**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 4 residents (Resident 1), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the resident at risk of negative outcomes and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication and Treatment Administration, dated January 2024, showed that medications would be administered as prescribed. The policy further showed that the Seven Rights of medication administration would be observed for right resident, right drug, right dose, right time, right route, right manufacturer/pharmacy recommendations, and right documentation.Resident 1 readmitted to the facility on [DATE] with diagnoses that included hiatal hernia (the upper part of the stomach [a muscular organ that digests food] bulges up into the chest through an opening in the diaphragm [muscle barrier that separates the abdominal cavity from the chest cavity]), gastroesophageal reflux disease with esophagitis (stomach acid flows back into the esophagus [tube that carries food from the throat down to the stomach] causing irritation and discomfort).Review of the admission Minimum Data Set (an assessment tool) dated 06/09/2025 showed Resident 1's cognition was intact.Review of the August 2025 and September 2025 Medication Administration Record (MAR), showed Resident 1 had the following medication orders:- Aluminum-Magnesium Simethicone (Mylanta - antacid medication that treats heart burn, upset stomach, and gas) Oral Suspension. Give 20 milliliters (ml - a unit of measurement) by mouth with meals at 8:00 AM, 12:00 PM, 6:00 PM; and at bedtime at 8:00 PM for gastrointestinal issues (conditions that affect the digestive system including the stomach and intestines). Give 30 ml of Lido [lidocaine-local anesthetic used to numb painful areas in the mouth and throat) oral solution]/Antacid 1:2 oral suspension.- Lidocaine Mouth/Throat Solution 2 %. Give 10 ml by mouth with meals at 8:00 AM, 12:00 PM, 6:00 PM; and at bedtime at 8:00 PM for gastrointestinal issues. Give 30 ml of Lido/Antacid 1:2 oral suspension. Review of the August 2025 MAR showed Resident 1 was not given their Mylanta on the following dates and times:- 08/01/2025 at 8:00 PM- 08/02/2025 at 8:00 AM and 12:00 PM- 08/06/2025 at 6:00 PM and 8:00 PM- 08/07/2025 at 8:00 AM, 12:00 PM, 6:00 PM, and 8:00 PM- 08/08/2025 at 12:00 PM, 6:00 PM and 8:00 PM- 08/12/2025 at 12:00 PM, 6:00 PM and 8:00 PM- 08/13/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/14/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/15/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/30/2025 at 8:00 PM- 08/31/2025 at 12:00 PM, 6:00 PM, and 8:00 PMFurther review of August 2025 MAR showed Resident 1 was not given their Lidocaine oral solution on the following dates and times:- 08/01/2025 at 8:00 PM- 08/02/2025 at 8:00 AM and 12:00 PM- 08/06/2025 at 6:00 PM and 8:00 PM- 08/07/2025 at 8:00 AM, 12:00 PM, 6:00 PM, and 8:00 PM- 08/08/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/12/2025 at 12:00 PM, 6:00 PM and 8:00 PM- 08/13/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/14/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/15/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/30/2025 at 8:00 PM- 08/31/2025 at 8:00 AM, 12:00 PM, 6:00 PM, and 8:00 PMReview of the September 2025 MAR showed Resident 1 was not given their Mylanta on the following dates and times:- 09/01/2025 at 8:00 AM and 12:00 PM- 09/02/2025 at 8:00 AM and 12:00 PFurther review of September 2025 MAR showed Resident 1 was not given their lidocaine oral solution on the following dates and times:- 09/01/2025 at 8:00 AM and 12:00 PM- 09/02/2025 at 8:00 AM and 12:00 PM- 09/07/2025 at 8:00 AM and 12:00 PM- 09/15/2025 at 8:00 AM and 12:00 PMReview of the progress note from 07/21/2025 to 09/15/2025 did not show documentation that the doctor was notified of the Mylanta and lidocaine medication not being available and/or not given to Resident 1.On 09/15/2025 at 12:55 PM, Resident 1 stated they had discomfort and bloating (swollen with fluid or gas) when they did not get their Mylanta-lidocaine. Resident 1 further stated that when they had bloating, it was hard to breathe, eat, sit-up, and walk. Observation on 09/15/2025 at 1:05 PM showed Staff C providing Resident 1 their medications. Staff C gave Resident 1 a white liquid in a medication cup stating, this is your aluminum magnesium simethicone. In an interview and joint record review on 09/15/2025 at 1:48 PM, Staff C, Licensed Practical Nurse, stated they followed the MAR when administering medications to the residents. A joint record review of September 2025 MAR showed Resident 1 had orders for Mylanta 20 ml by mouth before meals. Give 30ml of Lido/Antacid 1:2 oral suspension and for Lidocaine oral solution 10 ml before meals. Give 30ml of Lido/Antacid 1:2 oral suspension. Staff C stated they gave Resident 1 their aluminum magnesium simethicone (Mylanta) medication. Staff C stated they did not find lidocaine viscous and did not give it to Resident 1. Staff C stated they gave 20 ml of lido/antacid 1:2 oral suspension at 8:00 AM and 12:00 PM on 09/07/2025 and today [09/15/2025] to Resident 1. A joint observation of the medication refrigerator showed there were three bottles of 1200 ml of Resident 1's lido/antacid. The instructions on the bottle indicated, Give 30 ml of Lido/Antacid 1:2 oral suspension. Staff C stated they did not find Resident 1's Mylanta and lidocaine oral solution on 09/02/2025 and did not give Resident 1 their 8:00 AM and 12:00 PM doses. Staff C stated they did not know there was another refrigerator in the medication room and that on 09/07/2025 they found Resident 1's aluminum magnesium simethicone [Mylanta]. Staff C further stated they did not notify the doctor Resident 1's Mylanta and lidocaine oral solution was not available because they were not pertinent medications.In an interview on 09/15/2025 at 4:15 PM, Staff D, Pharmacist, stated that Aluminum-Magnesium Simethicone Oral Suspension 200- 200-20 MG/5ML. Give 20 ml and Lidocaine Mouth/Throat Solution 2% Give 10 ml were a compound (mixed medication). Staff D further stated that if the lido/antacid bottle indicated to give 30 ml, nurses should administer 30ml and sign the MAR for the medication separately as the facility software did not allow for the medications to be written as one order.In a follow-up interview on 09/18/2025 at 10:40 AM, Staff D stated nurses should give 30 ml of lido/antacid to Resident 1 before meals and at 8:00 PM.In an interview and joint record review on 09/18/2025 at 2:04 PM, Staff B, Resident Care Manager, stated they expected nurses to follow resident's MAR to provide medications. Saff B stated that when medications were not available, they expected the nurses to contact the pharmacy to reorder the medication, notify the family, notify the doctor that medication was not given, and document it in the resident's progress notes. A joint record review of August 2025 and September 2025 MARs showed Resident 1 was not given their Mylanta/lidocaine oral solution on 08/01/2025, 08/02/2025, 08/06/2025, 08/07/2025, 08/08/2025, 08/12/2025, 08/13/2025, 08/14/2025, 08/15/2025, 08/30/2025, 08/31/2025, 09/01/2025, 09/02/2025, 09/15/2025, 09/07/2025, and 09/15/2025. Staff B stated that the nurses should have notified the doctor about Resident 1's medication not being available. Staff B further stated that Staff C should have given 30 ml of lido/antacid to Resident 1 on 09/07/2025 and 09/15/2025.On 09/18/2025 at 3:11 PM, Staff A, Director of Nursing Services, stated nurses should have notified the doctor about Resident 1's lidocaine/antacid medications not being available and/or given. Staff A further stated that Staff C should have administered 30 ml of lido/antacid to Resident 1 on 09/07/2025 and 09/15/2025.Reference: (WAC) 388-97-1300 (1)(b)(ii)(3)(a).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 20 Review of the face sheet showed Resident 20 admitted to the facility on [DATE] with multiple diagnosis including major depression (a serious mood disorder that causes persistent feeling of sadness and loss of interest). Review of Resident 20's physician orders showed 50 milligrams (mg-a unit of measurement) of an antidepressant medication was ordered to give one and a half tablets by mouth at bedtime for depression with sleep disturbances related to major depression on 01/24/2024. In a joint record review and interview on 06/28/2024 at 2:21 PM with Staff D, showed there was no consent for the antidepressant in Resident 20's electronic health record. Staff D stated that if they received an order for a psychotropic medication, they would get a consent since it was a psychotropic medication. Staff D stated that they were unable to find the consent and would have to dig through the progress notes. In an interview on 06/28/2024 at 2:31 PM, Staff B stated that they would get consent for the antidepressant medication as part of their process. Reference: (WAC) 388-97-0260 Based on interview and record review, the facility failed to ensure informed consent for psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) was completed prior to administration for 2 of 5 residents (Residents 15 & 20), reviewed for unnecessary medications. This failure placed the residents and/or their representatives at risk of not being fully informed of the risks and benefits before making decisions about medications prior to administration. Findings included . Review of the facility's policy titled, Psychotropic Medication Management, revised in November 2021, showed that the resident/resident representative would be informed of the medication order, indication for use, and the right to refuse. The policy further showed that resident would be informed of the risk versus benefits of the medication to be administered. RESIDENT 15 Review of the physician's order dated 03/09/2024 showed Resident 15 had an order for a medication for anxiety. Review of the March 2024 to June 2024 medication administration record showed Resident 15 was taking a medication for anxiety since 03/10/2024. A joint record review and interview on 06/28/2024 at 10:30 AM with Staff D, Resident Care Manager, showed Resident 15 did not have a consent for a medication for anxiety. Staff D stated that Resident 15's consent was missed but that there should have been one. In an interview on 06/28/2024 at 11:33 AM, Staff B, Director of Nursing, stated that they expected residents to have a consent prior to taking psychotropic medications to explain the risks and benefits of the medication. Staff B stated that the consent should be completed prior to Resident 15 starting a medication for anxiety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 21 Review of the quarterly minimum data set (an assessment tool) dated 05/16/2024 showed that Resident 21 admitted to the facility on [DATE]. On 06/27/2024 at 11:19 AM, Resident 21 stated that they had an advance directive and that their Power of Attorney (POA- a type of advance directive) carried a copy with them. Review of Resident 21's nursing progress note dated 03/19/2024 showed that their representative was their POA. Review of Resident 21's EHR showed no documentation of their advance directive. In an interview on 06/27/2024 at 11:43 AM, Staff C stated that if a resident had an advance directive, the document would get scanned into the miscellaneous tab in point click care (charting system) and expected it would be there if the resident had one. Staff C stated that they did not see an advance directive for Resident 21 and that typically they would ask family to provide a copy of their advance directive. Staff C further stated that they were aware that Resident 21 had a POA but had no paperwork to back it up. In an interview on 06/28/2024 at 10:50 AM, Staff A stated that they expected staff to follow their policy. Staff A further stated that if a resident had an advance directive, they expected they would have a copy of it. Reference: (WAC) 388-97-0280 (3)(a) Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 2 of 3 residents (Residents 4 & 21), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives, revised in March 2024, showed, If the resident or legal representative has executed one or more advance directive(s), these documents are obtained, incorporated and consistently maintained in the same section of the resident's health information record readily retrievable. RESIDENT 4 Review of the admission Minimum Data Set (MDS-an assessment tool) dated 04/17/2024, showed Resident 4 admitted to the facility on [DATE]. Review of Resident 4's Electronic Health Record (EHR), showed no documentation that Resident 4 had an advance directive. On 06/27/2024 at 11:15 AM, Resident 4 stated, I have one [advance directive]. In an interview and joint record review on 06/27/2024 at 11:34 AM, Staff C, Social Services Director, stated that if a resident had an advance directive, it would be scanned into the EHR and that they expected it to be there. In a joint record review of Resident 4's EHR showed no documentation that Resident 4 had an advance directive. Staff D stated, I don't see any documentation of a DPOA or advance directive. On 06/28/2024 at 12:40 PM, Staff A, Administrator, stated that if a resident had an advance directive I would expect there to be a copy in their medical records.

Based on interview and record review, the facility failed to issue Notification of Medicare Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 1 of 3 residents (Resident 331), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk for not being fully informed and losing their right to an appeals process. Findings included . Review of the facility's policy titled, Medicare and Medicare Advantage Notices for Skilled Nursing Facilities, revised in February 2023, showed, It is the policy of the Company that notices for skilled nursing facilities are delivered to residents according to Medicare and Medicare Advantage plan guidelines. Review of the undated Centers for Medicare and Medicaid Services online form titled, Form instructions for the notice of Medicare Non-Coverage (NOMNC) CMS-10123, showed, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Review of the admission minimum data set (an assessment tool) dated 01/02/2024 showed that Resident 331 admitted to the facility under their skilled Medicare A benefits with a state date of 12/27/2023. Review of Resident 331's NOMNC showed a last day of Medicare A coverage of 01/23/2024, signed on 01/24/2024, one day after the end of Medicare A coverage. Review of the social services progress note dated 01/24/2024 showed that the NOMNC was signed on 01/24/2024 by Resident 331's representative and that Resident 331 had asked for their representative to sign for them. In an interview and joint record review on 06/26/2024 at 2:23 PM with Staff C, Social Services Director, stated they issued the NOMNC at least 2 days prior to end of Medicare coverage. Staff C stated that if a resident declined or was unable to sign the NOMNC form, they would email it to the resident's representative and have them acknowledge the receipt. Joint record review of Resident 331's NOMNC showed that it was signed on 01/24/2024. Staff C stated they emailed Resident 331's representative to inform them that Resident 331 would rather have them sign the NOMNC form and informed them to acknowledge the email. Staff C stated that they would find the email and would provide it. In a follow up interview at 2:41 PM, Staff C stated that they could not find the email that was sent to Resident 331's representative and that they should have emailed Resident 331's representative. In an interview on 06/28/2024 at 3:28 PM, Staff A, Administrator, stated that they expected the NOMNC to be issued at least 2 days before the last covered Medicare day and that it would be documented that it was given or that the resident preferred the representative to sign it. Reference: (WAC) 388-97-0300 (1)(e) .

Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the residents/representatives and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) for 2 of 3 residents (Residents 230 & 10), reviewed for hospitalization. These failures placed the residents at risk for not having an opportunity to make informed decision about transfers/discharges. Findings included . Review of the facility's policy titled, Discharge/Transfer, revised in November 2017, showed that the transfer/discharge notice would be issued as soon as practicable when an immediate transfer or discharge is required by the resident's urgent medical condition. The policy further showed that the copy of discharge notice must be sent to the State office of Long-Term Care Ombudsman. RESIDENT 230 Review of the nursing progress note dated 06/14/2024 showed that Resident 230 was sent to the hospital for further evaluation. Review of the Electronic Health Record (EHR) did not show documentation that a written notice of transfer/discharge was provided to Resident 230 and/or their representative, and to the Office of the State Long-Term Care Ombudsman. In an interview on 06/27/2024 at 3:26 PM, Staff C, Social Services Director, stated that they did not provide a written notice to the resident/family and State Ombudsman office and said, If it should be done that would be me but I have not been doing it. In an interview on 06/28/2024 at 10:30 AM, Staff D, Resident Care Manager, stated that they notified family by phone and did not provide a written transfer notice to Resident 230 and/or their representative. Staff D also stated that they did not notify the Ombudsman's office about the transfer. In an interview on 06/28/2024 at 11:33 AM, Staff B, Director of Nursing, stated that they informed the resident/their family by phone, and they did not have a written notice to provide to the resident and/or their representative. Staff B also stated that the facility did not send a copy of transfer notice to the State Long-Term Care Ombudsman office. In an interview on 06/28/2024 at 2:03 PM, Staff A, Administrator, stated that it was their expectation for the facility to follow its discharge/ transfer policy. RESIDENT 10 Review of the discharge minimum data set (an assessment tool) dated 03/30/2024 showed that Resident 10 discharged to the hospital. Review of the nursing progress notes dated 03/30/2024 showed that Resident 10 left to the emergency room due to emesis (vomiting) and abdominal pain. Review of Resident 10's EHR did not show documentation that the resident and/or their representative were notified in writing of the reason for discharge to the hospital. In an interview on 06/27/2024 at 3:45 PM, Staff C stated that they have not been notifying the resident and/or their representative in writing of the reason for discharge and sending a copy of the notice to the Ombudsman. Staff C further stated that if it were being done, it was done by nursing. In an interview on 06/27/2024 at 5:12 PM, Staff D stated they did not notify the resident and/or their representative in writing of the reason for discharge and do not send a copy of the notice to the Ombudsman. Staff D stated that they had not personally sent one to the Ombudsman. In an interview on 06/28/2024 at 2:20 PM, Staff B stated that they have not been notifying the residents and/or their representatives in writing of the reason for discharge and/or sent a notice to the Ombudsman. In a joint record review of the facility's discharge policy showed that the notice was to be given to the resident/representative and Ombudsman. Staff B stated that if it was the regulation, it should have been done. In an interview on 06/28/2024 at 2:29 PM, Staff A stated that they expected staff to follow their policy. Reference: (WAC) 388-97-0120 (2)(a)(b)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure bed hold (the opportunity to pay for the bed the resident currently occupied while out of the facility in order to ensure their bed/room was available when they are ready to return) notices were offered to residents who were hospitalized for 2 of 3 residents (Residents 230 & 10), reviewed for hospitalization. The failure to offer bed holds placed residents at risk for unwanted, avoidable room changes upon readmission, and frustration. Findings included . Review of the facility's policy titled, Bed Hold, revised on January 2020, showed before a nursing facility transferred a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed hold policy under the State plan, if any during which the resident is permitted to return and resume residence in the nursing facility and the bed payment policy. RESIDENT 230 Review of the nursing progress note dated 06/14/2024, showed that Resident 230 was sent to the hospital for further evaluation. Review of the Electronic Health Record (EHR) did not show that Resident 230 was offered a bed hold notice for their transfer to the hospital. In an interview on 06/26/2024 at 8:47 AM, Resident 230 stated that they were hospitalized on [DATE] and readmitted to the facility on [DATE]. Resident 230 stated they were not offered a bed hold notice. In an interview on 06/27/2024 at 3:26 PM, Staff C, Social Services Director, stated they spoke to Resident 230 and their representative about the bed hold but did not offer written bed hold notice. Staff C further stated that they did not offer the bed hold notice because the facility had no problem readmitting residents. In an interview on 06/28/2024 at 2:03 PM, Staff A, Administrator, stated that it was their expectation for the facility to follow its discharge/ transfer policy. RESIDENT 10 Review of the discharge minimum data set (an assessment tool) dated 03/30/2024 showed that Resident 10 discharged to the hospital. Review of the nursing progress notes dated 03/30/2024 showed that Resident 10 left to the emergency room due to emesis (vomiting) and abdominal pain. Review of Resident 10's EHR showed no documentation that the resident and/or their representative were notified of a bed hold notice. In an interview on 06/27/2024 at 3:45 PM, Staff C stated they did verbal communication of the bed hold notice and that it was not documented. Staff C further stated that they did not provide residents and/or their representatives with a written bed hold notice. In an interview on 06/28/2024 at 2:29 PM, Staff A stated that they expected staff to follow their bed hold policy. Reference: (WAC) 388-97-0120 (4)(a)(b)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 1 of 3 residents (Resident 28) reviewed for hospitalization. The failure to ensure accurate assessment regarding discharge status resulted in inaccurate information in the resident's clinical record and placed the resident at risk for unidentified care needs. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, showed: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). Review of Resident 28's electronic health record showed a nursing progress note dated 06/07/2024 that showed, This resident was cleared .to go home safely. Review of the discharge Minimum Data Set (MDS-an assessment tool) dated 06/08/2024, showed Resident 28's MDS was coded for discharge to Short-term General Hospital. In an interview and joint record review on 06/27/2024 at 3:44 PM, Staff E, MDS coordinator, stated that Resident 28 discharged to the community, and they expected the discharge MDS to be coded for that. In a joint review of the discharge MDS dated [DATE], showed it was coded for Short-term General Hospital. Staff E stated it should be coded for community and I will modify it. In an interview on 06/28/2024 at 1:59 PM, Staff B, Director of Nursing, stated they expected the MDS to be accurate. Reference: (WAC) 388-97-1000 (1)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services related to gastrostomy tube (G-tube - a medical device used to provide nutrients through a tube directly into the stomach) were followed for 1 of 1 resident (Resident 21), reviewed for tube feeding management. The failure to check for G-tube placement by visual inspection of aspirated stomach content prior to medication administration placed the resident at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Enteral [tube placed in the stomach to provide nutrition and medications] Tube Feeding and Medication Administration, dated November 2022, showed that medication administration would include checking placement prior to administration. It further showed that placement would be checked before each feeding and before each medication administration or intermittently as ordered. Review of the quarterly minimum data set (an assessment tool) dated 05/16/2024 showed that Resident 21 admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (surgical opening in the stomach) status. Further review showed that Resident 21 received nutrition through a feeding tube. Review of Resident 21's June 2024 medication administration record (MAR) showed an enteral feed order every shift to check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding dated 02/14/2024. Observation on 06/27/2024 at 11:02 AM, showed Staff G, Registered Nurse, inserted a syringe in Resident 21's G-tube port. Staff G removed the syringe from the G-tube port and removed the plunger from the syringe. Staff G then re-inserted the syringe back into the G-tube port and flushed it with water. Staff G poured a medication cup with one dissolved medication into the syringe and then flushed it with water. Staff G did this same process until they were done administering all of Resident 21's medications. When Staff G was done, they flushed the G-tube with water. Staff G did not check G-tube placement by visual inspection of aspirated stomach content prior to administering Resident 21's medications. In an interview on 06/27/2024 at 11:23 AM, Staff G stated that they did not check G-tube placement prior to administering Resident 21's medications and that they should have. In an interview on 06/27/2024 at 5:32 PM, Staff D, Resident Care Manager, stated that their process for administering medications by G-tube was to check for placement, and to flush with water before, in between, and after administering medications. Staff D stated that they followed the MAR on how to check for G-tube placement. Staff D further stated that they expected Staff G to check for G-tube placement prior to administering medications. In an interview on 06/28/2024 at 9:15 AM, Staff B, Director of Nursing, stated that they expected staff to check for G-tube placement per physician order. Staff B further stated that they expected Staff G to check for G-tube placement per physician order prior to administering medications. Reference: (WAC) 388-97-1060 (3)(f) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure side rails were safe to use for 1 of 6 residents (Resident 4) reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy titled, Side Rail Assessment, revised in August 2022, showed, The Maintenance department will conduct regular inspection of all the bed frames, mattresses, and side rails as part of their regular maintenance program to identify areas of possible entrapment. Review of the admission minimum data set (an assessment tool) dated 04/17/2024, showed Resident 4 admitted to the facility on [DATE]. Review of the mobility care plan revised on 04/30/2024 showed Resident 4 was one person limited to extensive assist for bed mobility and transfers. In a joint observation and interview on 06/25/2024 at 11:52 AM with Resident 4, showed Resident 4's bed with the right-side rail in the raised position. Resident 4 stated they used the side rails for getting up from lying down. Additional observations on 06/26/2024 at 2:16 PM and 2:29 PM, showed Resident 4 with bilateral (both sides) side rails in the raised position. On 06/27/2024 at 9:07 AM, Staff P, Certified Nursing Assistant, stated that Resident 4 used their side rails and they come in handy. In an interview and joint observation on 06/28/2024 at 9:16 AM with Staff S, Maintenance Manager, stated they have not been checking side rails for safety. Staff S stated that they had not seen any side rails and were not aware of any side rails in use by residents. In a joint observation of Resident 4's bed, showed bilateral side rails in the raised position. Staff S stated, I've never seen these before. Staff S further stated that beds were checked only when a resident discharged or admitted to the facility and there was no routine maintenance for side rails. In an interview on 06/28/2024 at 12:42 PM, Staff A, Administrator, stated that facilities was responsible for side rails being added to beds. In a follow-up interview at 1:23 PM, Staff A stated, there is no process for routine maintenance of side rails and there was no documentation that side rails were checked for safety. Reference: (WAC) 388-97-2100 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 4 of 5 residents (Residents 20, 12, 10, & 21), had a completed and an accurate Preadmission Screening Resident Review (PASRR) (an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), intellectual disabilities; or related conditions are not inappropriately placed in nursing homes for long term care) on admission. This failure placed these residents at risk for unmet care needs, unmet mental needs, and a decreased quality of life. Findings included . Record review of the facility's policy titled, PASSR-Preadmission Screening and Resident Review policy, dated October 2023, showed that the company will abide by the federal requirement for PASRR to ensure that individuals are not inappropriately placed in nursing facilities for long term care. This policy showed PASRR required that (1) all applicants to a Medicaid-certified nursing facility be evaluated for mental illness and/or intellectual disability; (2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and (3) receive the services they need in those settings. RESIDENT 20 Review of the face sheet showed Resident 20 admitted to the facility on [DATE] with multiple diagnoses including major depression (mood disorder that causes persistent feeling of sadness and loss of interest). Review of the Level I PASSR for Resident 20 showed it was completed on 06/28/2024, seven days after their admit day. On 06/28/2024 at 2:31 PM, Staff C, Social Services Director, stated that the PASSR was usually filled out by the hospital prior to admission to the facility. Staff C stated that if the PASSR was not filled out at the hospital, then they themselves would fill it out. Staff C admitted that Resident 20's PASSR was filled out a week after admission to the facility. RESIDENT 10 Review of the significant change in status MDS dated [DATE] showed that Resident 10 readmitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mental illness that affects a person's mood and thoughts). Review of Resident 10's Level I PASRR form completed on 04/04/2024 showed that SMI was marked no. RESIDENT 21 Review of the admission MDS dated [DATE] showed that Resident 21 admitted to the facility on [DATE] with multiple diagnoses that included depression and anxiety (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 21's Level I PASRR form completed on 02/14/2024 showed that SMI was marked no. In an interview and joint record review on 06/27/2024 at 11:59 AM, Staff C stated that they were responsible in ensuring the Level I PASRR form were accurate. Staff C stated that if the PASRR form was completed by the hospital, they would look at the diagnosis and verified it was accurate. Joint record review of Resident 10 and Resident 21's PASRR form showed that they were not marked for SMI. Staff C stated that they should have been marked for SMI and referred for Level II PASRR (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services). In an interview on 06/28/2024 at 10:56 AM, Staff A stated that they expected staff to follow the regulation and their policy. Staff A further stated that they expected the PASRR forms to be accurate. Reference: (WAC) 388-97-1915 (1); 1975(1)(2)(3) RESIDENT 12 Review of the entry Minimum Data Set (MDS- an assessment tool) dated 12/14/2023, showed Resident 12 admitted to the facility on [DATE]. Review of the comprehensive care plan printed on 06/26/2024, showed Resident 12 had a diagnosis of depression. Review of Resident 12's Level I PASRR dated 12/13/2023, showed nothing marked for SMI. In an interview and joint record review on 06/27/2024 at 11:59 AM, Staff C stated that when a resident admitted from the hospital, they checked the Level I PASRR and verified that it was accurate. In a joint record review of Resident 12's electronic health record, showed Resident 12 had a diagnosis of depression. In a joint record review of the Level I PASRR dated 12/13/2023, showed there was nothing marked under the SMI section for depression. Staff C stated the Level I PASRR should have been marked for depression and I didn't catch it. On 06/28/2024 at 12:38 PM, Staff A, Administrator, stated they expected the Level I PASRR to be looked at and be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 20 Review of the face sheet showed Resident 20 admitted to the facility on [DATE] with multiple diagnoses including a history of cerebral vascular accident (a loss of blood flow to part of the brain, which damages brain tissue). Review of Resident 20's physicians orders showed anticoagulant medication used to treat and prevent blood clots 2.5 milligrams (mg-a unit of measure) one tablet two times a day was ordered on 10/27/2024. In an interview and joint record review with Staff D, on 06/28/2024 at 2:07 PM, showed that the anticoagulant medication was not included in the care plan. Staff D stated, It looks like it did not make it in the care plan. Staff D stated that the anticoagulants were usually included. Staff D stated that when they clicked on a certain box in the electronic health record system, it would automatically create a care plan for anticoagulant therapy. In a joint record review and interview with Staff B on 06/28/2024 at 2:34 PM, Staff B stated that they just saw a blood thinner in the care plan but it looks like it was just added within the hour. Staff B stated their process for a resident starting an anticoagulant included updating their care plan. Reference: (WAC) 388-97-1020(1) Based on interview and record review, the facility failed to develop person-centered comprehensive care plans for 5 of 11 residents (Residents 230, 4, 19, 21, & 20) whose care plans were reviewed. The facility's failure to develop individualized, comprehensive care plans left residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Care Planning, revised in October 2023, showed that within 21 days of admission and/or 7 days after the completion of the comprehensive assessment the interdisciplinary team including the resident and/or responsible party would develop a comprehensive care plan. RESIDENT 230 Review of the physician's order, dated 05/29/2024, showed Resident 230 had an order of oxygen (O2) at two liters (unit of measurement) per minute via nasal cannula (flexible tubing that sits inside the nostrils and delivers O2 as needed for shortness of breath. Review of Resident 230's June 2024 Medication Administration Record (MAR) showed Resident 230 was using O2 since 05/29/2024. Review of Resident 230's comprehensive care plan printed on 06/26/2024, showed no O2 care plan. In an interview on 06/26/2024 at 8:17 AM, Resident 230 stated that they were using O2 since they admitted to the facility on [DATE]. In a joint record review and interview on 06/28/2024 at 10:30 AM with Staff D, Resident Care Manager, showed the care plan for O2 use was initiated on 06/26/2024. Staff D stated that Resident 230 was using O2 since 05/29/2024, and the care plan was not initiated until 06/26/2024. In an interview on 06/28/2024 at 11:33 AM, Staff B, Director of Nursing, stated the care plan for Resident 230's O2 use should have been developed whey they started using O2. RESIDENT 19 Review of the quarterly MDS dated [DATE] showed that Resident 19 readmitted to the facility on [DATE] with diagnoses that included congestive heart failure (long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply causing blood and fluids to collect in the lungs and legs over time). Review of Resident 19's June 2024 MAR showed an order for O2 saturation every shift for routine monitoring. Give O2 via nasal cannula to keep O2 saturation greater than 95 percent. Notify provider if using greater than three liters dated 06/04/2024. Review of Resident 19's comprehensive care plan printed on 06/26/2024 did not show a care plan for O2 use. In an observation and interview on 06/25/2024 at 2:05 PM showed Resident 19 sitting in their recliner using two liters of O2 via nasal cannula. Resident 19 stated that they started using O2 due to pneumonia (lung infection). In an interview and joint record review on 06/26/2024 at 3:45 PM, Staff F, RN, stated that O2 use would be part of the residents' care plan. In a joint record review of Resident 19's care plan did not show a care plan for O2 use. Staff F stated Resident 19 should have had a care plan. In an interview on 06/27/2024 at 5:22 PM, Staff D stated that O2 use should be care planned. Staff D stated that an O2 care plan was added on 06/26/2024 and that they should have had initiated a care plan when Resident 19 started using O2. In an interview on 06/28/2024 at 9:24 AM, Staff B stated that they expected O2 use to be care planned. RESIDENT 21 Review of the quarterly MDS dated [DATE] showed that Resident 21 was admitted to the facility on [DATE]. It showed that Resident 21 had an active range of motion restorative nursing program and was performed for two days for at least 15 minutes. Review of the restorative task form from 05/30/2024 to 06/23/2024 showed that Resident 21 was provided their restorative nursing program nine times. Review of Resident 21's comprehensive care plan printed on 06/26/2024 did not show a care plan for their restorative program. In an interview on 06/28/2024 at 1:56 PM, Staff E, MDS Coordinator, stated that once a resident comes off therapy, they would make recommendations for a restorative program. Staff E stated that the restorative program should be part of the resident's care plan and stated, there might be some that are not in there. Staff E reviewed Residents 21's [NAME] (care guide for CNAs) and stated that they did not see it. Staff E stated that if it was not in the [NAME], it was not in their care plan. Staff E stated that it needed to be in the care plan for it to show in the [NAME] and that Resident 21 should have had a restorative care plan. In an interview on 06/28/2024 at 2:09 PM, Staff B stated Resident 21 should have had a restorative care plan. RESIDENT 4 Review of the admission Minimum Data Set (MDS-an assessment tool) dated 04/17/2024, showed Resident 4 admitted to the facility on [DATE]. Review of the mobility care plan revised on 04/30/2024, showed Resident 4 was one person limited to extensive assist for bed mobility and transfers. In a joint observation and interview on 06/25/2024 at 11:52 AM, showed Resident 4's bed with the right-side rail in the raised position. Resident 4 stated they used the side rails for getting up from lying down. Additional observations on 06/26/2024 at 2:16 PM and at 2:29 PM, showed Resident 4 with bilateral (both sides) side rails in the raised position. Review of the comprehensive care plan printed on 06/26/2024, showed no care plan for Resident 4's side rails. On 06/27/2024 at 9:07 AM, Staff P, Certified Nursing Assistant, stated that Resident 4 used their side rails and they come in handy. In an interview and joint record review on 06/27/2024 at 9:25 AM, Staff G, Registered Nurse (RN), stated they would expect there to be a care plan for side rails. In a joint record review of Resident 4's comprehensive care plan, showed no care plan for side rails. Staff G stated, I would expect there to be one. In an interview on 06/28/2024 at 1:50 PM, Staff B stated that prior to adding side rails to a resident's bed, there needed to be an assessment, consent, physician's order, and it should be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 230 Review of the physician order dated 05/29/2024 showed Resident 230 had an order of O2 supply at two liters per minute via nasal cannula as needed for shortness of breath. Review of Resident 230's June 2024 MAR showed Resident 230 was using O2 since 05/29/2024. Observations on 06/26/2024 at 8:17 AM and on 06/26/2024 at 3:05 PM, showed the resident was lying in bed, receiving two liters per minute O2 via nasal cannula. The observation showed tubing was undated. The observations further showed that there were no O2 in use sign on the Resident 230's room door. In an interview on 06/26/2024 at 8:17 AM, Resident 230 stated that they were using O2 since they admitted to the facility. A joint observation and interview on 06/27/2024 at 8:23 AM with Staff J, RN, showed that the tubing was dated 06/26/2024. The observation also showed that there was no signage on Resident 230's door. Staff J said, the signage will be a good thing, but we did not put it. Staff J added that they change and date the tubing every week and the staff from 06/26/2024 night shift changed and dated the tubing. A joint record review and interview on 06/28/2024 at 10:30 AM with Staff D, showed the order for tubing change was placed on 06/26/2024. Staff D stated that there should have been an order for O2 tubing change when Resident 230 started using it on 05/29/2024. Staff D further stated that Resident 230's room door had no O2 in use sign. In an interview on 06/28/2024 at 11:33 AM, Staff B stated that an order for tube change should have been obtained when Resident 230 started using O2. Staff B added that they did not put O2 signage on the door because they were not a smoking facility. Staff B further stated that the facility's O2 policy should be followed. Reference: (WAC) 388-97-1060 (3)(j)(vi) RESIDENT 19 Review of the quarterly MDS dated [DATE] showed that Resident 19 readmitted to the facility on [DATE]. Review of the care plan printed on 06/26/2024 showed they had diagnoses that included pneumonia (infection in one or both of the lungs which can cause cough and difficulty breathing) and congestive heart failure (long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply causing blood and fluids to collect in the lungs and legs over time). Review of Resident 19's June 2024 MAR showed an order for O2 saturation every shift for routine monitoring. Give O2 via nasal cannula to keep O2 saturation greater than 95 percent. Notify provider if using greater than three liters dated 06/04/2024. Observation and interview on 06/25/2024 at 2:05 PM, showed Resident 19 sitting in their recliner using O2 via an unlabeled nasal cannula. Resident 19 stated that they started using O2 due to pneumonia. Observation on 06/26/2024 at 1:16 PM, showed Resident 19's O2 tubing on the floor and their unlabeled nasal cannula was laying on top of the O2 concentrator with the nasal prongs touching the floor and was not in a bag. In an interview and joint observation on 06/26/2024 at 3:45 PM, Staff F, RN, stated that they stored the nasal cannula in a bag when not in use, changed it every 72 hours and as needed and labeled/dated the nasal cannula tubing. Joint observation showed Resident 19's O2 nasal cannula was touching the floor, was unlabeled and was not stored in a bag. Staff F stated that the nasal cannula should not have been on the floor, that it should have been labeled and stored in a bag when not in use. On 06/28/2024 at 9:24 AM, Staff B stated that they expected the nasal cannula to be labeled, changed weekly and stored in a bag when not in use. Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care and services were provided in accordance with professional standards of practice for 3 of 3 residents (Residents 5, 19, & 230), reviewed for respiratory care. Specifically, oxygen (O2) equipment was not maintained to include care of O2 tubing and nasal cannula (flexible tubing that sits inside the nostrils and delivers O2) and did not have signage for when oxygen was in use. This failure had the potential to affect the resident's respiratory status, including respiratory infections and related complications and the potential to create a hazardous environment. Findings included . Review of the facility's policy titled, Oxygen/Respiratory Therapy and Safety, revised in January 2020, showed, The resident's room will have a sign signifying when oxygen is in use. The policy showed, Oxygen/respiratory equipment tubing/cannula/mask and plastic container bag will be changed at least weekly and anytime as needed .and would be dated and initialed each time it is changed. It further showed that When oxygen/respiratory equipment is not in use, place the tubing/cannula/mask into the bag to keep clean and prevent contamination. RESIDENT 5 Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 04/04/2024, showed Resident 5 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the June 2024 Medication Administration Record (MAR) showed Resident 5 had an order for Oxygen at 2L [Liters - a unit of measurement]/min [minute] via NC [nasal cannula] continuously. Observations on 06/25/2024 at 8:37 AM and at 1:21 PM, showed Resident 5 had an O2 concentrator (a machine that delivers oxygen) in their room with a nasal cannula not in use and not stored in a bag. It also showed there was no sign that stated O2 was in use. Observation on 06/26/2024 at 8:21 AM, showed Resident 5's nasal cannula on the floor and not stored in a bag. It also showed there was no sign that stated O2 was in use. Additional observation on 06/26/2024 at 9:41 AM, showed Staff R, Registered Nurse (RN), put the nasal cannula that was on the floor on Resident 5. In an interview and joint observation on 06/26/2024 at 9:50 AM, Staff R stated that O2 tubing should be labeled. Staff R stated when the nasal cannula was not in use, they just set it aside and if it was found on the floor, if it's soiled, throw away and get a new one [nasal cannula]. Joint observation of Resident 5's portable O2 tubing showed no label or date. Staff R stated that it was not labeled or dated. Staff R further stated that they had picked up the nasal cannula from the floor and put in on Resident 5 because it didn't look soiled. In an interview and joint observation on 06/27/2024 at 9:43 AM, Staff G, RN, stated that Resident 5 was on O2. Joint observation showed there was no O2 in use sign for Resident 5's O2. Staff G stated that there was no O2 in use sign and I've never seen a sign. In an interview on 06/28/2024 at 11:03 AM, Staff D, Resident Care Manager/Infection Preventionist, stated they expected the nasal cannula to be in a bag when not in use and should be off the floor. In an interview on 06/28/2024 at 1:58 PM, Staff B, Director of Nursing, stated they expected O2 tubing to be labeled and dated. Staff B stated that when the nasal cannula was not in use it should be in a bag and if it was found on the floor staff should replace it. Staff B further stated that the O2 in use sign should be there.

Based on observation, interview, and record review, the facility failed to maintain the medication room refrigerator temperature logs in 1 of 3 medication room refrigerators (Medicine Refrigerator) reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage in the Facility, revised on 01/01/2023, showed medications requiring refrigeration were kept in a refrigerator at temperatures between 36 Fahrenheit (F- a temperature scale)- 46 F with a thermometer to allow temperature monitoring. It further showed the facility should maintain a temperature log in the storage area to record temperatures at least once a day. Joint observation on 06/26/2024 at 3:25 PM with Staff B, Director of Nursing, showed that there were three refrigerators (medicine refrigerator, intravenous [within a vein] refrigerator and food refrigerator) in the medication storage room. The medicine refrigerator had one pneumococcal (helps protect against some types of bacterial infections) vaccine and other multiple resident medications. Record review of the facility's medication storage room temperature logs from April 2024 to June 2024 showed the following: -Five temperatures were logged for 04/01/2024 to 04/24/2024. -One temperature was logged for 05/01/2024 to 05/24/2024. -No temperature was logged for 06/01/2024 to 06/26/2024. In a joint record review and interview on 06/26/2024 at 4:05 PM with Staff B, showed that the June 2024 refrigerator temperature log was not completed for the medicine refrigerator for 26 of 26 days. Staff B stated that the temperature in medicine refrigerator should be tracked twice a day. Staff B further stated that temperatures were not consistently checked for April 2024 and May 2024. Joint observation of the medicine refrigerator on 06/27/2024 at 8:25 AM with Staff B showed the following: -Eight unopened medication that works by lowering levels of sugar in the blood) pens for Resident 230. -One opened box of a test for tuberculosis [a contagious infection caused by bacteria that mainly affects the lungs) -Three unopened boxes of a (brand name- tuberculosis testing solution) -One opened pneumonia vaccine -Four unopened boxes of a medication that prevents blood clots In an interview on 06/27/2024 at 8:35 AM, Staff B stated that the medications noted above were there on 06/26/2024 and that nothing had been taken out. Staff B further stated they should have been tracking the temperatures in the medicine refrigerator. Reference: (WAC) 388-97-1300 (2) .

Based on observation, interview, and record review, the facility failed to keep the kitchen refrigerator and storage free of expired food and staff failed to demonstrate handwashing while preparing lunch for all residents. These failures placed all residents at risk for a food borne illness by potentially serving expired food products and cross contamination from poor hand hygiene during food preparation. Findings included . Review of the facility's General Food Storage Standards, dated January 2023, showed the food storage should incorporate specific standards and criteria to maintain a clean and safe environment for healthful delivery to the residents. The procedure included that any food items that reached their expiration date would be discarded. Review of the facility's Hand Hygiene policy, dated 02/21/2022, showed that the facility considered hand hygiene the primary means to prevent the spread of infections. The policy showed all personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. The policy did not address hand hygiene during food preparation. The policy showed to perform hand hygiene after removing gloves and before and after eating or handling food. In a joint observation and interview on 06/27/2024 at 8:30 AM, a jar of thousand island dressing was observed in the refrigerator. The expiration label on the jar read 05/29/2024. Staff M, healthcare lead cook, stated that they did not know why it was there. Staff M stated, people put things where they shouldn't. In a joint observation and interview on 06/27/2024 at 8:32 AM, a tray of clams was observed on the refrigerator shelf. The label on this tray read Must use by 06/26/2024. Staff L, Kitchen staff/receiving, stated that they meant to discard the tray of clams but had not gotten to it. In a joint observation and interview with Staff N, Head chef on 06/27/2024 at 9:49 AM, three jars of mustard were observed on the shelf in the facility's dry storage room. The three jars of mustard had a manufacturer's expiration label of 04/26/2024. After pointing out the expiration date to Staff N, Staff N stated that it was just mustard, then continued to pull the mustard jars off the shelf to discard them. In an observation on 06/27/2024 at 9:31 AM, Staff O, kitchen cook, was observed cleaning a thermometer during meal preparation, then put the thermometer down and pick up a metal bowl. Observation showed Staff O continued to set up a tray of potatoes, don gloves, and finished preparing the potatoes before placing them in the oven. There was no handwashing observed in this sequence of events. Staff O was then observed picking up a dirty rag at the end of the counter that they had just worked on and stated, that shouldn't be on my table. On 06/27/2024 at 4:42 PM, Staff A, Administrator, stated that their expectation for labeling food was to follow the food labeling policy. Staff A stated, if it was expired, it should be thrown away. Staff A stated that they expect kitchen staff to follow the hand hygiene policy. Reference: WAC 388-97-1100 (3) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's water management program included a flow diagram to assess or monitor the potential growth of legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease), and to review infection prevention and control policy (IPCP) at least annually. Additionally, the facility failed to ensure proper hand hygiene practices were followed during room tray and activity flyer delivery for 2 of 6 staff (Staff H & I) and failed to put isolation precautions for Aerosolizing Generating Procedure (AGP-a medical procedure that produce minute particles that become suspended in the air) for 1 of 2 residents (Resident 4), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . LEGIONELLA WATER MANAGEMENT PROGRAM In an interview on 06/28/2024 at 8:50 AM, Staff K, Facility Services Director, stated that the facility's water management plan did not have a flow diagram to identify areas where legionella could grow and spread, and the facility did not have a process in place for communicating the water management program to residents, staff and/or others. Staff K further stated that the water management system for the entire building was overseen by the vendor, and they did not have a specific water management program for the floor where the skilled nursing unit was located. INFECTION PREVENTION AND CONTROL POLICY In an interview on 06/27/2024 at 2:10 PM, Staff D, Resident Care Manager/ Infection Preventionist, stated that they did not know how often the IPCP document was being reviewed. A joint record review and interview on 06/28/2024 at 11:33 AM with Staff B, Director of Nursing, showed that the IPCP was last revised in November 2017 and approved in February 2023. The IPCP also showed that the next IPCP review was in February 2024. Staff B stated that the policies were being reviewed at the corporate level and they did not know how often they reviewed the IPCP. In an interview on 06/28/2024 at 2:03 PM, Staff A, Administrator stated that they did not know about the facilities water management program and how often the IPCP document was being reviewed. HAND HYGIENE DURING MEAL ROOM TRAY DELIVERY Observation on 06/25/2024 at 12:59 PM, showed Staff H, CNA, took a meal tray from the meal cart and delivered it to room [ROOM NUMBER]. Staff H removed the plastic covering on the plates, opened a soda can, and poured it into a cup. Staff H then touched the bedside table, closed the door and went back to the meal cart without performing hand hygiene. Staff H then took another meal tray from the meal cart, filled a cup with coffee, opened a tea bag and placed it in a cup and delivered it to room [ROOM NUMBER] that had an Enhanced Barrier Precaution (EBP-an infection control intervention designed to reduce transmission of resident organism that employs targeted gown, and gloves use during high contact resident care activities) signage on the door. Staff H touched the doorknob to enter the room. Staff H took two plastic food bags from Resident 6 and placed it down on the bedside table. Staff H then left room [ROOM NUMBER], closing the door by touching the doorknob. Staff H took another meal tray from the meal cart, poured coffee in a cup, and opened the door and entered room [ROOM NUMBER] that had an EBP signage on the door. Staff H left room [ROOM NUMBER] and went back to the meal cart, took a meal tray that was on top of the cart and delivered it to room [ROOM NUMBER]. Staff H removed the plastic covering off the plate, closed the door as they exited the room and walked down the hallway without performing hand hygiene. Staff H did not perform hand hygiene before and after entering rooms on EBP precautions. In an interview and joint observation on 06/25/2024 at 1:14 PM, Staff H stated that they performed hand hygiene when entering/exiting rooms, when coming in contact with residents and when providing hygiene care. Staff H stated during meal pass, If I'm just setting it on the table, I don't need to sanitize hands and if that they were repositioning the resident, they would need to perform hand hygiene. Staff H stated that they would apply gown and gloves when they provided care to residents on EBP. Joint observation of the EBP signage on room [ROOM NUMBER]'s door showed EVERYONE MUST: Clean their hands, including before entering, and when leaving the room. Staff H stated that they should have performed hand hygiene before entering and after exiting resident rooms. In an interview on 06/27/2024 at 5:26 PM, Staff D stated that their process was to perform hand hygiene before and after entering any rooms, whether a resident was on EBP or not. Staff D further stated that Staff H should have performed hand hygiene before entering and after exiting resident rooms. HAND HYGIENE DURING ACTIVITY FLYER DELIVERY Observation on 06/26/2024 at 9:25 AM, showed Staff I, Activities Director, handing out activity flyers to residents. Staff I exited room [ROOM NUMBER] that had an EBP signage on their door and entered room [ROOM NUMBER] that had an EBP signage on their door. Staff I then entered room [ROOM NUMBER] without performing hand hygiene before entering and exiting rooms. In another observation at 9:31 AM, showed Staff I exited room [ROOM NUMBER] that had an EBP signage on their door without performing hand hygiene. In an interview on 06/26/2024 at 9:32 AM, Staff I stated that they perform hand hygiene before/after they provided snacks, during one on one activity, when providing resident care and when going to resident rooms. Staff I stated that they performed hand hygiene before going into EBP rooms. Joint observation of the EBP signage in room [ROOM NUMBER] showed that everyone must clean their hands before entering and leaving the room. Staff I stated that they should have performed hand hygiene before entering and after exiting resident rooms. In an interview on 06/27/2024 at 5:31 PM, Staff D stated that they expected Staff I to perform hand hygiene before entering and after exiting resident rooms. In an interview on 06/28/2024 at 9:18 AM, Staff B stated that they expected staff to perform hand hygiene anytime staff entered/exited resident rooms, linen change, peri care (cleaning the private areas), after touching anything in the residents' rooms, after they touch their face, hair, and cough. Staff B stated that they expected staff to perform hand hygiene before and after exiting residents' rooms on EBP and contact precautions. Staff B further stated that Staff H and Staff I should have performed hand hygiene before entering and after exiting resident rooms. Reference: (WAC) 388-97-1320 (1)(a)(c) AGP/CPAP Review of the admission minimum data set (an assessment tool) dated 04/17/2024, showed Resident 4 admitted to the facility on [DATE]. Review of Resident 4's physician orders showed, CPAP [Continuous Positive Airway Pressure- a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open {a type of AGP}] on at HS [bedtime]/Off at AM every day and evening shift. Observation on 06/25/2024 at 6:40 AM, showed an isolation cart outside Resident 4's room and a sign placed on top of the cart that showed Special Droplet/Contact Precautions (which required Personal Protective Equipment [PPE-including gown, gloves, and N95 mask {a protective device designed to have an efficient filtration of airborne particles} when entering the room]. In a joint observation and interview on 06/25/2024 at 6:43 AM, Staff Q, Certified Nursing Assistant (CNA), showed a Special Droplet/Contact precautions sign on top of the isolation cart. Staff Q stated, these signs weren't here before and they will ask a nurse before going in. Staff Q stated they spoke with a nurse that said Resident 4 used their CPAP until 8:00 AM and had a private caregiver who takes it off and then we can go in there [Resident 4's room] without PPE. Observation on 06/25/2024 at 7:40 AM, showed a newspaper, a container of sanitizing wipes, and a box of gloves sitting on top of the Special Droplet/Contact precautions sign. Observation on 06/25/2024 at 8:12 AM, showed Staff R, Registered Nurse, went in to Resident 4's room with no PPE and at 8:33 AM, showed Staff R went into Resident 4's room only wearing gloves. Additional observations on 06/26/2024 at 10:33 AM and on 06/27/2024 at 8:26 AM, showed a newspaper, a container of sanitizing wipes, and a box of gloves sitting on top of the Special Droplet/Contact precautions sign. In an interview on 06/27/2024 at 8:50 AM, Staff P, CNA, stated that Resident 4 was not on any precautions and if they were they would have a sign on the door and visible. Staff P stated that Resident 4 was on CPAP at night. In an interview and joint observation on 06/27/2024 at 9:43 AM, Staff G, RN, stated that Resident 4 was on CPAP. Joint observation showed the Special Droplet/Contact precautions sign on top of the isolation cart. Staff G stated, I thought it [the sign] was supposed to be on the door. Staff G further stated that they did not know if there was an amount of time after the CPAP was turned off that PPE should be used and I will ask about that. In a follow up interview on 06/27/2024 at 1:43 PM, Staff G stated they talked to Staff D who said that PPE should be worn while the CPAP was on and for three hours after. In an interview on 06/28/2024 at 11:03 AM, Staff D stated that they followed the Center for Disease Control and Prevention guidelines for AGP and that precautions should be in place anytime the CPAP is running and three hours after. Staff D stated they expected the Special Droplet/Contact precautions sign to be on the door and should not be on the isolation cart underneath a newspaper, a container of sanitizing wipes, and a box of gloves. In an interview on 06/28/2024 at 2:00 PM, Staff B stated PPE should be used when CPAP was in use and for three hours after. Staff B stated that the Special Droplet/Contact precautions sign should not be underneath a newspaper, a container of sanitizing wipes, and a box of gloves and if a resident did not want it on the door, it would need to be in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while dining for 2 of 3 Residents (Residents 18 & 24) and failed to remove mechanical lift (Hoyer lift - a device used to assist with transfers and support mobility) slings from underneath the residents for 3 of 3 residents (Resident 13, 18 & 24) reviewed for dining. The failure to provide a dignified experience during dining placed the residents at risk of diminished self-worth and over-all well-being. Findings included . STANDING OVER WHILE ASSISTING RESIDENTS WITH MEALS RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of the Activities of Daily Living (ADL) care plan dated 07/20/2021, showed that Resident 18 had severe cognitive/communication deficits (nonverbal) and required total assist with eating. On 03/15/2023 at 12:11 PM, Staff I, Certified Nursing Assistant (CNA), was standing over while assisting Resident 18 with eating in the dining room and throughout the resident's meal. On 03/15/2023 at 12:33 PM, Staff I stated that Resident 18 was tall and that it was easier to assist with meals while standing. On 03/17/2023 at 8:51 AM, Staff C, Minimum Data Set Coordinator, was also observed standing while assisting Resident 18 with their breakfast in the dining room. On 03/17/2023 at 9:25 AM, Staff C stated that Resident 18 was too tall for me to reach while sitting and that it was easier to stand while assisting Resident 18 with their meals. Staff C acknowledged that it was not the facility's process to stand while assisting residents with their meals. RESIDENT 24 Resident 24 admitted to the facility on [DATE]. Review of the ADL care plan dated 06/03/2022 showed Resident 24 required total assist with eating. Review of the profile record showed that Resident 24 was on mechanically altered diet. On 03/17/2023 at 8:48 AM, Staff H, CNA, was standing over while assisting Resident 24 with breakfast in the dining room. On 03/17/2023 at 9:06 AM, Staff H stated that Resident 24 was falling asleep and that it was easier to stand while assisting the resident with meals. On 03/20/2023 at 8:23 AM, Staff D, Resident Care Manager (RCM), stated they knew staff stands to oversee other residents while eating in the dining room and that staff were expected to be seated next to the residents. On 03/20/2023 at 8:46 AM, Staff B, Director of Nursing, acknowledged that standing over residents while assisting them to eat did not promote dignity and that they expected staff to stay seated next to the residents to maintain eye contact during meals. MECHANICAL LIFT SLINGS UNDERNEATH RESIDENTS RESIDENT 13 Resident 13 admitted to the facility on [DATE]. Review of the clinical records showed that Resident 13 required a two-person extensive assist with transfers using a Hoyer lift. RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of the ADL care plan initiated on 07/21/2021, showed that Resident 18 required a Hoyer lift for transfers. RESIDENT 24 Resident 24 admitted to the facility on [DATE]. Review of Resident 24's ADL care plan initiated on 06/03/2022, showed that Resident 24 required a Hoyer lift for transfers. Observation on 03/17/2023 at 8:08 AM, showed Resident 18 was in the dining room sitting in their wheelchair. The Hoyer lift sling used to transfer Resident 18 to their wheelchair was visibly underneath the resident. Observations on 03/17/2023 at 8:33 AM, 03/20/2023 at 8:44 AM, and 03/21/2023 at 8:59 AM, showed Residents 13, 18, and 24 were in the dining room in their wheelchairs with Hoyer lift slings visibly underneath and around them. On 03/21/2023 at 9:00 AM, Staff N, CNA, stated that for some of the residents it isn't practical to remove the sling and some residents were too heavy, and it was too hard to remove the slings after transferring the residents to their wheelchair. On 03/21/2023 at 2:29 PM, Staff O, CNA, stated that the process for using Hoyer lift slings was that they were to be removed from underneath residents after they were transferred to their wheelchair. On 03/21/2023 at 11:30 AM, Staff D stated that their expectation for staff was that Hoyer lift slings were to be removed from underneath residents after they were transferred to their wheelchair and that Hoyer lift slings should be removed for residents' comfort and dignity. On 03/22/2023 at 10:24 AM, Staff B stated that Hoyer lift slings should be removed after transfers due to possible skin irritation and dignity concerns for residents. Staff B acknowledged that Residents 13, 18, and 24 were observed in the dining room with Hoyer lift slings underneath them and that they should have been removed. Reference: (WAC) 388-97-0180 (3) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to inform the resident and/or their designated representatives before administering psychotropic (mind altering) medications for 2 of 7 residents (Residents 16 & 18) reviewed for unnecessary medications. In addition, the facility failed to inform the residents and/or their representatives before the use of reclining wheelchair and bed/chair alarms for 2 of 2 residents (Resident 18 & 23) reviewed for assistive devices. These failures placed the residents and/or their representatives at risk of not being fully informed of the risks and benefits before making decisions about their medications and the appropriate use of assistive devices. Findings included . Review of the facility policy titled, Psychotropic Medication Management, reviewed in November 2022, showed that the resident/resident representative will be informed of the medication order, indication for use, and the right to refuse. The resident will be informed of the risk versus benefits of the medication to be administered. PSYCHOTROPIC MEDICATIONS RESIDENT 16 Resident 16 admitted to the facility on [DATE]. Review of Resident 16's August 2022 Medication Administration Record (MAR) showed that Seroquel (an antipsychotic - a type of psychotropic medication used to treat certain mental/mood disorders) was first administered to Resident 16 on 08/24/2022. Review of Resident 16's clinical record showed that there was no documentation that risks and benefits had been explained to Resident 16 and/or their representative before administering the Seroquel. RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of the June 2021 MAR showed Resident 18 received Seroquel on 06/30/2021 at 8:00 PM. Further review of the July 2021 MAR showed that Resident 18 received Seroquel on 07/01/2021 at 8:00 AM, 4:00 PM, and 8:00 PM. Review of Resident 18's clinical record showed a form titled, Consent for Treatment with Anti-Psychotic Medications, signed and dated on 07/02/2021. This was two days after Resident 18 had received the first dose of Seroquel. On 03/21/2023 at 9:51 AM, Staff J, Registered Nurse, stated that the process for starting a psychotropic medication was to discuss the medication with the resident and/or their representative, sign the consent form, and then give the medication. On 03/21/2023 at 10:49 AM, Staff D, Resident Care Manager, stated that the facility's process for starting a psychotropic medication was to first provide the resident and/or their representative information about risks and benefits and then have them sign the consent form. Staff D acknowledged that they did not follow their process before starting the Seroquel for Resident 16 and Resident 18. On 03/22/2023 at 10:24 AM, Staff B, Director of Nursing Services, acknowledged that the facility did not follow their process of providing and documenting risks and benefits before starting the Seroquel for Resident 16 and Resident 18. TILT-IN-SPACE WHEELCHAIR ASSISTIVE DEVICE (a type of wheelchair that can lower the seated person's head and raises their feet at the same time). Resident 18 admitted to the facility on [DATE]. Review of Resident 18's quarterly Minimum Data Set (an assessment tool) dated 12/14/2022, showed that Resident 18 required a two-person assist for transfers. Observations on 03/15/2023 at 12:04 PM, 03/17/2023 at 8:16 AM, and 03/20/2023 at 8:44 AM, showed Resident 18 in the dining room was sitting in a tilt-in-space wheelchair in a reclined position. Review of Resident 18's clinical record showed there was no documentation that risks and benefits had been explained to Resident 18 and/or their representative before using the tilt-in-space wheelchair. On 03/22/2023 at 10:24 AM, Staff B stated that there should be consent and documentation of risks and benefits of using a tilt-in-space wheelchair before a resident used one and that there was no documentation that Resident 18 and/or their representative was informed before using the tilt-in-space wheelchair. BED/CHAIR ALARMS RESIDENT 23 Resident 23 admitted to the facility on [DATE] with diagnosis that included dementia (symptoms affecting memory, thinking and social abilities). Review of the physician order summary report showed that Resident 23 had the following orders: -Device: Bed alarm (monitor for placement and functionality) every shift for fall risk dated 09/29/2022. -Device: Chair alarm (monitor for placement and functionality) every shift for fall risk dated 09/29/2022. Review of Resident 23's Electronic Health Records (EHR) showed no consent forms obtained before starting the bed and chair alarms. On 03/21/2023 at 10:19 AM, Staff D stated that the process for obtaining a chair or bed alarm was to complete an assessment, get consent from the resident or their representative, and then get a physician's order. Joint record review of Resident 23's EHR with Staff D showed no consent for the use bed or chair alarm was found. On 03/21/2023 at 2:03 PM, Staff B acknowledged that they were not able to find the bed or chair alarm consent forms for Resident 23. Reference: (WAC) 388-97-0260 (2) (a-d) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 21 Resident 21 admitted to the facility on [DATE]. Review of the clinical records showed that Resident 21 was admitted to hospice care on 06/14/2022. Further review of Resident 21's clinical records showed that the significant change in status MDS assessment dated [DATE] was signed and completed on 07/12/2022, 28 days after Resident 21 was admitted to hospice care. The significant change in status MDS assessment should have been completed on 06/28/2022. On 03/21/2023 at 8:58 AM, Staff C reviewed Resident 21'a MDSs and stated that they used the RAI criteria for completing MDS assessments. Staff C stated that they set the ARD date within 14 days and that they have 14 days after the ARD to complete significant change in status MDS assessment. Reference: (WAC) 388-97-1000 (3)(b) . Based on interview and record review, the failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 2 out of 3 residents (Residents 18 & 21) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) dated October 2019, under Section 5.2 Timeliness Criteria, showed Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date or ARD (A2300) and no later than 14 days from the determination date of the significant change in status. A significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident(s) health status. RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of the clinical record showed that Resident 18 admitted to hospice care on 06/10/2022. Further review of Resident 18's clinical records showed the significant change in status MDS assessment dated [DATE] was signed and completed on 07/06/2022, 26 days after Resident 18 was admitted to hospice care. The significant change in status MDS assessment should have been completed on 06/24/2022. On 03/22/2023 at 8:39 AM, in a joint interview and record review, Staff C, MDS Coordinator, stated that they used the RAI criteria for completing MDS assessments. Staff C stated that they set the ARD date within 14 days and that they have 14 days after the ARD to complete significant change in status MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 31 Resident 31 admitted to the facility on [DATE]. Review of the discharge MDS assessment dated [DATE] showed Resident 31 was coded as discharged to a hospital. Review of the progress notes dated 02/17/2023 showed that Resident 31 was discharged to the community (home) on 02/17/2023 at 10:30 AM. On 03/17/2023 at 1:48 PM, joint record review with Staff C showed Resident 31 discharged to a community. Staff C then acknowledged that Resident 31 was discharged to a community and not to a hospital and stated that the MDS was coded incorrectly. Reference: (WAC) 388-97-1000 (1)(b) Based on interview and record review, the facility failed to accurately assess 3 of 15 residents (Residents 22,16, and 31) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding alarms and diagnosis placed the residents at risks for unidentified or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS assessment and ends at 11:59 PM on the day of the Assessment Reference Date (ARD). Different items on the MDS have different Observation Periods. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. In other words, if it did not occur during the observation period, it is not coded on the MDS. RESIDENT 22 Resident 22 admitted to the facility on [DATE]. Review of Resident 22's quarterly MDS assessment dated [DATE] showed that the bed and chair alarm were not coded on Section P (Restraints and Alarms). Review of the December 2022 Treatment Administration Record showed that the sensory alarm for bed and chair was monitored every shift for placement and functionality during the look back period. On 03/21/2023 at 9:09 AM, a joint interview and record review with Staff C, MDS Coordinator, showed that bed and chair alarms were not coded on Section P. Staff C stated that they follow the RAI manual for MDS completion. Staff C acknowledged that Resident 22's bed and chair alarm were not coded on the MDS and needed to be modified. RESIDENT 16 Resident 16 admitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] showed Resident 16's dementia (memory loss) diagnosis was not coded in Section I (Active Diagnoses). Review of a physician note dated 01/17/2023 showed that Resident 16 had a diagnosis of dementia. On 03/21/2023 at 3:01 PM, a joint record review and interview with Staff C showed that Resident 16 had a diagnosis of dementia. Staff C acknowledged that Resident 16's quarterly MDS assessment should have been coded for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan and/or provide written summary of the baseline care plan to the residents and/or their representatives within 48 hours of admission for 3 of 3 residents (Residents 182, 10 and 332) reviewed for baseline care plans. This failure placed newly admitted residents at risk of not receiving necessary care and services, not being informed of their initial plan for delivery of care and services, and a decreased quality of life. Findings included . The facility policy titled Baseline Care Plan revised in January 2020 showed that a written summary of the baseline care plan in the language the resident/resident representative understand will be provided to the resident/resident representative. The policy also showed that the medical record will show that a written summary of the baseline care plan was given to the resident/resident representative. RESIDENT 182 Resident 182 admitted to the facility on [DATE]. Review of the clinical record showed no documentation that the care plan was reviewed with Resident 182's and/or a summary was given to the resident and/or the representative within 48 hours of admission. On 03/15/2023 at 2:34 PM, Resident 182 stated that no care plan summary was given by the facility within two days of admission. On 03/21/23 at 8:42 AM, Staff D, Resident Care Manager, stated that Resident 182's clinical record did not show that the baseline care plan was reviewed with the resident and/or a copy given to their representative within 48 hours of admission.RESIDENT 332 Resident 332 admitted to the facility on [DATE]. Review of Resident 332's clinical record showed that a document titled, Baseline Care Plan, dated 03/01/2023, did not show whether a written summary of the baseline care plan was provided to Resident 332 and/or their representative. During a joint record review and interview on 03/21/2023 at 11:45 AM, Staff B acknowledged that Resident 332's baseline care plan form and/or clinical record did not show that a written summary had been provided to Resident 332 and/or their representative. Reference: (WAC) 388-97-1020(3) RESIDENT 10 Resident 10 admitted to the facility on [DATE] for rehabilitation services. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 02/20/2023 showed the resident was cognitively intact. On 03/17/2023 at 1:25 PM, Resident 10 stated that they did not remember if the facility gave them their baseline care plan summary. Review of Resident 10's Electronic Health Record (EHR) under assessment tab showed that the baseline care plan dated 02/17/2023 was incomplete and status showed Error. On 03/20/2023 at 8:54 AM, Resident 10's EHR and hard chart record showed no documentation that a summary of the baseline care plan was provided to Resident 10. On 03/21/2023 at 1:09 PM, during joint record review and interview with Staff D, Resident Care Manager and Staff B, Director of Nursing Services, Staff B stated that the baseline care plan was not completed, and summary was not given to Resident 10.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the policy titled, Side Rail Assessment, revised on 08/2022 states that the resident care plan will include the use of side rails as assessed. RESIDENT 22 Resident 22 admitted to the facility on [DATE]. Observations on 03/17/2023 at 11:23 AM and 03/20/2023 at 8:26 AM, showed that Resident 22 had bilateral (both) half bed rails in the up position. Review of the care plan printed on 3/17/2023 showed no care plan for the bed rails. On 03/20/2023 at 2:50 PM, a joint record review and interview with Staff D, Resident Care Manager, showed that Resident 22 did not have a care plan for bed rails. Staff D stated there should have been a care plan for bed rails and acknowledged that Resident 22 did not have a care plan in place. On 03/20/2023 at 3:03 PM, Staff B stated that their process was to care plan the use of bed rails and that Resident 22's bed rails should have been care planned. Reference: (WAC) 388-97-1020 (1) (2)(a) Review of the facility's policy titled, Safety: Special Devices for Residents at Risk, approved in June 2021, showed that any resident who requires a safety device will be identified in several different ways in order to ensure that all staff, regular and on-call, are aware of the resident's individual needs. It also showed that the safety device will be identified on the resident's care plan and will indicate the type of special device needed. RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of Resident 18's quarterly Minimum Data Set (an assessment tool) dated 12/14/2022, showed that Resident 18 required 2-person physical assist and was totally dependent for transfers. The quarterly MDS assessment also showed that Resident 18 used a wheelchair for mobility. Observations on 03/15/2023 at 12:04 PM, 03/17/2023 at 8:16 AM, and 03/20/2023 at 8:44 AM showed Resident 18 in the dining room sitting in a tilt-in-space wheelchair. Review of Resident 18's comprehensive care plan printed on 03/17/2023 showed that there was no care plan initiated for a tilt-in-space wheelchair. On 03/20/2023 at 9:05 AM, Staff K stated that they make sure the wheelchair is tilted for Resident 18 to prevent falls. They also acknowledged that it doesn't say anywhere to do that. On 03/20/2023 at 11:00 AM, in a joint interview and record review, Staff J, Registered Nurse (RN), stated that they would expect to see a care plan for use of a tilt-in-space wheelchair. In a joint review of the clinical record, Staff J acknowledged that there was no care plan for a tilt-in-space wheelchair for Resident 18. On 03/22/2023 at 10:24 AM, Staff B, Director of Nursing Services, acknowledged that there was no care plan for a tilt-in-space wheelchair for Resident 18 and that there should have been one. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (CP) for 3 of 15 residents (Residents 23, 18 and 22) reviewed for comprehensive CPs. The failure to develop CPs for residents' eating preference, use of tilt-in-space wheelchair (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) and bed rails placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Care Plan: Comprehensive dated February 2023, showed It is the policy of the company to have a comprehensive and individualized person-centered care plan in place for every resident . The comprehensive care plan will address . choices/preferences, needs . and will include person-centered interventions . RESIDENT 23 Resident 23 admitted to the facility on [DATE] with diagnosis that included dementia (symptoms affecting memory, thinking and social abilities). Review of Resident 23's activities of daily living CP showed, Eating: The resident requires setup assistance and encouragement by one staff to eat initiated on 12/07/2021. Further review of the CP did not include Resident 23's preference to eat with hands. Observations on 03/15/2023 at 12:42 PM, 03/16/2023 at 8:49 AM, 03/20/2023 at 8:41 AM, and 03/21/2023 at 8:50 AM, showed that Resident 23 was eating meals independently using their hands. On 03/22/2023 at 8:50 AM, Staff K, Certified Nursing Assistant (CNA), stated that most of the time Resident 23 used their hands to eat, even after utensils were offered, resident still uses their hands. On 03/21/2023 at 3:10 PM, Staff J, Registered Nurse, stated that Resident 23 eats with their hands and uses utensils. Staff J also stated that Resident 23 preferred to eat with their fingers. On 03/22/2023 at 9:39 AM, Staff D, Resident Care Manager, stated that they were not aware that Resident 23 eats with their hands. Staff D also stated that if it was the resident's preference to eat with their hands, they would have care planned it. On 03/22/2023 at 10:01 AM, Staff B, Director of Nursing Services, stated that they would care plan for residents' preferences if they wanted to eat with their hands or fingers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to follow physician bowel medication orders for 1 of 3 residents (Resident 14) reviewed for constipation. This failure placed the resident at risk for discomfort or bowel impaction and a diminished quality of care. Findings included . Review of the policy titled, Bowel Care Management, revised on 02/2023 stated, The Charge Nurse will review all resident's bowel monitoring records/reports/dashboard alerts or the 24-hour report daily .Any resident that has gone three days without a bowel movement recorded will be added to the Bowel Care List. The Bowel Care List will be given the following bowel care interventions or as ordered by physician: a. Evening shift (third day of following no bowel movement [BM] for three days)-Milk of Magnesia (MOM) will be given. b. If no BM by morning on day four- A suppository will be given. c. If NO BM by the evening shift day four- A fleet enema will be given. RESIDENT 14 Resident 14 admitted to the facility on [DATE] with a history of constipation. On 03/15/2023 at 2:22 PM, Resident 14 stated they sometimes had hard stools. Review of the February 2023 and March 2023 bowel elimination record showed that Resident 14 had constipation/hard stools on 02/19/2023 and 03/19/2023. Further review of the February 2023 bowel elimination record showed that Resident 14 did not have a BM on 02/23/2023 to 02/26/2023 (4 days). Review of the February 2023 physician orders showed the following as needed (PRN) bowel medications: - Miralax Packet 17 grams (gm) Give 1 packet by mouth every 24 hours PRN for constipation dated 07/09/2021. - MOM suspension 400 milligrams (mg)/5 milliliters (ml) Give 30 ml by mouth every 24 hours PRN for constipation dated 07/09/2021. - Dulcolax Suppository 10 mg Insert 1 suppository rectally every 24 hours PRN for constipation if MOM ineffective dated 07/09/2021. - Enema Ready-To-Use Enema 7-19 gm/118 ml Insert 1 application rectally every 24 hours PRN for constipation if suppository and MOM ineffective dated 07/09/2021. Review of the February 2023 and March 2023 Medication Administration Record showed that Resident 14 did not receive any PRN bowel medications on 02/19/2023, 02/25/2023, 02/26/2023 and 03/19/2023. Review of the progress notes for February 2023 and March 2023 showed no documentation that addressed Resident 14's constipation and/or if bowel medications were given or refused by the resident. Review of the revised care plan dated 07/20/2022, showed that the resident was at risk for constipation related to decreased mobility, pain, and use/side effects of medication. It also showed that the resident will pass soft formed stool at the preferred frequency of every 1-2 days through the review date. On 03/17/2023 at 9:21 AM, Staff L, Certified Nursing Assistant, stated that they would let the nurse know if a resident had any concerns of constipation and that the nurse tracked the resident's BM. On 03/17/2023 at 1:51 PM, Staff M, Registered Nurse, stated that they would have documentation if a resident did not have a BM. Staff M also stated that if a resident did not have a BM for three days that they would follow the facility bowel protocol. On 03/20/2023 at 3:08 PM, Staff B, Director of Nursing Services, stated that their process was to run a bowel report and follow the bowel protocol. Staff B stated that their expectation was for the staff to follow the bowel protocol for residents who complained of constipation or did not have a BM for 3 days. Reference: (WAC) 388-97-1060 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 21 Resident 21 admitted to the facility on [DATE] with diagnoses that included Alzheimer's and Sleep Apnea (breathing disorder). Review of the facility policy titled, Aerosol Generating Procedures- Covid 19 revised in July 2022 showed that sterile distilled water used in respiratory treatments must be dated and initialed when opened. The policy also showed that the CPAP machine tubing should be stored in plastic bag, marked with date and the resident's name. On 03/15/2023 at 1:39 PM, observation showed that Resident 21's CPAP machine was not in use and the mask and tubing were lying on the bedside table without covering and the sterile distilled water container used for CPAP machine was not labelled. Further observations on 03/16/2023 at 8:55 AM, 03/17/2023 at 10:32 AM, and 03/20/2023 at 8:40 AM showed that Resident 21's CPAP machine mask and tubing were still lying on the bedside table without any covering and the sterile distilled water container was not labelled. On 03/20/2023 at 8:43 AM, Staff D stated that the facility staff had training on CPAP mask and tubing care. Reference: (WAC) 388-97-1060 (3)(j)(vi) Based on observation, interview, and record review, the facility failed to ensure proper care of suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) including the suction tubing and suction tip (Yankauer) for 1 of 1 resident (Resident 12) and failed to cover the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) tubing and mask when not in use and label the distilled water (a type of purified water) used for CPAP for 1 of 1 resident (Resident 21). These failures placed the residents at risk for respiratory infections and related complications. Findings included . Review of the facility policy titled, Suctioning revised in February 2022 showed After completing a single episode of suctioning, wrap the suction catheter around a gloved hand . Discard both into a designated trash receptacle . clean suction collection canister . the suction connecting tubing becomes visibly soiled with secretions ., new tubing may be attached. RESIDENT 12 Resident 12 admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- chronic inflammatory lung disease that causes obstructed airflow from the lungs), Alzheimer's (a progressive brain disorder that causes problems with memory, thinking and behavior) and dysphagia (difficulty swallowing). Review of the progress notes dated 02/07/2023 at 9:43 PM, showed that Resident 12 seem declining, has shortness of breath, open mouth for air, has difficulty with talking, stiffness on her tongue and goggling when talking . assisted with elevated head of bed, oral care and oral suction as needed. Further review of the progress notes dated 02/07/2023 at 11:13 PM, showed Suction was initiated. Review of the February 2023 and March 2023 Medication Administration Record and Treatment Administration Record showed no suctioning order and no equipment care/maintenance in place. Observations on 03/15/2023 at 10:03 AM, 03/16/2023 at 8:51 AM, and 03/17/2023 at 8:28 AM, showed a suction machine on Resident 12's bedside table. The suction machine tubing was hanging on the bedside table, unlabeled and it had a brown like secretions in the suction tubing. Further observation showed that the Yankauer suction tip that was attached to the suction tubing was not covered and had a visible white secretion. The suction canister was unlabeled, with clear secretions in it. On 03/17/2023 at 10:20 AM, Staff P, Registered Nurse, stated that the suction tubing and Yankauer suction tip should have been dated, changed weekly, or if dirty, the suction canister should be changed as needed. Staff P also stated that the suction machine should be cleaned, ready to use for an emergency and should be in a clean plastic bag. Joint observation with Staff P on 03/17/2023 at 10:36 AM, showed that the suction machine was on Resident 12's bedside table. Staff P acknowledged that the suction tubing, canister and Yankauer suction tip were not covered/labeled and that it should have been dated. On 03/17/2023 at 12:03 PM, Staff D, Resident Care Manager, stated that they did not know why Resident 12 had a suction machine in their room. Staff D stated that when a suctioning device was in use, the suction tubing and the Yankauer suction tip should have been covered in a bag and labeled. Joint observation on 03/17/2023 at 12:19 PM with Staff D showed that the suction machine was used. Staff D stated that the suction machine tubing and Yankauer suction tip should have been disposed and that the suction machine should have been cleaned and that the suction machine should not have been stored in Resident 12's room. On 03/17/2023 at 1:41 PM, Staff B, Director of Nursing Services, stated that they were not sure on the care and maintenance of a suctioning device, not our normal procedure. Staff B acknowledged that the suctioning device was used on 02/07/2023 and that a physician's order should be in place. Staff B observed the suction machine in Resident 12's room and confirmed that the suction machine and tubing were used and acknowledged that the suction tubing and Yankauer suction tip were not covered and labelled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a bed rail was placed on a resident's bed with resident knowledge, consent, education, assessment, and care plan developed to meet the needs of 1 of 4 residents (Resident 10) reviewed for bed rail use. This failure placed the resident at risk for entrapment, injury, and a diminished quality of life. Findings included . Review of the facility policy titled: Side Rail [bed rail] Assessment last revised in August 2022 showed that individual side rail assessments will be performed on a regular basis. The side rail evaluation will include data collection analysis and determination of potential alternatives to side rail usage. When the side rails are deemed necessary and appropriate, the facility will provide education to the resident or resident's representative pertaining to the risk and benefits of side rail use. The policy also showed that it is the policy of the facility to obtain informed consent, obtain physician order, and care plan for use of side rail. Resident 10 admitted to the facility on [DATE] for rehabilitation services. Review of the admission Minimum Data Set (an assessment tool) dated 02/20/2023, showed Resident 10 was cognitively intact and required one person limited assist for bed mobility and transfers. Review of the nursing progress notes from 02/19/2023 to 03/16/2023 documented that Resident 10 was using bed rails as assist [assistive] device: 1/2 side rail(s). Observations on 03/15/2023 at 11:08 AM and on 03/17/2023 at 1:25 PM, showed that Resident 10's bed had an upper half bed rails on each side in the raised position. Another observation on 03/20/2023 at 8:31 AM, showed Resident 10 was lying in bed. Resident 10's bed had an upper half bed rails on each side of the bed in the raised position. On 03/20/2023 at 1:47 PM, a joint record review with Staff D, Resident Care Manager, showed Resident 10 did not have an assessment, order, consent, or care plan for bed rail use. Staff D stated that Resident 10 did not have an assessment, order, consent, or care plan for bed rails. On 03/20/2023 at 1:52 PM, a joint observation with Staff D showed that Resident 10's bed had two upper half bed rails in the raised position. On 03/20/2023 at 1:54 PM, Resident 10 stated that they did not know why their bed had rails and sometimes they were using it to transfer. On 03/20/2023 at 1:55 PM, Staff D stated that a bed rail assessment, order, consent, and care plan should have been completed for Resident 10. On 03/20/2023 at 2:32 PM, Staff B, Director of Nursing Services, stated that their expectation was that an assessment, order, consent, and care plan for bed rail use should have been completed before use. Reference: (WAC) 388-97-1060 (3)(g), 0260 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 6 residents (Resident 14) reviewed for unnecessary medications were free from unnecessary use of antibiotic ointment. This failure placed the resident at risk for receiving unnecessary medication and a diminished quality of life. Findings included . Review of the facility policy titled, Antibiotic Stewardship, revised and/or approved on 04/2022 stated, Monitoring will include (but not limited to): . Monitor antibiotic use . Monitoring of inappropriate use of Antibiotics. Examples may include .Prescribing course of antibacterial therapy that are no longer necessary. Resident 14 admitted to the facility on [DATE] with care needs including an ingrown nail to right great toe. Review of the October 2022 to March 2023 Treatment Administration Record (TAR) showed a treatment for the Right great toe wound that included the following: 1. Clean area with wound cleanser. 2. Apply topical antibiotic. 3. Skin Prep to periwound (surrounding skin) 4. cover with band aid or border dressing, until resolved every evening shift every other day dated 10/10/2022. Further review of the October 2022 to March 2023 TAR showed that staff had been signing the TAR indicating that the treatment were completed. Review of the skin assessment for February 2023 showed a skin assessment dated [DATE] that stated, right great toenail appears unchanged. Dried blood at nail bed unchanged. No warmth or purulent [fluid] drainage noted when dressing changed. Denies pain to area. Further review of the skin assessment showed no further documentation of the resident's right great toe since 02/09/2023 to 03/22/2023. Review of the progress notes for March 2023 showed no skin documentation of Resident 14's right great toe. On 03/21/2023 at 9:40 AM, Staff B, Director of Nursing Services, stated that they monitored the antibiotic ointment use as part of the antibiotic stewardship program and acknowledged that Resident was not monitored in the monthly line list. Staff B stated that they were not aware that Resident 14 currently had issues on their right great toe and did not know that resident was on an antibiotic ointment treatment. On 03/21/2023 At 10:13 AM, Staff B stated that Resident 14's right great toe was assessed that day and that it had resolved. On 03/21/2023 at 1:51 PM, Staff P, Registered Nurse, stated that the triple antibiotic ointment was being used for Resident 14's ingrown nail. Staff P reported that the treatment was provided on the evening shift and that they had not seen the wound recently. Staff P further stated that the wound was resolved and not sure why the order was not discontinued. On 03/21/2023 at 3:03 PM, Staff Q, Licensed Practical Nurse, stated that the treatment should have been discontinued and monitored, but they kept following the treatment order. On 03/22/2023 at 11:02 AM, Staff D, Resident Care Manager, stated that wounds were monitored in the TAR. Staff D stated that sometimes they would miss to discontinue treatment orders when the skin issue had resolved. On 03/22/2023 at 11:16 AM, Staff B acknowledged that the staff lacked communication and documentation of Resident 14's right great toe wound. Staff B also stated that their expectation was that staff should have communicated to them or to the medical doctor regarding the right great toe antibiotic ointment use. Reference: (WAC) 388-97-1060(3)(k)(i) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Gradual Dose Reduction (GDRs) for the use of psychotropic (mind altering) medications were followed for 1 of 6 residents (Resident 12) reviewed for unnecessary medications. The failure to attempt a GDR for the administration of psychotropic medications placed the resident at risk to receive unnecessary medications and/or experience adverse side effects. Findings included . Review of the facility policy titled, Psychotropic Medication Management revised on June 2021, showed that Residents who use psychotropic drugs receive GDR . first year after admission or initiation: GDR or tapering in two separate quarters with at least one month in between unless clinically contraindicated, after first year: GDR annually unless clinically contraindicated. Resident 12 admitted to the facility on [DATE] with diagnoses that included Alzheimer's (problems with memory, thinking and behavior) and major depressive disorder with severe psychotic symptoms (a condition of the mind that results in difficulties determining what is real and what is not real). Review of the February 2023 and March 2023 Medication Administration Record showed the following orders: - Escitalopram Oxalate (an antidepressant) 10 milligram (mg) give one tablet by mouth one time a day for dysthymic disorder (persistent depression) dated 07/17/2021. - Mirtazapine (an antidepressant) 7.5 mg give two tablets by mouth one time a day for appetite stimulant and depression dated 03/01/2023. - Risperidone (an antipsychotic - works by changing the effects of chemicals in the brain) give 0.25 mg tablet by mouth two times a day for major depressive disorder dated 02/21/2023. Review of the Electronic Health Record (EHR) showed Resident 12 had been on Escitalopram Oxalate 10 mg and Risperidone 0.25 mg twice a day since 09/01/2020. A GDR was not conducted for both medications since 09/01/2020. Review of the pharmacy Medication Regimen Review (MRR) dated 06/24/2021 documented that Resident 12 had the following psychotropic medications: - Mirtazapine 15 mg at bedtime for depression/anxiety since 05/18/2021. - Escitalopram 10 mg daily for dysthymic disorder since 08/30/2020. - Risperidone 0.25 mg twice a day for personality disorder since 09/01/2020. Further review of MRR dated 06/24/2021 showed a documentation that the Regulatory compliance requires a GDR be attempted approximately every 6 months unless previous attempts failed, or a GDR is clinically contraindicated . Suggest reviewing and determine if this resident is a candidate for GDR of the above medications. Document showed response agree by physician and commented: added lowest effective dose as of 06/28/2021 to orders mirtazapine, Escitalopram, and Risperidone. The facility was not able to provide supporting documents that a GDR was attempted for the Escitalopram and Risperidone since 09/01/2020. Joint record review of the EHR on 03/21/2023 at 1:40 PM with Staff D, Resident Care Manager, showed that Resident 12 was on Risperidone 0.25 mg twice a day and Escitalopram 10 mg daily since 09/01/2020. Staff D acknowledged that there was no GDR attempt since 09/01/2020 for both medications. On 03/22/2023 at 10:05 AM, Staff B, Director of Nursing Services, stated that it was their expectations to follow the regulatory requirements for a GDR and if a GDR failed, the facility would need to document the reason why it failed. Staff B stated that they would follow up and talk to the physician regarding Resident 12's GDR. Reference: (WAC) 388-97-1060(3)(k)(i) .

Based on observation, interview, and record review, the facility failed to ensure foods stored in 2 of 3 freezers were labeled/dated with use by date and food products discarded on or before the use by date. These failures placed the residents at risk for food borne illnesses (an illness caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility provided policy titled, General Storage Standards - Dining revised in August 2022, showed that Frozen items should be wrapped or in commercial cartons, dated and labeled. All potentially hazardous foods must be labeled with a date sticker as soon as the package is opened, or the item is prepared. Only such items that have a date sticker less than seven days old will remain on our shelves for consumption by the residents. TENTH FLOOR KITCHEN Observation and interview on 03/15/2023 at 9:10 AM with Staff G, Chef de Cuisine, showed the tenth-floor kitchen refrigerator had a clear plastic container with crushed ginger in it that was labeled ginger with a sticker discard by EOD [End of Day] of 03/08/2023. When asked about their process on use by date foods, Staff G stated that the quality of the ginger was still good, Staff G then removed the old label and replaced it with a new sticker that showed discard by EOD of 03/18/2023. Observation and interview on 03/15/2023 at 9:15 AM with Staff F, Executive Chef, showed the freezer facing the steam table had eight re-packed lidded ice cream paper cups and a pack of biscuits in a clear plastic bag, both food items were unlabeled and undated. When asked about these food items, Staff F stated, It is for IL [Independent Living Facility]. NINTH FLOOR KITCHEN Observation and interview on 03/15/2023 at 9:15 AM with Staff F, showed the walk-in freezer on the ninth-floor kitchen had a pack of chopped raw fish in a clear vacuumed plastic bag with a use by date of 09/11/2022, and a pack of raw beef with a use by date of 01/10/2023. Staff F stated that the fish and beef were expired and needed to be thrown away. Further observation on 03/17/2023 at 10:17 AM, showed the ninth-floor kitchen walk-in freezer had a gallon of resealable plastic (Ziplock) bag containing sliced/peeled peaches that was unlabeled and undated. When asked about it, Staff G stated that Staff F was cleaning the walk-in freezer and forgot to label and date the bag of peaches. On 03/21/2023 at 9:20 AM, a phone interview was conducted with Staff E, Director of Dietary Services. Staff E acknowledged that the food items were cooked and prepared on the ninth and tenth floor kitchen and that staff were expected to label and date food items once opened and discard the items beyond used by dates. Reference: (WAC) 388-97-1100 (3) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Level 1 Pre admission Screening and Resident Review (PASARR) was accurate prior to admission for one of two residents (#30). Failure to ensure the PASRR accurately identified Resident #30 as having mental health issues increased the risk of the resident being admitted to the facility without having a PASARR Level II evaluation and determination completed prior to admission to the facility. Findings included . Resident #30 was admitted to the facility on [DATE] with multiple medical diagnoses including depression. The physician admission orders included an anti-depressant medication which was administered on a daily basis. Review of the PASARR form in the clinical record did not show that the resident had a diagnosis of depression. During an interview on 01/13/19 at 1:15 PM, Staff A, facility Social Worker, was asked about the PASARR process followed by the facility. Staff A stated that if the PASARR document provided was not accurate, the facility policy was to complete a new PASARR form, make the determination if a Level II evaluation was needed, and maintain it in the clinical record. After reviewing the PASARR found in the Resident 30's record, Staff A stated the PASARR was not accurate and should have been revised on admission. Reference WAC 388-97-1975(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT #23 The resident re-admitted to the facility on [DATE]. The Minimum Data Set (MDS), dated [DATE], showed the resident had a diagnosis of dementia. Reveiw of the facility policy titled Elopement dated 01/10/20 showed that if it was determined that resident was at risk for elopement risk, the following would be done: 1. Interventions to minimize the risk for elopement will be identified for the resident and would be recorded in the resident's plan of care. Review of a progress note, dated 11/24/19, identified the resident as an elopement risk. Another progress note, dated 11/30/19, showed the resident was awake around 2 AM, was confused and made attempts to get out of the building. The note showed staff tried to redirect the resident without success. Review of the assessment form titled, Elopement risk, dated 11/20/19, showed the resident was cognitively impaired with poor decision making skills and dementia. The assessment showed the resident expressed the desire to go home and had a history of elopement. The assessment included interventions such as recreational activities, safety alarms, and frequent monitoring, and directed that a care plan was to be initiated to include the listed interventions. Review of the resident's care plan, dated 12/06/19, did not show that the resident was at risk for elopement, and did not show any goals and interventions for elopement. During an interview on 01/14/20 at 11:38 AM, the DNS stated that she would look into the documentation to determine where the ball might have been dropped for not having the resident's elopement risk and interventions listed on the care plan. Reference (WAC) [PHONE NUMBER](1), (2)(a)(b) Based on observation, interview, and record review, the facility failed to develop and/or implement comprehensive care plans for three of 12 sample residents reviewed (#30, #7, #23 ). Failure to develop and consistently implement comprehensive care plan placed residents at risk for unidentified and/or unmet care needs that could negatively affect a resident's overall health and wellbeing. Findings included . RESIDENT #30 The resident was admitted to the facility on [DATE] for rehabilitation after surgical repair of a hip fracture. The Minimum Data Set assessment (MDS), dated [DATE], showed the resident was alert and oriented, needed extensive assist with activities of daily living (ADLs), and had surgery to repair a fractured hip. The admission orders showed the resident was to receive a routine dose of acetaminophen two 500 mg(milligram) tablets (Tylenol) three times a day at 7:00 AM, 3:00 PM and 11:00 PM. The resident also had a lidocaine patch that was placed at 8:00 am and removed at bedtime. In addition, the orders showed three different narcotic medications to be given as needed (PRN): -Tramaldol 50 mg 1/2 tablet every 8 hours PRN for breakthrough pain; -Oxycodone 2.5 mg every 4 hours for PRN for moderate pain [which would be 4 - 6 on the standard (0-10) pain level scale]; and -Oxycodone 5 mg every four hours PRN for severe pain, [which would be 7-10 on the pain level scale]. The December 2019 Medication Administration Record (MAR) showed the 2.5 mg dose of Oxycodone was administered several times for severe pain, (the pain level was reported to be at 7, 8 and 10). In addition, the MAR did not provide any directives about non-pharmacologic interventions which could be attempted prior to administering the PRN medications. The care plan showed staff were to provide medication as ordered. The care plan did not show specific information as to when and/or which dose of narcotic medication was to be administered. In addition, the care plan identified a non-pharmacologic intervention repositioning that should be tried prior to using the PRN medication. However there was no documentation showing this non-pharmacologic intervention was attempted prior to administering PRN pain medication. By not ensuring the comprehensive care plan provided staff with clear directions as to which dose of narcotic medication should be administered, and ensure non-pharmacologic interventions were attempted prior to administering a PRN medication increased the risk for unrelieved pain and unnecessary medications. RESIDENT #7 Observations on 01/07/20 at 3:30 PM and 01/13/20 at 4:30 PM showed Resident #7 had multiple skin tears on the back of the left hand. When asked about the injuries, the resident stated that he did not know how the skin tears occurred. Review of the resident's care plan showed the staff were to complete a weekly skin check, verify it was completed, and document any new skin issues found. During an interview and record review on 01/13/20 at 2:00 pm, the Director of Nursing (DNS) found that the resident's skin checks were documented on the December 2019 and January 2020 Treatment Administration Records (TARs), however the documentation did not show any skin issues. The DNS stated that any skin issues should have been reported to her, and none had been reported. Observations on 01/07/20 at 3:30 PM and 01/13/20 at 4:30 PM showed Resident #7 had multiple skin tears on the back of the left hand. However, the weekly skin check completed and signed on 01/12/19 by Staff H, a Registered Nurse (RN), did not identify the skin tears. During an interview on 01/13/20 at 4:35 PM, Staff H stated that she was not aware the resident had any skin tears. When asked about the skin check that was completed the previous evening, Staff H stated I guess I did not do a thorough skin check.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT #87 The resident re-admitted to the facility on [DATE]. The resident was able to make his needs known. The resident went to the hospital in January 2020. Hospital discharge notes, dated 01/03/20, showed the resident had hernia repair and was discharged back to the facility for recovery. Review of the progress notes, dated from 01/03/20 to 01/06/20, showed the resident was having residual pain from the hernia repair up to 8 out of 10 (severe) on the pain scale. Review of the care plan, dated 11/14/19, showed the resident was identified to have chronic left hip pain secondary to severe end stage osteoarthritis. Further review of the care plan showed it was not updated to reflect the resident's most recent pain from the hernia repair on 01/03/20. During an observation and interview on 01/06/20 at 9:20 AM, the resident was seen coughing followed by facial grimacing and yelling out loud. He stated that he had significant pain at the surgical site when he coughed that was 10/10 pain on the pain scale. During a joint review and interview on 01/11/20 at 9:48 AM, Staff C, Charge Nurse RN, stated that the care plan was not updated to reflect the resident's most recent source of pain, which was the hernia repair, and the care plan should have been updated. Reference (WAC) 388-97-1020(2)(c)(d) Based on interview and record review, the facility failed to ensure the comprehensive care plans were reviewed and revised when changes in care occurred for three of 12 sample residents reviewed (#17, #20 and #23) . Failure to update care plans and ensure the accurately identified current interventions in use placed residents at risk for not receiving care and services as needed. Findings included . RESIDENT #17 The resident was admitted to the facility on [DATE] with multiple diagnoses including dementia and malnutrition. The last MDS assessment, dated 11/01/19, showed the resident needed extensive and or limited assistance with most Activities of Daily Living (ADL) such as transfers, walking, dressing, toileting and hygiene, and showed the resident had no pressure ulcers. The care plan, dated 08/12/19, showed the resident was at risk for skin breakdown and listed multiple interventions, including staff were to provide physician ordered treatments. A subsection, also dated 8/12/19, showed the resident had impaired skin integrity related to Pressure Ulcers (PU) and four Stage one pressure ulcers on the bilateral heels and bilateral great toes. On 11/15/19, staff documented the PU issue was resolved. Review of the clinical record showed that on 12/20/19 a reddened spot appeared on the right great toe, however the care plan was not updated to reflect the current skin condition. The Skin Evaluation Form, dated 12/20/19, showed under type friction and /or shear and under treatment NO shoes or tight socks. Review of the guidebook maintained by the facility for skin monitoring and assessment, friction/ shear injuries were pressure ulcers. The facility pocket guide (a document that is provided to each Certified Nursing Assistant at the beginning of their shift) that was provided on 01/05/20, did not show any special directives for the use of shoes. The document noted it was last updated 12/26/19. Not ensuring the care plan and interventions were implemented placed the resident at risk for deterioration of a pressure ulcer and skin breakdown. Resident #20 The resident was admitted to the facility on [DATE] after hospitalization and surgical procedure with multiple diagnosis. The last quarterly MDS assessment, dated November 2019, documented the resident was independent with walking, used an assistive device and had a history of falls. The most recent fall occurred on 12/19/19 in the public cafe, located on the first floor of the facility. The care plan, dated 02/20/18, noted a fall prevention plan was in place, and also noted Resident 20 was on an anticoagulant medication. On 01/13/19 during an interview at 2:30 pm, the DNS stated the care plan was not accurate and was currently not administered an anticoagulant, or blood thinner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services in accordance with accepted standards of practice for two of 12 sample residents (#8, #7). Failure to coordinate a request for the Medical Director to assess Resident #8 may have contributed to a delay in treatment. In addition, failure to identify and assess skin injuries for Resident #7 increased of risk the resident would sustain additional similar injuries. Findings included . RESIDENT #8 Resident #8 was re-admitted to the facility on [DATE] after being hospitalized for a fall that resulted in rib fractures. The last quarterly Minimum Data Set (MDS) assessment, dated 10/16/19, listed multiple diagnoses, including dementia. The MDS showed the resident needed extensive assistance of two staff for most Activities of Daily Living (ADLs), including transfers and mobility, toileting, dressing and hygiene. The resident only needed supervision and set-up for eating ADL. An observation and interview on 01/06/20 at 11:40 AM showed a visitor seated in the resident's room at bedside. When asked if she was a family member, she stated, No I am just a family friend (FF) who comes to visit a lot. The resident who appeared to be sleeping, had difficulty hearing when she was greeted, but did awaken to verbal cues. The FF stated she was not a paid caregiver, but was close family friend who assisted the resident because the family resided outside the country. The clinical record did show the FF was the designated primary contact. Observation on 01/06/19 at 1:15 pm showed a family member and FF were in the resident's room while the resident slept. When the family member was asked if would do an interview, but deferred to the FF. The FF stated that Resident #8 had experienced a decline in condition, and was not eating and/or drinking well, and that facility staff were aware of the decline. The FF reported the resident had recently completed treatment for urinary tract infection. The FF further stated that the resident's Primary Care Physician (PCP) in the community followed the Resident #8, but the resident was too ill to see the PCP in the clinic. The FF then stated that the facility process to coordinate care with the PCP was to send a written request to the Medical Director (MD) to assist with an assessment of Resident #8 to obtain authorization for diagnostic lab testing. On 01/07/20 at 2:40 PM, a different FF was at the bedside. The resident was sleeping. the FF stated they were still waiting to hear from the MD, and that the MD had not been into see the resident yet. The FF stated that the resident was not eating or drinking well. On 01/08/20 at 12:15 PM, the FF was at the resident's bedside. When asked if the MD had been in to assess Resident #8, she stated no. She stated the MD was in the facility on 01/06/20 and she thought the MD would stop in see to Resident #8, but did not. On 01/08/20 at 12:45 PM, the clinical record located at the nurses station, showed faxes to the MD and PCP. However, there was no evidence the PCP's request had been sent to the MD. On 01/08/20 at 1:12 PM, the Director of Nursing(DNS) stated that a copy of fax communications should be located in the chart at the nurse's station. When asked about the resident's change in condition, the DNS stated that the resident's PCP was in the community and that Resident #8 went out to a clinic to see the PCP. After being informed of the concerns expressed by the FF, and the verbal report requesting assistance with an assessment by the MD, the DNS stated they will notify the MD and ask him to see the resident and assess the resident. On 01/09/20, new orders for the diagnostic testing were signed by the MD. The DNS also provided copy of a letter, dated 01/06/20, from the PCP to the MD that was printed on 01/08/20 at 4:36 PM. The fax cover sheet, dated 01/08/20, had a hand written notation documented second request. During an interview on 01/13/20 at 2:00 PM, the DNS stated that she would look for evidence the letter was faxed to the MD prior to 01/08/20. On 01/14/20 at 2:00 PM, the DNS stated that she was not able to find evidence to verify the MD was notified of the request until 01/08/20 (after she was alerted about the issue). Not ensuring the facility staff assisted in coordinating care for Resident #8, may have contributed to a delay in the assessment of a resident who had experienced a decline in condition. RESIDENT #7 Resident #7 was last re admitted to the facility in 2016, with multiple diagnoses including dementia. The last MDS assessment showed the resident needed extensive assistance from staff for all Activities of Daily Living (ADLs) including transfers and mobility, toileting, dressing and hygiene, and used a wheel chair for mobility. An observation on 01/07/20 at 11:00 AM showed Resident #7 verbally responded to greetings, but appeared to be confused. The resident had multiple skin tears on the back of the left hand. During an interview on 01/07/20 at 3:30 PM with the Resident Representative,(RR), the RR was asked about the skin tears on the back of Resident #7's hand. The RR stated that she did not know how the injuries occurred. Review of the clinical record found no evidence the staff had identified, documented, assessed or reported the skin tears. During an interview on 01/13/19 at 2:30 PM, the DNS was asked about the skin tears. The DNS stated the expectation was to report skin issues to her, investigate the root cause of the injury, and monitor them until healed on the Treatment Administration Record. The DNS then reviewed the clinical record and found no evidence the skin tears were documented, assessed or were being monitored for healing. An additional observation on 01/13/20 at 4:34 PM showed the skin tears as being a circular scab that was about the size of a dime, and a V- shaped skin tear that was about 3 - 4 centimeters in length in the center of the back of the left hand. During an interview at 4:35 PM, Staff H, a Registered Nurse,stated that she was not aware the resident had any skin tears. Staff H was asked if she had completed the skin check on 01/12/19. She stated she had done the skin check and stated, I guess I did not do a thorough skin check. Not ensuring the skin tears were documented, assessed and investigated left the Resident #7 at risk for a similar injuries. Reference WAC 388-97-1060 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide consistent monitoring for a pressure and consistantly implement interventions to reduce and/or minimze pressure to the area for one of two resident (#17) reviewed who were at risk for pressure ulcers. Failure to meet these requirements placed the residents at risk for pressure ulcer development, worsening pressure ulcers and diminished quality of life. Findings included . Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including dementia and malnutrition. The last MDS assessment, dated 11/01/19, showed the resident needed extensive and or limited assistance with most Activities of Daily Living (ADLs) such as transfers, walking, dressing, toileting and hygiene. The care plan, dated 08/12/19, showed the resident was at risk for skin breakdown and identified multiple interventions including one that showed staff to provide physician ordered treatments. A subsection, also dated 8/12/19, showed the resident had impaired skin integrity related to Pressure Ulcers (PU) and four stage one pressure ulcers on the bilateral heels and bilateral great toes. The section was resolved on 11/15/19. The January 2020 Treatment Administration Record (TAR) showed that staff were to Monitor the skin on toes twice daily at 7 AM and 7 PM. The TAR also showed staff were to remove shoes and socks when in bed or resting for a nap to relieve pressure on the toe, which was (according to the document) initiated on 10/15/19. An observation on 01/12/19 at 12:15 PM showed Resident 17 sittng in a recliner in his room with the leg rest extended. The resident was wearing a white colored pair of tennis shoes. The resident stated that he was not feeling well and wanted to rest instead of going to the dining room for the noon meal. An observation on 01/13/19 at 1:30 PM showed the resident was sleeping, his legs were elevated, and the shoes remained in place/on his feet while resting. On 01/05/19, the pocket care guide, dated 12/26/20 was provided by Staff C, the Charge Nurse, to the survey team members. Review of the document showed no information or directives regarding the use of shoes was provided to the direct care staff. According an interview with the DNS, the document was provided to each nursing assistant(NAC and was used to inform direct care staff of resident directives, had last been updated on 12/26/19. The clinical record showed that on 12/20/19, a Skin Evaluation Form (SEF) was initiated after the staff identified the Resident #17 had a reddened area on the right great toe. The SEF showed the resident has pain when touched. The SEF showed the type of injury was shear/friction and noted under treatment NO shoes or tight socks. The size of the area was not documented. An SEF showed the area was re-evaluated on 12/29/19 (nine days later) and documented the redness has reduced to a dark red, res(resident) reports mild pain when touched, skin intact. The size of the area was not documented. The SEF dated 01/11/20 showed dark red discoloration, blanchable, small scab 0.3 x 0.3 cm in size at the tip, dorsal side of the toe. The size of the reddened area was not documented. During an interview and joint record review on 01/13/20 at 2:58 PM, the Director of Nursing Services reviewed the SEF's and stated the documentation showed the pressure ulcer was not tracked or monitored weekly and did not document the size of the area. The facility failed to update the care plan, follow physician directives, and follow the facility policy to ensure weekly monitoring of the pressure ulcer occured left the resident at risk for progession of the wound and additional skin breakdown. In addition, it left the facility without sufficent information to determine if the wound was deteriorating or improving to guide treatment decisions. Reference WAC 388-97-1060 (3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a maintenance restorative program for two of three residents (#24 and #17). This failure placed the residents at risk for worsening contractures, decline in range of motion, and diminished quality of life. Findings included . Reveiw of the facility policy titled Restorative Program: Nursing Rehabilitation/Restorative care dated 01/10/20, stated it was the policy of the company to develop and implement a nursing rehabilitation /restorative care program to help residents achieve and or maintain optimal physical, mental and psychosocial functioning. The policy also stated the following: 1. Restorative nursing programs were initiated when a resident was discharged from a formalized physical, occupational or speech rehabilitation therapy. RESIDENT #24 The resident admitted to the facility on [DATE] with diagnoses to include muscle weakness and gout. According to the resident's Minimum Data Set (MDS), dated [DATE], showed the resident had bilateral upper extremity impairment and was not receiving active, passive range of motion (ROM) or splinting. Review of the Physicians progress note, dated 05/09/19, showed the resident had bilateral contractures of the hand Review of the to the Occupational Therapy (OT) notes, dated from 07/13/19 to 08/03/19, showed the resident was receiving skilled OT for the reduction/management of contractures. The notes showed the resident's condition had potential to improve as a result of skilled rehab and could benefit from continued OT to increase quality of life. Review of the occupational discharge summary notes, dated 07/30/19, showed the resident made consistent progress with skilled intervention and functional abilities had progressed as a result of skilled interventions. The note further showed the prognosis was to maintain current level of function with consistent staff follow through. However the note showed a restorative program was not designed or instructed to staff. There was no evidence the resident was given education/information on benefits of a restorative program. Review of the resident's care plan, initiated on 07/22/19, showed there was no specific care plan with goals and interventions related to the resident's bilateral hand contractures. An observation on 01/05/20 at 10:20 AM, showed the resident's hands had severe bilateral hand contractures with no splinting. Further observation showed the left hand contracture was more severe from the right. During an interview on 01/06/20 at 10:27 AM, the resident stated that she performed her own stretching on her hand contractures that she stated were getting worse. She stated that she got restorative once a week with a staffperson who came in every Tuesday to do exercises. The resident began to get upset and teary eyed stating that she desperately wanted to keep her hand function as she missed doing her art. She also stated that her finernails were getting long, and that she tried to prevent the nails from digging into the palm of her hand, but It was getting harder to do. During another interview on 01/09/20 at 8:50 AM, the resident stated that she had a hand splint given to her, but she stopped wearing and eventually gave it back because it was getting in the way of toileting to where she could not take it off in time and would have accidents. She stated that she tried to stretch her hand, but did not feel she was making any progress. The resident started to get teary eyed and stated she was afraid she would eventually not be able to hold a paint brush or her coffee cup anymore. The resident stated that the staffperson exercised her right hand, but had never worked or assisted her to exercise the left. During an interview at 8:58 AM, Staff K, Restorative Aid (RA) stated that the resident was never placed on a restorative program and she had never assisted the resident with hand exercises or splinting. During an interview on 01/10/20 t 10:54 AM, Staff L, Occupational Therapist (OT) stated that she did not feel that the resident would benefit from being placed on a restorative program for the prevention of the contractures or current contractures from getting worse, and therefore a restorative program was never implemented. However, she stated that she visited with the resident once a week and did focused exercises for mostly the right hand which happened to be the most functional. During a joint interview on 01/10/20 at 12:11 PM, Staff M and Staff L stated that not implementing a restorative program did not allow for ongoing effective monitoring for the resident's hand function. Both staff members stated they would reevaluate the resident for current therapy needs. During an interview on 01/10/20 at 2:31 PM, the DNS stated that she could not find a care plan for restorative, but stated that the resident's hand contractures should have been care planned for goals and interventions. RESIDENT 17 Resident 17 was admitted to the facility on [DATE] with multiple diagnoses including dementia and malnutrition. The last MDS assessment, dated 11/01/19, showed the resident needed extensive and or limited assistance with most Activities of Daily Living (ADLs) for transfers, dressing, toileting and hygiene. The resident's care plan showed the resident walked in a Restorative Nursing Program for walking and was walked one to three times a day to meals Monday through Friday for up to 15 minutes or as tolerated. Observations on 01/06/19 and 01/08/20 showed the resident was not walked to the dining room. The resident used a wheelchair to go to the dining room before lunch. During an interview on 01/08/20 at 3:17 PM, Staff K, the Restorative Nursing Assistant (RNA) was asked about the resident's walking program. Staff K stated that Resident #17 was walked from dining room to his room after the breakfast, and then walked to down to the dining room for lunch. He stated that the resident walked 60 feet after breakfast earlier in the day, but that he did not offer the program to the resident after lunch today as,I just did not get there. Staff K then stated that Resident #17's participation in the walking had declined. Staff K stated that he documented the RNP programs on a paper monthly for each resident's participation, and stated it was later entered in to the electronic record. When asked, he provided the paper documentation for the month of December 2019. Review of the monthly record of participation for November 2019 in the Electronic Health Record showed the Resident #17 participated in the program on 14 of the 21 days (that included Mondays through Fridays). The paper documentation, for December 2019, showed the resident had not participated in the program during the entire month. The EHR documented the resident participated in the program on 12/10, 12/12, 12/16, 12/17, 12/18/2019, for 5 days at breakfast,and the distance walked was also recorded. The record also showed the resident participated 10 days at lunch time, however the total feet walked was not recorded. On some days occasionally, the resident did walk twice a day and also walked to lunch meal. During an interview on 11/13/19 at 3:00 PM, the DNS stated that she was not aware Resident #17 had declined and /or was unable to consistently participate in the participation with walking. She stated that the RNP programs were only provided Monday through Friday. Not ensuring the resident was consistently offered opportunities to participate in the walking program placed the resident at risk for a decline in the ability to walk. Reference WAC 388-97-1060

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate toileting services for one of three residents (#23) reviewed for bowel and bladder. This failure placed the resident at risk for skin breakdown, infection, and compromised the resident's quality of life during the end of life period. Findings included . Review of the facility policy titled Bowel and Bladder program, which was last reviewed 01/2018, stated it was the policy of the company to prevent complications from incontinence and preserve the resident's dignity and comfort. RESIDENT #23 The resident's Minimum Data Set (MDS), dated [DATE], showed the resident was occasionally incontinent of urine and stool. Review of the facility assessment for bowel and bladder continence, dated [DATE], showed the resident was incontinent daily, had an overactive bladder, and also showed the resident was on scheduled toileting. Review of the record showed statements were made by family members that they were concerned that resident was not getting adequate bowel and bladder care. The resident re-admitted to the facility on [DATE] and was placed on Hospice on [DATE]. The resident eventually expired on [DATE]. Review of the care plan, dated [DATE], showed the resident was identified with urinary incontinence related to occasional to frequent incontinence secondary to diuretic use. Goals included the resident's skin would remain clean, dry and free of breakdown related to incontinence. Second goal listed in the care plan was to reduce incontinent episodes and establish routine toileting pattern to meet resident needs. Interventions included the following: 1. Scheduled toileting program: Toilet at 10 AM, 2 PM, 5 PM, 9 PM and as needed. 2. Monitor for compliance with scheduled toileting, notify LN of start, non-compliance and/or changes in incontinence/continence. Review of progress notes from [DATE] to [DATE], showed multiple episodes of incontinence which described the resident's clothing and skin tear dressings as being saturated with urine. Some incontinent episodes were documented with stool, and other episodes were described as having a strong urine odor. However there were at least 3 notes that showed the resident was changed up to 3 times for the day. During an interview on [DATE] at 9:05 AM, the Director of Nursing(DNS) stated she was not able to provide any documentation the resident was being checked and toileted at the scheduled times as stated by the care plan. She stated that she understood the concerns made by family and stated that the documentation did not show frequent bowel and bladder monitoring and toileting. The DNS stated that moving forward she would include a point of care system to show when and how often residents were being monitored for toileting. Reference (WAC) 388-97-1060 (3)(c)

Based on observation interview and record review, the facility failed to consistently assess and have an effective pain management program in place for one of two residents (#30) reviewed for pain. The failure to ensure pain was assessed, and have care plan interventions that included non-pharmacological interventions left the resident at risk for unrelieved pain. Findings included . The facility policy, reviewed 03/2017, titled Pain Management - SNF (Skilled Nursing Facility), showed the assessment would include usual time of occurrence and exact location as well as pain intensity. The related diagnosis, conditions or other factors related to or possibly causing pain. The over-all effect on the resident's psychosocial (well-being), activity, ADL (Activities of Daily Living such as transfers, bed mobility, dressing, grooming and ambulation) and nutritional status. The policy also showed that alternatives for pain control will include and not be limited to medication, massage, heat, music, PT/OT consults, tens units, repositioning, dressings and other supportive devices as deemed appropriate . Resident #30 was admitted to the facility after being hospitalized for the surgical repair of a hip fracture. The Minimum Data Set (MDS) assessment, dated 12/11/19, showed the resident had pain, received medications routinely and as needed (PRN), and had non-pharmacological interventions in place. The assessment showed that during an interview, Resident #30 reported occasional pain, and on a scale of 1 to 10, the reported pain was a level 5. There was no comprehensive pain assessment that identified the source of pain, a description of the pain, what effect it had on the resident's functional abilities, and what nonpharmacological interventions might be helpful. An observation on 01/06/20 at 10:25 AM showed Resident #30 was seated in a recliner chair when asked how she is doing the resident stated, I cannot sit up for too long, it is painful. The resident was asked about her pain, she stated, It gets bad if I have to wait for the medications. During an interview on 01/09/20 at 12:16 PM, Resident 30 was asked how her pain was currently and she stated that it was fine. She then stated the pain was terrible last night. The January 2020 Medication Administration Record (MAR) showed 5 mg dose of oxycodone was administered at 4:40 AM. The care plan, initiated 12/11/19, showed the resident had a fractured hip and a compression fracture in the lower spine and osteoarthritis. The care plan directed staff to administer analgesics as ordered and noted non-pharmacological intervention was to reposition. The December 2019 MAR included a scheduled dose of Acetaminophen three times a day, and orders for three different narcotic medications which could be administered if needed (or PRN): -Tramaldol 50 mg 1/2 tablet every 8 hours PRN for breakthrough pain; -Oxycodone 2.5 mg every 4 hours for PRN for moderate pain [which would be 4 - 6 on the standard (0-10) pain level scale]; and -Oxycodone 5 mg every four hours PRN for severe pain, [which would be 7-10 on the pain level scale]. The MAR did not identify any non-pharmacological interventions for staff to utilize prior to administering the PRN medications. The December 2019 MAR showed all three narcotic medications were administered sporadically throughout the month. Although the resident reported a severe pain level (7-10 on a scale of 10) on multiple occasions (December 8, 12, 13, 19, 20, and 23), the dose designated for moderate pain was administered (oxycodone 2.5 mg). During an interview on 01/11/20 at 2:31 PM, Staff B, a Licensed Practical Nurse, was providing care for Resident 30. When asked how she made a determination which of the three narcotic medications ordered PRN will be administered, she reported the residents family does not want us to give narcotic medications, because they make her loopy, should be administering tramadol. Also on 01/11/20 12:52 PM, the Director of Nursing Services(DNS) was not able to locate a comprehensive pain assessment and stated one should have been completed at the time of admission. When asked what non-pharmacological interventions were in place, she referred to the care plan which identified repositioning as the only non pharmacological intervention. The DNS stated that it should be identified on the MAR, but was not able to find any directive for the alterative interventions on the MAR. The DNS stated non pharmacological interventions should be attempted prior to administering a PRN medication. The facility failed to conduct a comprehensive pain assessment, failed to identify and ensure non pharmacological interventions were implemented prior to administering a PRN medication. In addition the facility failed to identify what effect the pain may have on the resident ability to participate in activities, ADLs, and/ or how pain affected the residents overall psychosocial well-being. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure that pharmacist consults and recommendations were acted on for one of five residents (#7) reviewed for unnecessary medications. Failure to ensure a gradual dose reduction (GDR) of a psychotropic drug was initiated timely, and to ensure a physician and facility staff reviewed an anti-hypertensive drug regime after they were alerted to concerns by the pharmacy placed the resident at risk for unnecessary drugs. Finding included . RESIDENT #7 The resident was last re-admitted to the facility in 2016 with multiple diagnoses including dementia. The last quarterly Minimum Data Set (MDS) assessment, dated 10/09/19, included a diagnosis of depression. The MDS documented extensive assistance from staff was needed for Activities of Daily Living, including transfers and mobility, toileting, dressing and hygiene. Review of the record showed the resident's medication regime included two anti-depressant medications, Celexa and Trazadone. In addition, Resident #7, had orders for anti-hypertensive medications, including Propranolol 10 milligram(mg) twice a day, Losartan 25 mg a day, Torsemide 60 mg a day and an as needed (PRN) order for Hydralazine which could be administered as needed. Failure to timely implement a gradual dose reduction, Gradual Dose Reduction (GDR) for an Anti-Depressant(AD) medication: On 05/09/19, the pharmacist review recommended a GDR, for Celexia. The pharmacist's review showed the AD medication was started on 10/13/18, and was administered to treat anxiety/panic attacks. The report showed the behaviors for which the medication was being used to treat had not occurred during the past six months. It also showed the MSW (Social Worker) asked the resident to decrease the Trazadone, and reported the resident refused changes to Celexa or Trazadone, and deferred to a care conference note. The form communicating the pharmacist's review, included a series of check boxes. The following guidance was provided Please check the appropriate response and add additional information as requested. The physician placed a check mark next to the statement dose reduction was contraindicated . and the physician also noted that they agreed to the recommendation (later on the form) by checking another box on the form. The care conference notes, dated 05/07/19, did not show any information to verify a discussion of dose reductions of the AD medications occurred. On 06/13/19, the pharmacist's consult form repeated the same information- the box was checked that a GDR was clinically contraindicated again, and later on the same form the physician noted they agreed with the recommendation. On 09/20/19, the pharmacist's consult form showed the following statement (in bold) was included, Recommend decreasing Celexa to 10 mg daily in attempts to establish lowest effective dose. The physician disagreed with the recommendation and wrote, PT(patient) is stable on current meds. On 12/05/19, the pharmacy consult showed the following in bold, IDT (Inter-Disciplinary Team) recommends an attempt to GDR Celexa to 10 mg daily. Review of the Medication Administration Record (MAR) documented the GDR was implemented on 12/05/19 which was seven months after the GDR was recomended. Failure to act on recommendation for anti-hypertensive medications: On 11/14/19, the pharmacist recommendation showed the blood pressure checks had wide variations. The note stated Systolic (SBP) reading varied 119 - 182, Diastolic (DBP) reading were 55-94, and pulse (P) was 46 - 94 beats/minute. The pharmacy consult showed the Hydralazine was administered for SBP of less than 160 and recommended the nurses receive inservice training about the monitoring the vital sign parameters for administration of the medications. The parameters established by physician orders directed staff to: Hold Propranolol (10 mg dose administered twice a day, noting if SBP less than (<) 100, if pulse (P) < 60, the medication would be placed on hold (or not administered). The order for Losartan 25 mg a day, directed staff to hold the medication if SBP < 100. The order for Hydralazine 25 mg directed staff to administer if SBP was greater than (>) 160. Review of the MAR identified vital sign parameters and included a place to document the results of the SBP/ DBP and P, at the time of administration of the Propranolol and Losartan at 8:00 AM, and for the second dose of Propranolol that was administered at 8:00 PM. In additon, a third check of SBP/DBP and P was documented at 5:00 PM. The December 2019 MAR showed the Propranolol 8 am dose was held on 10 different occasions, however the Losartan was only held on one day(12/01/19) . The vital signs were only noted on one of the ten days, 12/19/19, which showed the pulse was below 60. Although the MAR had an area to document the vital signs (SBP, DBP and P), these vital signs were not documented. The Propranolol, administered at 8:00 pm, was held on 6 occasions. The reasons for the medication hold were only noted on two occasions. On 12/6/19, a pulse of less then 60 was obtained (P was 58), and on 12/12/19, the SBP was less than 100 (SBP was 98) The vitals were not documented on the other 4 occasions. In additon, the PRN Hydralazine 25 mg ordered as a (for SBP >160). Review of the SBP checks completed at 5 PM and 8 PM the SBP was > 160 on 9 different occassions. The MAR documented the PRN was administered 5 occassions that included on 12/13/19 at 8:08 AM, noting the SBP was 158, which was not consistant with phsycian order to administer if SBP >160. There was no evidence the Hydralazine was administered when the SBP was >160 on the following dates and times; on 12/02/19 at 8:00 PM the SBP was 190; on 12/05/19 at 5:00 PM the SBP was 200; on 12/6/19 at 5:00 PM the SBP was 168; on 12/10/19 at 5:00 PM the SBP was 200; on 12/20/19 at 5:00 and 8:00 PM the SBP was 176; and on 12/24/19 at 8:00 PM the SBP was 162) During an interview on 01/13/20 at 2:30 pm, the Director of Nursing(DNS) was asked if there was any additional documentation to show that the physician documented why the GDR was clinically contraindicated. The DNS stated that she would review the record and provide additional information. The DNS was also asked to provide clarification about any steps taken to review/address the anti-hypertensive medications, such as a physician review or training provided after the pharmacy alerted them to the problems. During an interview on 01/14/20 at 2:00 pm, the DNS stated that she was not able to locate any additional documentation why the GDR was clinically contraindicated or any additional documentation to show that the concerns identified with the anti-hypertensive medications were addressed. Reference WAC 388-97-1300 (4)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a gradual dose reduction (GDR) to minimize potential side effects for the use of an antipsychotic medication for three of five residents (#33, #7 and #30) reviewed for unnecessay medications. This failure placed the residents at risk for medication side effects and reduced quality of life. Findings included . RESIDENT #33 The resident admitted to the facility on [DATE] and was able to make her needs known. Review of the physician's orders on 01/07/20 showed the resident was prescribed the antipsychotic medication Seroquel 12.5mg on 11/15/18. Review of the Medication Administration Records (MAR) from 11/2018 to 01/2020 showed the resident was being given the medication at that dose during this period related to making a statement that management was killing her. No dose reductions were documented during this period. Review of the care plan, dated 01/05/18, for Psychotropic drug use showed the resident with a potential for drug related complications associated with use of psychotropic medications. Interventions included the following: 1. Consult with pharmacy, PCP to consider dose reduction when clinically appropriate. 2. Interdisciplinary team (IDT) review for evaluation of interventions effectiveness. The care plan did not include any updates to show attempted or failed GDR of the antipsychotic medication. During a joint review of the medical record and interview on 01/11/20 at 9:38 AM with Staff C, Charge Nurse RN, record review showed the first reduction of the Seroquel was 25 mg to 12.5 mg on 1/17/18. According to the records reviewed by Staff C, there had been no dose reductions since 4/13/18 where the medication was changed from every morning to evening administrations at the same dose. Staff C stated that the only clinical indications for the use of the drug were for the statement made by the resident in 2017 that staff were trying to kill her and coins that were placed in her stomach. The resident had not had any delusional episodes since then. The facility provided documentation dated in 2018 that showed a dose reduction was contraindicated from a GDR done on 01/17/18. Pharmacy recommendations made by the pharmacist in January 2019 were to consider a dose reduction with the ordering physician agreeing, however was never initiated. RESIDENT #7 Resident #7 was last re-admitted to the facility in 2016 with multiple diagnoses including dementia and anxiety. The last quarterly MDS assessment, dated 10/09/19, showed a diagnosis of depression was added. The MDS showed extensive assistance from staff was needed for Activities of Daily Living(ADLs) including transfers and mobility, toileting, dressing and hygiene. The January 2020 MAR noted two different anti-depressant medications were being administered, Celexa 10 mg and Trazadone 50 mg. The behavior monitor showed the resident had not displayed any behaviors during the past three months. A pharmacist recommendation, dated 05/09/19, recommended that a Gradual Dose Reduction (GDR) of the psychotropic medication, noting that a review of the behavior monitors for the past 6 months did not document any behaviors. The physician declined the recommendation, but failed to provide written documentation that a GDR was clinically contraindicated. The pharmacist's reviews, dated 6/13/19, 09/20/19, 10/10/19, 11/14/19, and 12/05/19, provided the recommendation again. However, it was not until 12/05/19, when the recommendation was acted on and a GDR was implemented, which reduced the dose of Celexa from 20 mg to a 10 mg dose. On 01/13/20, at 2:30 PM, the DNS was asked to provide any additional information documented by the physician to justify the clinical rational for not implementing a GDR. On 01/14/20 at 2:00 pm, the DNS reported she was not able to locate any further documentation or rational to justify why a GDR was not attempted. Not ensuring the recommendation was acted on and without the physician documentation that the GDR was clinically contraindicated, increased the risk for unnecessary drug. (See F 756 for the citation for failure to act on pharmacy recommendations.) RESIDENT #30 Resident #30 was admitted to the facility on [DATE], for rehab after the surgical repair of a hip fracture. The Minimum Data Set (MDS) assessment, dated 12/11/19, showed the resident was alert and oriented, needed extensive assist with ADLs and was prescribed an Anti-Depressant (AD) medication. The admission orders included an AD daily. The December 2019 MAR did not show that the staff were monitoring for target behaviors and/or adverse side effects the resident may experience related to the medication. During an interview on 01/13/20 at 2:30 PM, the DNS stated that the expectation for residents admitted with psychotropic medications was to initiate monitoring for target behaviors and adverse side effects at the time of admission. WAC Reference 388-97-1060 (3) (k) (i)

Based on observation and interview, the facility failed to ensure food were stored, prepared, and served under sanitary conditions. Failure to meet these requirements increased the risk for a food borne illness. Findings included . Failure to ensure cross contamination An observation of the meal service on 01/13/20 showed Staff J, a cook, was using a cutting board to cut medium rare steak into bite-size pieces. The cutting board contained the liquid drippings from red meat. The staff then placed a serving of cooked shrimp on the same cutting board which was cut into bite-size pieces. After asking about the facility practice, Staff J, set up a second cutting board to prevent cross contamination between the two cooked food items. An observation on 01/14/20 showed an unnamed dietary aide was in the dish room. The staffperson was loading soiled dishware into a rack and then placed them into the dishwashing machine wearing gloves. The staff member then moved from the soiled side of the dish machine to the cleaned dishes side, removed the gloves, and began stacking the clean dishware without washing their hands. Failure to maintain food preparation equipment under sanitary conditions The initial observation tour of the main kitchen on 01/05/20 between 9:30 and 10:00 AM showed the following concerns: The Robo Coup (a food processor) was observed with dried food splash on the base. Three mixers in the dessert preparation area had dried food spills and splash on the surfaces of the bases. An ice machine located on the 10th floor had dried food splash on the outside. An unnamed dietary aide, working in the area stated it was the ice machine that was used to supply ice for the nursing home. A follow-up tour on 01/14/20 at 11:00 AM showed the Ice machine remained in the same condition(dried food splash on the outside). A log was found attached to the side of the machine which showed the machine was last serviced on 12/18/18. Staff I, the dietary manager, CDM, who was present during the tour was asked how often the ice machines were clean cleaned and sanitized. Staff I stated that he did not know how often it was routinely cleaned and/or serviced. Also during the tour on 01/14/20, a second ice machine was found on the 9th floor. An attached log documented the ice machine was last serviced 08/30/19. There was no evidence that either of these units were routinely cleaned and sanitizied or serviced routinely. Also on 01/14/20, a slicer was found with bits of sliced meats adhered to the blade with a unnamed cook working in close proximity. When asked about the soiled equipment, the cook stated that he was not certain who had used the equipment, and stated the expectation was to clean the equipment after use. The staff stated the slicer was soiled. Failure to ensure safe food storage During the initial tour on 01/05/20, a refrigerator located next to the main cooking area was found with two large roll-in carts. One of the carts had a steamtable pan with cooked meat (that appeared to be beef). The pan was not covered, labeled, and/or dated. In addition, no thermometer was found in the refrigerator. Approximately 10 to 15 minutes later, the cook who was working in the area was asked about the refrigerator thermometer. The cook was unable to locate a thermometer in the refrigerator. A reach-in freezer located in next to the main cooking area,had 3 to 4 small packages of frozen bread; none of the small packages were dated. Lastly, during the follow up inspection of a walk-in referigerator on 01/14/20, a part of a ham was found, wrapped clear plastic wrap, that was not dated and or labeled. WAC 388-97-1100 (3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for one of two sample residents (#7) with contact precautions in place to prevent the spread of infectious disease. Failure to ensure staff were trained to clean and sanitize the environment to minimize exposure to an infectious pathogen placed Resident #7 and other residents at risk for the infection. Findings included . On 01/14/19 at 1:30 PM, an undated policy titled, C Diff Cleaning Process, was provided for review. The policy directed staff to follow precautions for Personal Protective Equipment (PPE) posted outside the room, and place goggles on when using bleach solution. It directed staff to gather supplies /equipment and cleaning supplies required and leave the cart outside the room. It directed staff to clean and disinfect all furniture, and high touch surfaces and everything touched by the resident and allow the bleach / water solution to sit on the surface for 10 minutes. It instructed staff to remove the PPE in the room and wash their hands prior to exiting the room. The policy directed staff to place all cloths, gloves and handled tools used for decontamination must be placed in a clearly marked plastic lined waste receptacle. Resident #7 The resident was last re-admitted to the facility in 2016 with multiple diagnoses including dementia, and anxiety depression. The last quarterly MDS assessment, dated 10/09/19, showed a diagnosis of depression was added. The MDS documented extensive assistance from staff was needed for Activities of Daily Living such as transfers and mobility, toileting, dressing and hygiene, and used a wheelchair for mobility. During an interview on 01/07/13 at 3:30 PM, the Resident Representative stated that the resident was treated for a C-Difficile (a gastrointestinal infection) in December 2019 just prior to leaving for a vacation for holidays. The representative stated that when she returned in early January, the infection had resolved. An observation on 01/10/19 at 10:00 AM showed Resident 7 had a new sign posted identifying contact precautions were needed. The posting directed anyone entering the room to wear a gown, gloves and a mask as PPE(personal protection equipment). During an interview on 01/10/20 at 10:35 AM, Staff C, a Charge Nurse, was asked about Resident #7. He stated that the resident had developed loose stools the previous evening, and the facility protocol was to conduct testing to ensure the loose stools were not related to a reoccurrence of C- Diff. Staff C stated that the facility protocol was to initiate the contact precautions if an infection was suspected. An observation on 01/10/20 at 11:47 AM, Staff E, was exiting the resident's room carrying a dust mop, still wearing gown, gloves, and face mask. Staff E then discarded the removable cloth from the head of the dust mop and placed the dust mop back on the cart where other cleaning tools were held. After this, the staff removed the gown and gloves and discard them. Also during this observation, Staff E was not carrying any cleaning products, such as bleach. The staff did not discard the PPE before exiting the room or wash her hands before exiting the room. The tool used, a dust mop, was placed back on the cart, after the cloth was placed in a bag on the cart that was not marked. In addition, Staff E was not wearing eye protection or goggles as directed by the policy. An observation on 01/12/20 at 12:13 PM showed Staff D, Housekeeper, in the hallway near Resident #7's room. When asked what cleaning agents were available on the carts. Staff D stated bleach was available and a floor cleaner called Alpha. Staff D stated that she was not aware of any special cleaning methods and then commented she had not cleaned the room yet. During an interview on 01/13/20 at 12:04 PM, Staff G, the Housekeeping Supervisor was asked about infection control practices. Staff G, who supervises the laundry and housekeeping, stated that the department's staff had not received any training about infection control practices from the Director of Nursing(DNS) or Staff F, the Assistant Director of Nursing (who was identified was responsible staff training and development). During an interview on 01/14/20, at 12:00 PM, Staff F, a housekeeper was asked if they had been provided any training on how to clean a room where a resident was suspected of having a C - Diff infection. Staff F stated that there were two products available, (Bleach and Virex) but needed to use bleach if a resident had a C-Diff infection. When asked the last time training had been provided, Staff F stated, it was a long time ago. During an interview on 01/14/20 at 12:15 PM, Staff E stated that bleach was used to clean a room for a resident who had a C-Diff infection. When asked, Staff E stated that she had not received any special training to clean the room. The Housekeeping Supervisor, Staff G, who was also present during the interview, was asked if she knew how long the bleach had to remain on a surface to kill C - Diff spores, she stated, No. Reference WAC 388-97--1915 (1)(2)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT #6 The resident readmitted to the facility on [DATE]. Review of the facility weight tracking report showed that on 12/05/19 the resident weighed 210 lbs. The next weight recorded on 01/06/20 was 196 lbs, resulting in a total weight loss of 14 lbs in a month. Review of the resident's nutrition/Hydration care plan, dated 07/25/17, stated Resident at nutrition risk related to high BMI, Dx, Diuretic therapy, advanced age and dependence for feeding assistance. The goal stated in the care plan was the resident would maintain comfort and enjoyment with nutrition/dietary interventions as able. The care plan was not clear on identifying what type of nutrition-related problems the resident was at risk for (e.g weight loss, weight gain, malnutrition etc.). and did not list specific/appropriate interventions to address her current significant weight loss of 14 lbs in a month. During an interview on 01/12/20 at 2:29 PM, the DNS stated the care plan was not specific enough to address issues with weight loss or weight gain. She stated the care plan could have stated more specific goals and interventions to address the significant weight loss and stated that the resident's current weight of 196 lbs was a significant weight loss. The DNS stated that she would revise the care plan to address the resident's current condition. Reference (WAC) 388-97-1060 (3)(h) Based on observation, interview and record review, the facility failed to ensure that four of six residents(#17, #30, #8, #6) reviewed for nutrition and/or hydration status were assessed and had care plan interventions to assist with maintaining adequate fluid intake and or maintain normal body weight in place. Failure to do so placed these residents at risk for weight loss, dehydration and other health complications associated with inadequate fluid and food intake. Findings included . RESIDENT #30 Resident #30 was admitted to the facility on [DATE] for rehabilitation after the surgical repair of a hip fracture. The Minimum Data Set (MDS) assessment, dated 12/11/19,showed the resident was alert and oriented, needed extensive assist with Activities of Daily Living(ADLs) and had surgery to repair a fractured hip. A physician note, dated 12/23/19, showed the resident was being treated with an antibiotic for cellulitis of the surgical incision for the hip fracture. An observation and interview on 01/06/20 at 12:15 PM showed Resident #30 seated in her room with a meal tray that included salmon that remained untouched. The resident stated that no one talked to her about food and fluid preferences since admission. She stated, I don't like coffee and I don't like salmon and I got served both of them today. An observation and interview on 01/09/20 at 12:30 PM showed Resident 30 seated upright in bed with a lunch tray was on the overbed table before her. The resident stated that the meal was okay. The items included roast pork tender loin with gravy, mashed potatoes, and steamed green beans. The cut pieces of meat appeared to be about 2 to 2.5 inches in diameter. Bits of meat that appeared to be partially chewed and placed back onto the plate were observed. The resident attempted to pick apart the green beans that appeared to be cooked al [NAME] (steamed to a crisp state). During observation of the tray preparation on 01/13/20 between 11:30 and 12:00 PM, Staff J, a Dietary Aide, cut a serving of steak in half and cut one of the half-pieces was into smaller pieces which were then placed on a small salad bowl for service to Resident #30. The diet tray card showed regular portion serving sizes should be served. An observation and interview on 01/13/20 at 12:30 PM showed Resident #30 again seated in bed with the noon meal before her on the over bed table. The meal entrée was a steak salad, and even though the meat had been cut into bite size pieces, partially chewed bits of meat had been placed back in the bowl. Resident #30's clinical record showed her weight on admission,12/05/19, was 127.8 pounds (lbs). On 01/04/20, a weight of 109.8 lbs was documented which was a 14% loss of body weight in less 30 days (classified as severe weight loss). The resident's BMI dropped to 20.7 Review of the clinical record on 01/13/19 showed no evidence the registered dietician(RD) re-evaluated the dietary interventions since the initial assessment on 12/11/19. Review of the RD assessment dated [DATE], showed a weight of 124 lbs and the Body Mass Index (BMI) was 23, below the ideal range of 24-30 and below an ideal weight was between 127 - 158 lbs. (The BMI is commonly accepted as an indicator of a healthy weight). The RD assessment showed a 3 lbs weight change and noted, some weight fluctuations were expected due to a diuretic medication. [However, review of the Medication Administration record (MAR) for December 2019 showed no evidence the resident was receiving a diuretic medication.] The assessment showed the resident's meal intake was 100% based on only two meals that were documented between 12/06/19 - 12/11/19, and concluded true intake was unknown. Recommendations by the RD included small portions and regular size servings of protein foods, and a liquid supplement Ensure supplement once a day given at dinner time. Additional review of the clinical record found no evidence the RD re-evaluated or reassessed the interventions since the initial assessment on 12/11/19. The care plan, dated 12/11/19, showed the goal was to maintain weight 124 to 130 lbs. The interventions showed the facility would provide the diet as ordered and offer assist with meals as needed. The care plan directed staff to monitor consumption of meals, offer meal replacements if less than 50% of the meal was consumed, and offer snacks between meals. The section of the care plan intended to identify needed assist with ADLs provided no additional information about what assist was needed with meals. During an interview on 01/10/19 at 11:30 PM, Staff I, Certified Dietary Manager (CDM) was asked how residents who experienced weight loss were identified and reviewed. He stated, The RD attends a weekly meeting as part of the Interdisciplinary Team (IDT) review and stated that he ran a report prior to the meeting to identify residents who had lost weight. Staff I stated that the team reviewed intake records, discussed food likes and dislikes, and if a resident was identified with poor intake, they added supplements. Staff I stated all residents were screened for preferences at the time of admission and that he usually filled out the nutrition section of the MDS. Staff I stated that the IDT team meetings for nutrition and skin were not entered(documented) into the clinical record of residents who were reviewed. When asked, Staff I stated he maintained handwritten documentation to identify which residents were reviewed and any recommendations made. He then provided the documentation of the Skin and Nutrition meetings for the month of October 2019 through January 8, 2020. Review of the hand written notations, dated 01/08/19, showed Resident #30 experienced severe weight loss of 13.3 % of body weight. No changes to the diet were recommended. The staff noted the current interventions and documented they would continue to follow. Further review showed there were some interventions implemented on 12/11/19, however the resident then continued to lose weight. So even though the resident had been noted to have lost more weight on 01/08/20, no changes in the interventions were made. During an interview on 01/13/20 at 2:00 PM, the Director of Nursing(DNS) was asked if any changes to the care plan were made. The DNS stated that they had recently changed the supplement to Resource. Review of a diet interview, dated 12/07/19, showed the resident's only preference was for tea with breakfast. No other food preferences were noted. The RD assessment, dated 12/11/19, showed staff were not consistently documenting meal intake, as directed by the current care plan, which was implemented 12/12/19. The care plan showed the staff provide assistance as needed (PRN), the resident was provided with set up help only. During observation of the meal service on 01/13/20, the resident was served a 1/2 portion of the protein food item, despite the tray card directive to serve a full serving of protein. Failure to ensure care plan interventions were consistently followed and/or ensure the RD re-evaluated the significant weight loss to revise the care plan interventions left the resident at risk for additional weight loss. RESIDENT #17 Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including dementia and malnutrition. The last MDS assessment, dated 11/01/19, showed the resident needed extensive and/or limited assistance with most ADLs suach as transfers, walking, dressing, toileting and hygiene. During an observational tour of the facility on 01/05/20 at at 9:30 AM, Resident #17 was not in their room. In the room, there was a bulletin board(BB) that included written directives for staff and showed the resident was on a fluid restriction of 1500 cubic centimeters(cc) a day. An observation on 01/05/20 at 2:18 PM showed the resident was sleeping in bed. A large glass of water had been placed next to the resident on an overbed table, the glass had a lid and a straw, and had 1/3 of the water left in it. An observation on 01/06/20 at 8:55 AM showed Resident #17 was sleeping in an armchair in his room, and next to him on the overbed table was small glass that contained a liquid supplement. A large full glass of water with a straw and a lid, was on a night stand on the other side of the room. An later observation on 01/06/20 at 1:00 PM showed Resident #17 was sleeping in his armchair, the supplement remained on overbed table and appeared to be untouched. The water glass was on the night stand next to bed and also appeared to be untouched. During an joint interview on 01/07/20 at 2:15 PM, a Family Member (FM) was seated in the arm chair at the resident's bedside. When asked about the directives posted in the BB in the room, he stated that the family members kept the information updated to remind the staff of the resident's care needs. The FM explained the resident had been on a fluid restriction since the time of admission, and stated that the resident needed help from the staff to drink fluids. When asked about the lunch meal, Resident #17 stated he did go to the Dining room for the noon meal, but did not eat much because he really did not have much of an appetite. When asked if he got enough to drink, the FM stated they helped him get some water when they arrived. Review of the physician orders on admission showed an order for the fluid restriction, based on a diagnosis hyponatremia (low sodium) and a medical history of SIADH (Sudden Inappropriate Anti- diuretic Hormone) which contributes to electrolyte imbalances. The resident's medication orders also included sodium tablets, to assist with maintaining a normal sodium level in the blood stream. Review of the care plan in the section Dehydration/ Fluid Maintenance, showed the fluid restriction was in place and directed staff to monitor for physical signs and symptoms of dehydration, skin turgor and mucus membranes every shift. However, review of the MAR & TAR (treatment administration record) showed there was no documentation on the MAR or TAR indicating the nurses were completing the monitoring for dehydration. During an interview on 01/07/20 at 9:11 AM, an unnamed nursing assistant (CNA), who was providing care for Resident #17, was asked about the resident's ability to drink fluids. The CNA stated that Resident #17 needed help to drink fluids and that staff entered the total fluid intake on the meal monitor. During an interview on 01/12/20 at 9:43 AM, Staff C, an RN/Charge Nurse was asked about fluid monitoring. Staff C stated that the NACs would be monitoring the fluid intake and if water kept in the room, was consumed it should be included on the meal monitor. Staff C stated the only fluid intake documented by nurses was nutritional supplements. When asked how the facility ensured the resident consumed 1500 cc of fluid a day, Staff C stated, I don't know. On 01/12/20 at 1:10 PM, the DNS was asked to provide Resident #17's meal monitor for food and fluid intake for the last three months. The daily average fluid intake for the first 7 days of each month was reviewed. Between 12/01/19 and 12/07/19, the meal monitor showed the average daily fluid intake was only 632 cc of fluid. The November 2019 record (11/01/19 to 11/07/19) showed an average daily fluid intake was 742 cc, and the October 2019 record (10/01/19 and 10/07/20), showed an daily average fluid intake of 240 cc. In addition, the review of the 21 days of documentation also showed missing data for food and/or fluid intake on multiple days. During an interview on 01/13/20 at 9:40 AM, the Director of Nursing(DNS) was asked who evaluated the resident's fluid intake, she stated IDT meetings for skin and nutrition would assess the fluid intakes during the weekly meeting. When asked about Resident #17's fluid intake, she stated staff were assisting with obtaining fluids. The DNS stated that the water glasses were placed in the room during the night shift every day, and stated the meal monitor should include water consumed from the glass. When asked if any one analyzed the meal monitors, the DNS stated that it was completed at the weekly skin and nutrition meeting. After sharing the analysis, of the average daily inake of fluids described above. The DNS stated she was not aware of any system, to analyze the fluid intake and agreed the facility lacked a system to ensure adequate amounts of fluid were consumed, and/or verify the fluid restriction was followed. When asked what the facility had done to address the nutrition/hydration issues, the DNS stated that the nurses were providing a ensure supplement three times a day, and said the amount consumed would be documented on the Medication Administration Record. When asked, what date the directive was implemented, the DNS responded on 01/07/20. Not ensuring the fluid intake was monitored to ensure 1500 cc of fluid were consumed placed the resident at risk for dehydration and weight loss. RESIDENT #8 Resident #8 was re-admitted to the facility on [DATE]. The last quarterly Minimum Data Set (MDS) assessment, dated 10/16/19, identified multiple diagnoses including dementia. The MDS documented the resident needed extensive assistance of two staff with all ADLs such as transfers and mobility, toileting, dressing and hygiene. The Eating ADL only required supervision and set up. During an interview on 01/06/20 at 1:34 PM, a Resident Representative who was identified as a Family Friend(FF) stated the resident had a decline in food and fluid intake after a new anti-depressant medication was initiated in December 2019. The FF stated the decline was reported to the nursing staff. The weight record showed the last weight documented in the clinical record was on10/21/19 which was 161.3 lbs. The MDS completed 10/16/19 showed the resident's weight was 162 pounds. A quarterly nutrition note, dated 10/09/19, was completed by Staff N, a Licensed Practical Nurse/ Resident Care Manager, showed the resident's weight was stable. The last nutrition assessment completed by the RD was dated 01/19/19. There was no weight documented in the clinical record since 10/21/19, even though concerns about reduced food and fluid intake had been expressed by the FF. The care plan, dated 01/19/19, under Nutrition/Hydration directed staff to monitor monthly weights. Another section, under Skin At Risk, also dated 01/19/19, directed staff to obtain weekly weights. Review of the handwritten notes of the Nutrition/Skin meeting, documented by the Certified Dietary Manager (CDM) showed the resident was being followed during the month of October 2019 due to a reddened area the IDT was monitoring. However the resident was discharged from further weekly follow-up on 10/16/19. A hand written notation entered into the IDT notes, dated 12/31/19, showed a list of residents who did not have a current weight which included Resident #8. During an interview on 01/10/20 at 11:30 AM, Staff I, the CDM, stated he had not heard of any concerns about Resident 8's food and fluid intake. Staff I stated that if no weight was documented, the nursing staff was notified and a current weight was obtained. During an interview on 01/13/19, the DNS was asked about the Resident 8's weight record. The DNS stated the resident had refused to allow staff to weigh her. Although the resident was identified with care refusals and despite the FF report of reduced food and fluid intake, the facility did not follow the care plan to monitor weight.