility failed to ensure expired medication and medical supplies were disposed timley for 4 of 4 medication rooms (East 2A, East 2B, North, & East 1) reviewed. These failures placed residents at risk for receiving medications with decreased or no potency, and use of medical supplies with compromised integrity. Findings included . <East 1 Medication Room> Observation on 08/02/2023 at 1:20 PM showed two boxes of safety needles expired on 05/31/2020, two boxes of lancets (equipment used to check blood sugar) expired on 12/07/2020, a box of disposable viral test kits expired 09/14/2022, and a bottle of local anesthetic expired 12/2022. These items were dispersed throughout the room. In an interview on 08/02/2023 at 1:35 PM, Staff H (Charge Nurse) stated the expired supplies should be removed from the medication room prior to the items expiring. <East 3 Medication Room> Observation on 08/02/2023 at 1:00 PM showed two urinary catheters (a tube to assist in bladder emptying) expired on 12/28/2022, extension tubing intended for urinary catheters expired on 03/10/2022, a bag with needles expired on 10/31/2022, a box of diagnostic supplies intended for laboratory testing expired on 08/2022. These items were dispersed throughout the room. In an interview on 08/02/2023 at 1:30 PM, Staff I (Charge Nurse) stated they expected the expired items to be removed from the unit prior to the items expiring. <North Medication Room> Observation on 08/03/2023 at 9:22 AM showed six syringes of blood thinning medication that expired on 7/31/2023, a dressing kit expired on 10/31/2019, six cotton swabs expired on 07/31/2022, and many blood collection tubes expired on 09/30/2022. These items were dispersed throughout the room. In an interview on 08/03/2023 at 9:40 AM, Staff G (Charge Nurse) stated the items should have been removed from the unit prior to expiring. <East 2B Medication Room> Observation on 08/03/2023 at 1:00 PM showed a bag containing multiple viral test kits expired on 07/30/2021, two bags containing multiple medications belonging to discharged residents that expired in 2022, four viral test kits that expired on 05/2022, a box of cotton swabs expired 06/30/2023, a bag of IV solution expired 08/02/2022. These items were dispersed throughout the room. In an interview on 08/03/2023 at 1:30 PM, Staff F (Charge Nurse) stated the expired medications and supplies should be removed before they expired. In an interview on 08/04/2023 at 11:30 AM, Staff A (Director of Nursing) stated they expected expired medications and supplies to be removed from the storage units before they expire. REFERENCE: WAC 388-97-1300(2), (3)(a). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Centers for Medicaid and Medicare Services (CMS) Form CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) with adequate information for two of three residents (Resident 30 and Resident 121) reviewed for advance beneficiary notices when their Medicare Part A services were ending. The failure to provide residents/residents' representatives with ABNs as required, detracted from their ability to make informed financial and care decisions related to their continued stay. Findings included . 1. Resident 30's admission Record located in the Profile tab of the electronic medical record (EMR) revealed they admitted from the hospital on [DATE] for skilled therapy services. Review of Resident 30's SNFABN provided by the facility revealed their Medicare Part A stay began on 12/21/21. The resident's last covered day (LCD) of Medicare Part A Skilled Nursing Services was 01/11/2022. The SNFABN indicated Skilled Nursing Services would no longer be covered, in the section titled, Reason Medicare May Not Pay: with the explanation Daily skilled care not required. The section for Estimated Cost: was completed with $_/day Medicaid PAR [undefined abbreviation]. The facility did not provide an explanation of why Medicare might not pay for continued skilled services or what the estimated cost of continued services would be. 2. Review of Resident 121's admission Record located in the Profile tab of the EMR revealed they admitted to the facility on [DATE]. Review of Resident 121's SNFABN revealed they began a Medicare Part A stay on 11/20/2021 and her LCD was 12/17/2021. The SNFABN indicated Skilled Nursing Services would no longer be covered, in the section titled, Reason Medicare May Not Pay: with the explanation Daily skilled care not required. The section for Estimated Cost: was completed with $_/day Medicaid PAR. The facility did not provide an explanation of why Medicare might not pay for continued skilled services or what the estimated cost of the continued services would be. Review of the . Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018) . revealed in the section titled, Reason Medicare May Not Pay revealed, The SNF must give the applicable Medicare coverage guideline(s) and a brief explanation of why the beneficiary's medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the beneficiary to understand why Medicare may deny payment . The section titled, Estimated Cost stated, . In this section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNFs must make a good faith effort to insert a reasonable cost estimate for the care . In an interview on 04/07/2022 at 9:58 AM, Staff F (Director of Social Services) stated the SNFABNs were completed to provide residents with information related to their transition of care and return to their prior level of cost. Staff F stated the SNFABN was used by the facility to provide information to the resident or their responsible party regarding the cost of returning to long-term care. Staff F was not aware the SNFABN was to provide the resident or their responsible party the cost related to continuing the Medicare Part A skilled therapies or skilled nursing services. In an interview on 04/07/2022 at 12:33 PM, Staff F stated the facility followed the instructions for completing the SNFABN located on the CMS website. REFERENCE: WAC 388-97-0300 (1)(e), (5), (6) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess 3 (Residents 320, 321 & 165) of 35 residents reviewed for accurate Minimum Data Set (MDS - an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 320 Resident 320 was admitted to the facility on [DATE]. According to the 03/24/2022 admission /Medicare - 5 Day MDS, Resident 320 had medically complex diagnoses including quadriplegia (paralysis of all four limbs). This MDS assessed Resident 320 with functional limitations in range of motion to both upper extremities and with no impairment to lower extremities. Review of the MDS 3.0 RAI (Resident Assessment Instrument) Manual showed Quadriplegia referred to the paralysis of all four limbs, arms, and legs, caused by spinal cord injury. Observations on 04/05/2022 at 8:06 AM showed Resident 320 sitting up in a motorized wheelchair (w/c) holding a book while flipping through the pages with their hands. On 04/05/2022 at 1:07 PM Resident 320 was observed using their upper extremities to eat lunch and drink fluids independently. In an interview on 04/07/2022 at 3:25 PM, Staff P, MDS Coordinator, stated the 03/24/2022 MDS incorrectly reflected a diagnosis of quadriplegia and required correction. Resident 321 According to the 03/29/2022 admission /Medicare - 5 Day MDS, Resident 321 was assessed with an obvious or likely cavity, or broken natural teeth. This MDS was locked and signed as completed on 04/07/2022. In an interview on 04/04/2022 at 10:17 AM Resident 321 indicated they had upper and lower dentures and stated, I only use them to eat because they don't fit well, they are worn out after all these years. Observations made at this time showed Resident 321's dentures were in a cup at the bedside. Review of Resident 321's personal inventory dated 03/25/2022 showed the resident was admitted to the facility with upper and lower dentures. In an interview on 04/07/2022 at 3:25 PM, when asked about Resident 321's dental status, Staff P stated I must have coded it in error, I will go fix that now. Resident 165 According to the 03/18/2022 Admission/ Medicare - 5 Day MDS, Resident 165 was identified with an open lesion (wound) and no venous ulcers (wounds on the leg or ankle caused by abnormal or damaged veins). This MDS showed the resident required staff assistance with activities of daily living, but the activity of dressing did not take place during the assessment period. Review of March 2022 Documentation flowsheet records showed Resident 165 received assistance with dressing from staff daily during the assessment period. According to a 03/17/2022 Wound Care Surgical Note, Resident 165 had a wound to the right lateral lower extremity with an etiology of venous stasis disease (a condition that occurs when the veins or valves in the leg are not working effectively). In an interview on 04/07/2022 at 3:25 PM, Staff P stated the 03/18/2022 MDS should have reflected extensive assistance for dressing and stated this MDS did not identify Resident 165's open lesion to lower extremity as a venous ulcer. REFERENCE: WAC 388-97-1000(1)(b). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 130 According to the 3/2/2022 Significant change MDS, Resident 130 had multiple medically complex diagnoses and was assessed as cognitively intact with no behaviors. This MDS identified that Resident 130 had skin tears. A review of the CP revised on 11/22/2021 for high risk of falls, showed interventions for per resident request: scoop mattress, low bed, fall mats at bilateral bedside when resident is in bed. Observations on 4/4/2022 at 11:45 AM and 3:57 PM, 4/5/2022 at 8:30 AM and 5:00 PM, and 4/6/2022 at 9:17 AM, showed Resident 130 was lying in bed, bed was not in lowest position, and no fall mats at bedside. A review of a 01/26/2022 physician order gave directions to apply geri sleeves to both legs and to leave in place except on request of resident for comfort, and to provide care or hygiene. According to Resident 130's CP an intervention, dated 02/11/2022, included geri sleeves to be used to both legs, and Resident 130 preferred to wear them only for transfers. Observations on 4/4/2022 at 11:45 AM and 3:57 PM showed Resident 130 had no geri sleeves on their legs. On 4/5/2022 at 11:25 AM, staff were observed transferring Resident 130 from the bed to the wheelchair without placing geri sleeves on their legs as the CP directed. In an interview on 4/6/2022 at 9:20 AM, Resident 130 stated they had skin tears on their lower legs last month that occurred during transfers, but indicate they never had any geri sleeves on their legs. In an interview on 4/6/2022 at 11:35 AM, Staff W (Residential Care Manager- RN), stated Resident 130 did not want bed in low position or fall mats on the floor. Staff W indicated Resident 130 did not need the geri sleeves on anymore and stated the CP needed to be updated and revised. Resident 27 According to the 1/4/2022 Quarterly MDS, Resident 27 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication. This MDS assessed Resident 27 with severe cognitive impairment with delusions. Review of a 4/4/2022 Physician Order showed Resident 27 received Trazodone (antidepressant) for sleeping. Review of Resident 27's CP on 04/05/22 revealed no CP was initiated regarding the resident taking Trazodone or any interventions regarding the use of the medication. In an interview on 04/06/2022 at 8:15 AM, Staff B (Director of Nursing) stated staff should have initiated the care plan but it was missed. REFERENCE: WAC 388-97-1020(2)(c)(d). Resident 165 According to a 03/18/2022 admission /Medicare - 5 Day MDS Resident 165 had multiple medically complex diagnoses and was assessed with clear speech, able to be understood and understand conversation. This MDS assessed Resident 165 to require physical assistance from staff for bed mobility, transfers, personal hygiene, and bathing. In an interview on 04/04/2022 at 4:00 PM, Resident 165 stated they were not getting enough showers and indicated they would like at least twice weekly. Review of March 2022 Bathing documentation flowsheets showed Resident 165 only received weekly bathing. In an interview on 04/05/2022 at 1:01 PM, Staff U (Certified Nursing Assistant), stated they were the shower aid and only provided weekly showers to residents unless their CP identified a different preference. Observations on 04/04/2022 at 4:00 PM showed Resident 165 wearing glasses. In an interview at this time Resident 165 indicated they required the use of glasses for reading. Review of Resident 165's CP on 04/04/2022 revealed no CP addressing bathing preferences or frequency, and no CP that addressed the use of corrective lenses. Resident 165's 03/11/2022 risk for falls CP indicated, The resident is (SPECIFY High, Moderate, Low) risk for falls r/t [related to]. Staff did not identify which level of risk the resident was or indicate why Resident 165 was at risk for falls. A CP for an actual fall was added on 03/21/2022 that indicated interventions of low bed, fall mats at bilateral bedside whenever the resident is in bed. Observations on 04/05/2022 at 3:31 PM and 04/06/2022 at 8:06 AM showed Resident 165 lying in bed with no fall mats at bedside. In an interview on 04/06/2022 at 5:06 PM, Staff M (admission Director, Licensed Practical Nurse) stated the care plan needed to be updated and revised as the resident no longer required the use of fall mats at bilateral bedside. According to a 03/11/2022 limited physical mobility CP staff indicated a goal that Resident 165 will demonstrate the appropriate use of SPECIFY adaptive device(s) to increase mobility through the review. No adaptive devices were listed by staff. Review of a 03/11/2022 bowel elimination CP showed staff did not identify any interventions for this CP and was left blank. In an interview on 04/07/2022 at 2:20 PM Staff M confirmed Resident 165's CP should have, but was not updated and revised to reflect the resident's current condition and preferences. Resident 320 According to a 03/24/2022 Admission/ Medicare - 5 Day MDS Resident 320 had multiple medically complex diagnoses and was assessed as cognitively intact with clear speech, able to be understood and understand conversation. This MDS assessed Resident 320 to require physical assistance from staff with bed mobility, transfers, dressing and personal hygiene. In an interview on 04/04/22 at 10:48 AM Resident 320 stated they wear a splint to their right hand at night and a leg splint when up transferring and working with therapy. Observations at this time revealed a hand splint and leg splint in the room and not currently in use. Observations on 04/05/22 at 8:06 AM showed a dry-erase white communication board located in Resident 320's room with written instructions that said, splints at night. Review of a 03/29/2022 occupational therapy note showed staff indicated they will update Resident 320's CP to include nursing to assist with putting on and off the hand splint in evening for eight hours. Review of Resident 320's CP on 04/06/2022 revealed no identified interventions regarding the use of splints. According to a 04/05/2022 physical therapy note, Resident 320 was to use a Sarita lift for all transfers. Observations on 04/05/2022 at 1:07 PM revealed Resident 320's communication board had directions to use Sarita lift for toileting. Review of Resident 320's ADL CP on 04/06/2022 revealed interventions for staff to use a Hoyer (a lift that allows a person to be lifted and transferred with a minimum of physical effort) for transfers. In an interview on 04/06/2022 at 1:36 PM Staff M confirmed staff should have but did not, update and individualize Resident 320's CPs to reflect the use and directions for splints, or revise which lift should be used for Resident 320. Resident 321 According to a 03/29/2022 Admission/ Medicare - 5 Day MDS Resident 321 had multiple medically complex diagnoses including heart failure. This MDS assessed Resident 321 to require physical assistance from staff for bed mobility, transfers, dressing and personal hygiene. Observations on 04/04/2022 at 10:17 AM and 04/05/2022 at 1:04 PM showed a dry-erase white communication board on Resident 321's wall dated March 31st 2022, and had handwritten information regarding the resident's care. The board identified Resident 321 had glasses, upper and lower dentures, and preferred male caregivers. On 04/06/2022 at 3:15 PM the communication board was still dated March 31st 2022, and had a note to elevate legs with two pillows. Review of Resident 321's medical record on 04/06/2022 revealed no CP that identified the resident had glasses, dentures, or edema to bilateral lower legs and required elevation. In an interview on 04/06/2022 at 1:36 PM Staff M stated their expectation is the resident's CP in the medical records must be updated and revised with changes to reflect their current condition. Staff M indicated the white communication board is just used as a quick reference for staff and confirmed the board is erasable and not a part of the resident's medical record. Based on observation, interview, and record review, the facility failed to ensure care plans were maintained, revised, and updated as required for 6 (Residents 104, 165, 320, 321, 130, & 27) of 35 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 104 According to the 02/15/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 104 had diagnoses including Diabetes Mellitus (type II Diabetes), and was not on a physician-prescribed weight loss program. Resident 104 was assessed to require extensive assistance from two or more people for transferring between surfaces. Resident 104 was assessed to be at risk for pressure ulcers and to have an unstageable (a wound that cannot be assessed for depth/severity) Deep Tissue Injury (DTI - a type of pressure ulcer covered in a layer of skin). Review of weight records revealed from Resident 104 weighed 174 pounds (Lbs) on admission on [DATE]. On 3/29/2022 Resident 104 weighed 152.4 Lbs, representing a 12.4% (percent) weight loss. According to Weight Status and History section of quarterly nursing assessments dated 10/26/2021 and 2/15/2022, Resident 104 wanted to lose weight based on the advice of their doctor. According to the 10/15/2021 Nutrition Care Plan (CP) Resident 104's goal was to maintain their weight. The CP did not identify Resident 104's stated goal of weight loss. In an interview on 04/07/2022 at 10:36 AM, Staff J (Assistant Director of Nursing/Infection Preventionist) and Staff A (Administrator) stated the CP did not reflect Resident 104's weight loss goals and needed to be updated. According to the 10/19/2021 Activities of Daily Living (ADL) CP, for toileting Resident 104 required two-person extensive assistance using a Sarita lift (a lift that allows a person some physical assistance to move from a sit to stand position) to transfer to/from the toilet/commode. In an interview on 04/05/2022 at 3:53 PM Staff X (Charge Nurse, Registered Nurse - RN) stated the Sarita lift was not a good match as Resident 104 banged their shins on it and had fragile skin and should no longer be on the care plan. The Hoyer lift is better.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were secured in accordance with professional standards for 4 (Resident 170, 171, 130, & 173) of 35 residents reviewed, which placed residents at risk for accidental ingestion. Findings included . According to the revised 01/01/2022 facility policy titled, Storage and Expiration Dating of Medications, Biologicals, the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Unsecured medications at bedside Observations on 04/04/2022 at 10:48 AM and 12:51 PM showed Resident 170 had a bottle of antacid chewable tablets at the bedside. On 04/07/2022 at 8:40 AM, a clear bag containing tablets which Resident 170 identified as antacid tablets, was observed at the bedside. In an interview at this time Resident 170 indicated they previously had both a bottle and a clear bag containing the antacids at the bedside. Staff R, Registered Nurse (RN), confirmed medications were unsecured (not locked and was accessible by others) at bedside. Observations on 04/04/2022 at 1:11 PM showed Resident 171 had a bottle of Ketocanozole 2% (an antifungal) shampoo, Clobetasol propionate 0.05% (a topical steroidal solution), and a tube of Clotrimazole 2% (an antifungal) cream in their room . Similar observations of medications at bedside were noted on 04/05/2022 at 2:11 PM. Observations on 04/07/2022 at 8:50 AM revealed an Albuterol inhaler with the previously identified medications. During an observation on 04/07/2022 at 8:56 AM, Staff M, Admissions Director/Licensed Practical Nurse, confirmed the medications were unsecured at the bedside for Resident 171 and stated medications should not be left unsecured at the bedside. Observations on 4/4/2022 at 3:45 PM, showed Resident 130 had two inhalers (Flovent and Albuterol) and Artificial Tears eye drops in a tray on their bed side table in their room. Similar observations of unsecured medications were noted on 4/5/2022 at 12:05 PM, in addition to a bottle of Nystatin (antifungal) powder. On 4/5/2022 at 2:30 PM the identified medications were still observed unsecured at bedside. In an interview on 04/05/2022 at 12:35 PM, Resident 130 stated the nurses left the medications in their room. In an interview on 04/05/2022 at 2:30 PM, Staff Q, RN, stated the medications should not be left in the resident's rooms, they should be secured in the medication cart. Medications unsecured on medication cart Observations on 04/06/2022 at 8:01 AM showed a pre-packaged card with tablets of Colchicine (a medication used to treat inflammation) for Resident 173 unsecured on top of the medication cart located near room [ROOM NUMBER]. At this time, no staff was observed near the medication cart. Staff A, Administrator, was observed to approach the cart, identify the unsecured medications and pick up the medication card. A nurse was then observed to exit a nearby room. Staff A educated the nurse that medications should not be left unsecured on the medication cart. In an interview on 04/07/2022 at 8:26 AM Staff A stated it was their expectation that medications be locked and stored securely. REFERENCE: WAC 3988-97-1300(2), -2340. .

Based on interview and record review the facility failed to assure resident medical records were complete and accurate for 1 (Resident 104) of 35 sample residents whose records were reviewed. The failure to maintain accurate medical records left residents at risk for inaccurate and incomplete medical records and unmet care needs. Findings included . Resident 104 According to the 02/15/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 104 had diagnoses including depression, anxiety, and difficulty with life management. Resident 104 was assessed to experience both hallucinations and delusions and to have no episodes of behavior during the assessment look back period (the time through which data for the assessment was collected.) The 10/24/2021 Admissions MDS assessed Resident 104 to have anxiety and depression and with no episodes of hallucinations or delusions. This MDS assessed Resident 104 to be at risk for the development of pressure ulcers and to have an unstageable (not easily measured due to the presentation of the wound) deep tissue injury (DTI - a type of pressure injury where the external skin is intact) Pre-admission Screening and Resident Review (PASRR) Review of the electronic health record (EHR) revealed a 10/19/2021 Level 1 PASRR (an assessment that determines if a resident is suitable for skilled nursing and is required for all residents prior to admission). The Level I PASRR that assessed Resident 104 to have hallucinations and no other indicators of serious mental illness. The Level I PASRR did not identify Resident 104's anxiety or depression diagnoses. In an interview on 2:17 PM 4/6/2021 at 2:17 PM Staff S (Social Worker) acknowledged that the PASSR was incomplete and stated that when errors on PASSRs are identified, it was the responsibility of Staff T (Admissions Social Worker) to get them corrected. In an interview on 04/06/2022 at 02:25 PM Staff T stated they identified the Level I PASSR was inaccurate at admission and obtained a corrected version. Staff T went to their desk and returned with a copy of the corrected Level I PASSR that included Resident 104's anxiety and depression diagnoses and no longer included hallucinations. Staff T stated the corrected Level I PASSR was not but should have been added to Resident 104's medical record. Skin Assessments Review of Resident 104's weekly skin assessments revealed the following: the 01/30/2022 skin assessment did not stage (wound staging: a scale from 1-4 that assesses the seriousness) Resident 104's coccyx wound or assess it to be unstageable and included no measurements of width, breadth and depth; the 02/06/2022 skin assessment did not stage the wound, assess it to be unstageable, or include wound measurements; the 2/13/2022 skin assessment included no measurement of the wound; the 3/6/2022 skin assessment did not stage the wound or assess it to be unstageable and included no measurements; the 3/13/2022, 3/20/2022 and 3/27/2022 skin assessments included no measurements of the wound. In an interview on 04/07/2022 at 04:39 PM, Staff A (Administrator) and Staff B (Director of Nursing) stated it was important for skin assessments to be completed consistently and accurately. REFERENCE: WAC 388-97-1720(1)(a)(i-v)(b) .

Based on observation, interview, and policy review the facility failed to store, prepare, and serve food under sanitary conditions for 190 out of 193 residents who received food from the facility kitchen. Specifically, the facility failed to ensure a meat slicer was clean and sanitary; and that beard restraints were available for use and worn by staff with beards during food preparation. The facility reported a census of 193 and three residents received tube feedings. Findings included . During an observation on 04/04/22 at 9:20 AM, Staff N had a beard measuring 0.50 - 1.00 inch in length. Staff N was working in the food preparation area of the kitchen in preparation for the noon meal. Staff N was wearing a surgical mask for COVID-19 prevention but failed to wear a beard restraint. The surgical mask failed to cover the sides of the face and failed to cover the entire beard. This had the potential to allow hair to fall onto the food being prepared. During an interview on 04/04/22 at 9:25 AM, Staff N confirmed they were only wearing a surgical mask and failed to wear a beard restraint/guard. Staff N stated, I should be wearing a beard guard. There are no beard guards currently available. During an observation on 04/04/22 at 9:35 AM of the meat slicer revealed, it was covered indicating it was clean and ready for use. Uncovering the meat slicer revealed food residue remained on the back side of the blade. During an interview on 04/04/22 at 9:35 AM, Staff N confirmed food residue on the back of the meat slicer blade. The slicer was last used last week, it should be clean, it needs to be rewashed. A review of the facility policy, Personal Hygiene, an undated document revealed, Policy: These are the guidelines for personal hygiene to promote a safe and sanitary department. Procedure: 3 . Beards or any body hair that may be exposed (i.e., arms) must be covered. A review of the facility policy, Sanitization an undated document revealed, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: . 3. All equipment, food contact surfaces and utensils shall be washed to remove or complexly loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. REFERENCE: WAC 388-97-1100 (3), and WAC 388-97-2980 .