Does THE BROADVIEW CENTER have any serious inspection findings?

Yes, THE BROADVIEW CENTER has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 85 total deficiencies from recent inspections.

What are the staffing levels at THE BROADVIEW CENTER?

THE BROADVIEW CENTER has a four-star staffing rating from CMS with 0.97 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE BROADVIEW CENTER located?

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

How many beds does THE BROADVIEW CENTER have?

THE BROADVIEW CENTER has 211 certified beds.

Who owns THE BROADVIEW CENTER?

THE BROADVIEW CENTER is a for profit - limited liability company facility and operates independently (not part of a chain).

What questions should families ask when visiting THE BROADVIEW CENTER?

Families visiting THE BROADVIEW CENTER should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does THE BROADVIEW CENTER compare to other nursing homes?

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

THE BROADVIEW CENTER

Name: THE BROADVIEW CENTER
Address: 13023 GREENWOOD AVENUE NORTH, SEATTLE, WA, 98133, US
Telephone: (206) 364-1300
Rating: 2.0

13023 GREENWOOD AVENUE NORTH, SEATTLE, WA 98133 · (206) 364-1300

For profit - Limited Liability company 211 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

36/100

#157 of 190 in WA

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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

The Broadview Center has a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #157 out of 190 facilities in Washington places it in the bottom half, and #39 out of 46 in King County shows that only a few local options are better. The facility's situation is worsening, with issues increasing from 28 in 2024 to 43 in 2025. Staffing is rated at 4 out of 5 stars with a turnover rate of 45%, which is slightly better than the state average, suggesting staff stability despite other issues. However, there are concerning incidents, such as a resident being injured after being startled by an unleashed dog, and failures in food storage that could lead to foodborne illnesses, highlighting both the facility's strengths and weaknesses.

Trust Score: F
In Washington: #157/190
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 45% turnover. Near Washington's 48% average. Typical for the industry.
Penalties: $13,543 in fines. Higher than 67% of Washington facilities. Some compliance issues.
Skilled Nurses: Each resident gets 57 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
Violations: 85 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 28 issues

2025: 43 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (45%)
3 points below Washington average of 48%

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

The Bad

2-Star Overall Rating

Below Washington average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 45%

Near Washington avg (46%)

Typical for the industry

Federal Fines: $13,543

Below median ($33,413)

Minor penalties assessed

The Ugly 85 deficiencies on record

1 life-threatening

Sept 2025 13 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate assessment and supervision for electronic cigarette use and ensure safe storage of smoking materials for 1 of 1 resident (Resident 7) that constituted an Immediate Jeopardy (IJ) and failed to supervise and restrain a pet (dog) for 1 of 1 staff (Staff F), reviewed for accident/hazards. Resident 9 experienced harm when they sustained a laceration (cut) on the back of their head when a staff member's dog was unleashed, wandered under the table in the dining room, startled the resident who fell backwards in their wheelchair hitting their head and required transport to the hospital for further evaluation. These failures placed the residents at risk for significant safety hazards including explosion and/or fire related to the electronic cigarette battery, avoidable accidents, bodily injury, and other negative outcomes. An IJ was identified, and the facility was notified of the noncompliance on 09/05/2025. The IJ was determined to have begun on 09/05/2025 when the facility failed to adequately assess Resident 7 for smoking and to ensure safe storage of smoking materials. The IJ was removed on 09/08/2025 when an on-site inspection confirmed the facility implemented their removal plan by removing the smoking materials in Resident 7's room for safe storage, completed a smoking assessment and updated Resident 7's care plan with the facility providing supervised vaping, completed interviews and observations of all residents and their rooms to ensure smoking materials were stored safely, and all residents and/or resident representatives, and staff were educated on the facility's non-smoking policy. Findings included . RESIDENT 7Review of the facility's policy titled, “Smoking Prohibited,” dated 10/01/2021, showed that smoking or vaping by residents was prohibited within the facility and on the grounds of the facility. It showed that vaping referred to the use of electronic nicotine delivery system or electronic smoking devices such as e-cigarettes [or E-cigar]. It further showed that residents may not keep smoking materials in their rooms and that if a resident had smoking materials, they were to be given to the “nurse” for secure storage. Review of a face sheet showed Resident 7 admitted to the facility on [DATE] with diagnosis that included stroke (caused by a blocked blood vessel in the brain), unsteadiness on feet and need for assistance with personal care. Review of a quarterly Minimum Data Set (MDS – an assessment tool), dated 08/25/2025 showed Resident 7 was cognitively intact (a person's thinking and memory are working well) with a Brief Interview for Mental Status (BIMS -a cognitive screening tool) score of 15 (highest possible score). Review of a document titled, admission Nursing Collection, dated 07/09/2025, showed that a “Smoking Safety Screen” was completed for Resident 7. It further showed that Resident 7 was identified to “use tobacco products” upon admission to the facility. Review of Resident 7's care plan titled, “Tobacco Use,” dated 07/14/2025, showed that Resident 7 “preferred” to smoke cigarettes, cigar, pipes, and via electronic delivery systems, including electronic cigarettes and vape pen. It showed that the care plan goal was, “The resident will smoke safely thru the review period.” It further showed a care plan intervention for the facility to complete a smoking assessment as needed. Review of Resident 7's Electronic Health Records (EHR) did not show documentation of a completed smoking assessment. Review of a nursing progress note dated 07/10/2025, showed that Resident 7 “request to smoke vapes, on routine nicotine (smoking cessation) patch” and that “Staff educate [Resident 7] that no smoking is allowed in the facility.” Review of July 2025 Medication Administration Record (MAR) showed that Resident 7 refused their nicotine patch on eight occasions from July 10, 2025, through July 31, 2025. Review of August 2025 MAR showed that Resident7 refused their nicotine patch every day from 08/01/2025 through 08/19/2025. It further showed that Resident 7 physician's order for routine nicotine patch was discontinued on 08/19/2025. An observation and interview on 09/05/2025 at 10:30 AM showed Resident 7 was lying in bed, holding a slim, rectangular device, which they raised to their mouth before exhaling a cloud of white, odorless vapor. When asked if Resident 7 was vaping, Resident 7 stated, “Yes” and that they were aware that residents were not allowed to use a vape within the facility. When asked if Resident 7 independently stored and charged the battery of their vape device, Resident 7 stated, “Yes.” Resident further stated that their vape device was a “Juul [brand name].” A follow up observation and interview on 09/05/2025 at 12:10 PM, showed Resident 7 was sitting upright on the side of their bed and used their vape pen while watching television. Resident 7 stated that the facility knew about their use of a vape device and that Resident 7 refused nicotine patches that were offered by the facility. When asked how often they vaped, Resident 7 stated, “not that often, I would say, three times a day,” and that they vaped unsupervised in their room. When asked if staff had ever seen Resident 7 used their vape inside the facility, Resident 7 stated, “Yes,” and that “They (Staff) don't [do not] pay attention to it, they're [they are] working.” In an interview and joint record review on 09/05/2025 at 12:19 PM, Staff D, Registered Nurse (RN), was asked if there were residents that smoked in the facility, Staff D stated, “I know [Resident 7] uses e-cigarettes.” Staff D stated that residents were not allowed to smoke within the facility and that they did not know if residents could vape within the facility. Staff D stated that they saw Resident 7 vaping in the facility “once in a while,” and that Staff D last saw Resident 7 vaping in the facility on 09/05/2025. When asked what their action was after observing Resident 7 vaping in the facility, Staff D stated that they “reminded [Resident 7] of the risks for “hypertension [high blood pressure] and heart problems.” When asked if they offered to safely store Resident 7's vape device, Staff D stated that Resident 7's vape was their “own supply” and that they had not been told “how to keep or safe keep those e-cigarettes.” When asked if residents were allowed to smoke outside of the facility, Staff D stated, “Yes, it's [it is] open, there's [there is] a patio.” Staff D then stated that they were not “aware” that Resident 7 needed to be supervised for smoking because Staff D did not “know about e-cigarettes.” Staff D further stated that they were “not sure” if the facility had a smoking policy that included vape devices. In an interview and joint record review on 09/05/2025 at 1:15 PM, Staff E, RN, Unit Manager, stated that the facility was a non-smoking facility, which meant that residents were not allowed to smoke within the facility and within the facility premises. Staff E stated that they were “not sure” if the facility's non-smoking policy included the use of vaping devices. When asked what the facility's process was when smoking materials were identified within the facility, Staff E stated that they would “clarify with the Director of Nursing [DON]” if they could “confiscate” the smoking materials and “keep in a safe place away from the resident.” A joint record review of Resident 7's EHR showed a Tobacco Use Care Plan, dated 07/14/2025, that listed an intervention to complete a smoking assessment as needed. Staff E stated that Resident 7 was screened for tobacco use on admission and that they did not see documentation of a completed smoking assessment. When asked what the purpose was of completing a smoking assessment, Staff E further stated that they had “no idea,” and that they had not completed a smoking assessment before because the facility was a “non-smoking facility.” When asked if Resident 7 should have been assessed for smoking, Staff E stated that they would “clarify it with the DON.” In an interview on 09/05/2025 at 1:32 PM, Staff B, DON, stated that the facility had a smoking policy and that they were “not sure” if the policy included the use of vape devices. When asked if vape devices were considered smoking materials, Staff B stated, “Yes,” and that they “believed” there were no residents that had vape devices “in-house.” Staff B stated that they expected that smoking materials would be “kept in the nurses' station” accessible only to staff. Staff B stated that vape devices posed “fire hazards” and that vape devices would be considered smoking materials. Staff B further stated that if a resident was observed using e-cigarettes and/or vape devices that they would expect staff to “right away” educate the resident on the associated risks, intervene to stop the activity, and secure any smoking materials. Staff B stated that the reason for removing the smoking supplies from a resident's procession was for “safety reasons, safe storage, and to keep everybody safe.” When asked if a smoking assessment should be completed for a resident identified on admit having used tobacco, Staff B stated that they expected there would be an “evaluation that is followed up on by nursing [staff].” When asked if Resident 7 should have been assessed for smoking, Staff B stated that they would “have to look into it.” In an interview on 09/05/2025 at 2:20 PM with Staff B, and Staff A, Interim Administrator, Staff B stated that they were “under the impression” that the facility had a designated smoking area in the “courtyard,” and that they would “get the determination of that.” Staff A clarified that the facility was a “non-smoking facility.” Record review of Resident 7's EHR showed a progress note signed by Staff D on 09/05/2025 at 3:11 PM, showed “This writer saw [Resident 7] has E-cigar in her room,” and that Staff B was notified. Record review of Resident 7's EHR showed a progress note signed by Staff B on 09/05/2025 at 3:41 PM, showed “Smoking Evaluation completed.” RESIDENT 9 Review of the Pet, Animal Policy, revised in January 2025 showed, Personal Pet Visits:The following rules and restrictions apply to personal pet visits:a. A staff member, volunteer, or other designated individual must always accompany animals at all times. b. Animals must be on a leash and/or restrained while in the facility. Safety Precautions: Animals will not be allowed in food preparation areas, dining areas, bathrooms or treatment areas. Review of the quarterly MDS dated [DATE] showed Resident 9 was admitted to the facility on [DATE] with a diagnosis list that included dementia (impaired memory) and required partial to moderate assistance for transfers and mobility. The MDS further showed the resident used a wheelchair. Review of the incident investigation dated 08/04/2025 showed Resident 9 was eating breakfast in the dining room when a dog entered the dining room and crawled under the table that Resident 9 sat at in their wheelchair to eat breakfast. The investigation showed Resident 9 was startled and they lifted both feet up which caused the wheelchair to tip backwards with Resident 9 in the wheelchair. A licensed nurse (LN) found Resident 9 on the floor, on their back. The LN assessed the resident and found a laceration (cut) on their head that measured 1.0 centimeters (cm-a unit of measurement) by 0.5 cm. Resident 9 complained of pain when the area was touched. First Aide was performed to clean the cut, and pressure was applied to the area to control the bleeding. Resident 9 required extensive assistance from staff to be transferred from the floor to their wheelchair. Resident 9 was transported to the local hospital for assessment and evaluation of their head and pain on 08/04/2025 and returned to the facility the same day. A computed tomography (CT-imaging to create detailed images of the body) scan was completed and was negative for any traumatic injury of the head or neck. The incident investigation dated 08/04/2025 further showed a LN (Staff M, Licensed Practical Nurse - LPN) observed the dog come into the dining room from the gym (therapy room) and go between Resident 9 and another resident that sat at the table, the dog then went under the table between the two residents, when Resident 9 screamed “help.” Staff M walked towards Resident 9's table, the dog barked and Resident 9's wheelchair flipped back, and Resident 9 was found on their back. The investigation then stated it seemed like the dog was stuck under the table and could not figure their way out from the table. In an interview on 08/15/2025 at 12:45 PM Staff F, Rehabilitation Director, stated, “the dog went into the dining room, he (the dog) was eating crumbs that fell on the floor under the table and got stuck in the wheelchair. He should have been on his leash; this accident would not have happened. They sent Resident 9 to the hospital. The rules were broken and Resident 9 got harmed because the dog was not on a leash. He (the dog) got tangled up in their wheelchair and tipped it over. Resident 9 would not have been hurt if he (the dog) was on a leash, we would have been able to stop him from going under the table, getting tangled up in the wheelchair and tipping it over. It was a broken policy, the policy said 100% the dogs need to be on a leash, always and he was not.” In an interview on 08/15/2025 at 1:29 PM, Staff L, Speech Therapist, stated that they went to the gym, the door was left open, and the dog went to the dining room from the gym, then they heard a loud bang that came from the dining room, and went to see what the noise was and saw Resident 9 on the floor, with the back of their head bleeding. The dog was not on a leash; he (the dog) smelled food that came from the dining room and went to get some food. The dog was not on a leash while he was in the gym or in the dining room. In an interview on 09/15/2025 at 11:59 PM Staff M stated, “I was in the dining room, Resident 9 was sitting in their wheelchair at the table eating breakfast when the dog went under the table, Resident 9 tried to move their legs away from the dog, fell backwards and hit the back of their head on the floor. There was blood from a cut on the back of their head, Resident 9 was frightened. The dog was not on a leash, the dog should not be in a resident area, especially not in the dining room when the residents eat. The dog was not on a leash when I saw the dog come from the gym (therapy) room. The dog was by itself. There was nobody with the dog when it entered the dining room. This accident could have been avoided if the dog had been on a leash with someone supervising and holding the leash to prevent the dog from going under the table. Resident 9 would not have fallen backwards in their wheelchair and cut the back of their head because the dog would not have been under the table.” In an interview on 09/15/2025 at 12:30 PM, Staff N, Registered Nurse, Unit Manager, stated, “all dogs were supposed to always be on leashes and supervised when they were in the facility. Staff N further stated if the dog had been on a leash, Resident 9 would not have been harmed on 08/04/2025 when the dog went under the dining room table and Resident 9 fell backwards in their wheelchair and cut the back of their head.” In interview on 09/15/2025 at 3:29 PM, Staff B stated Resident 9's accident on 08/04/2025 could have been avoided if the dog was on a leash, Resident 9 would not have injured the back of their head when they fell backwards in their wheelchair. In an interview on 09/15/2025 at 4:01 PM, Staff C, Administrator, stated, “I think the dog got in the way and tripped Resident 9. I am not sure about that, but per policy the dog should have been on a leash. This would not have happened if the dog was on a leash.” Reference: (WAC) 388-97-1060(3)(g)

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure shower preferences were reasonably accommodated for 2 of 6 residents (Residents 2 & 3), reviewed for preferences. This failure placed the residents at risk of unmet care needs and a diminished quality of life.Findings included… Review of the facility's undated policy titled, “Dignity,” showed, “The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.” The policy further showed residents were supported in exercising their rights and allowed them to choose when to sleep, eat and conduct activities of daily living (ADL). RESIDENT 2Review of Resident 2's “Shower Preference Questionnaire,” dated 07/03/2023 and another one dated 05/30/2024, showed Resident 2 preferred a shower in the morning twice a week. Review of Resident 2's care plan printed on 09/09/2025, did not show Resident 2's shower preferences. Review of Resident 2's Electronic Health Record (EHR), under task- ADL Bathing/Showering, showed Resident 2 was scheduled for a shower on Thursday evenings and as needed. The task further showed Resident 2 did not receive a shower twice a week in the morning per their preference. In an interview and joint record review on 09/10/2025 at 1:20 PM, Staff E, Resident Care Manager, stated a resident was asked about their shower preferences upon admission. A joint record review of Resident 2's “Shower Preference Questionnaire,” dated 07/03/2023 showed Resident 2 preferred a shower in the morning twice a week. Additional joint record review of Resident 2's EHR showed Resident 2 was scheduled for showers every Thursday once a week and as needed. Staff E stated that if the facility could accommodate the residents' preferences, they would try to honor them. When asked if the facility was currently honoring Resident 2's shower preferences, Staff E stated, “How it is does not reflect it now.” In an interview and joint record review on 09/15/2025 at 4:59 PM, Staff B, Director of Nursing, stated the facility was not honoring Resident 2's shower preferences and that they should have. Joint record review of Resident 2's “Shower Preference Questionnaire,” showed a new questionnaire was completed and dated 09/15/2025 with the same shower preferences. Staff B stated that Resident 2's shower schedule had been updated to Tuesdays and Thursdays during the day. On 09/16/2025 at 2:11 PM, Staff C, Administrator, stated they would expect to honor resident's shower preferences “within reason.” Staff C further stated that a shower twice a week seemed like a “reasonable” request. RESIDENT 3Review of Resident 3's care plan for preferences dated 12/02/2019 and revised on 01/07/2025 showed Resident 3 preferred bed baths. In an interview on 09/08/2025 on 3:27 PM, Resident 3 stated, “I prefer bed baths, and I prefer to get them two times a week. A long time ago I was asked if I would like to take showers or bed baths. I chose bed baths because I don't like getting out of bed to take a shower. I told the staff I would like to receive two bed baths a week in the evening. Review of Resident 3's EHR, under task- ADL Bathing/Showering, showed Resident 3 was scheduled for a shower/bath every Sunday and Thursday evening and as needed. The task further showed Resident 3 did not receive bed baths two times a week from 08/13/2025 to 08/25/2025. In an interview and joint record review on 09/11/2025 at 2:43 PM Staff E RCM stated, we recently went to interview and update all the residents shower preferences and care planned their choices, I know Resident 3 preferred bed baths. In a joint record review of Resident 3's EHR under task showed Resident 3 did not receive bed baths two times a week per Resident 3's preference from 08/13/2025 to 08/25/2025. Staff E also stated Resident 3 refused at times and that all refusals should be documented. Further joint review of the task record dated 08/13/2025 to 08/25/2025 with Staff E did not show documented refusals of the bed baths, Staff E then stated Resident 3 did not receive two showers per week during this time. In an interview and joint record review on 09/11/2025 at 3:20 PM with Staff B stated, the task record showed Resident 3 preferred bed baths two times per week and did not receive two times a week from 08/13/2025 to 08/25/2025. Staff B then stated Resident 3's preference for two bed baths per week was not honored. In an interview on 09/15/2025 at 4:01 PM Staff C stated, “I expect the Resident's preferences to be honored for showers and bed baths.” Reference: (WAC) 388-97 0860 (2) .

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop care plans for 2 of 2 residents (Residents 8 & 4), reviewed for comprehensive care plans. The failure to develop care plans for assistive device use, independent community outings, and refusal of incontinent care (toileting assistance) placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .Review of the facility's undated policy titled, Care Planning - Comprehensive Person-Centered, showed, A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. It showed that Comprehensive Care Plan meant an interdisciplinary communication tool developed after completion of a comprehensive MDS [Minimum Data Set - an assessment tool] and review of the Care Area Assessments. It showed, The resident will receive the services and/or items included in the plan of care, and any services that would otherwise be required but are not provided due to the resident's exercise of right to refuse treatment. It further showed that the comprehensive care plan will Incorporate identified problem areas.Incorporate risk factors associated with identified problems.promote resident safety.RESIDENT 8Review of a face sheet showed Resident 8 initially admitted to the facility on [DATE] with diagnosis that included generalized (not specific) muscle weakness and a history of person injured in unspecified motor-vehicle accident. It further showed that Resident 8 readmitted to the facility on [DATE].Review of an initial admission nursing progress note dated 07/01/2025 showed that Resident 8 Arrived in electric wheelchair. Review of the admission MDS dated [DATE] showed that Resident 8 was coded to have impairment (limitation that interfered with daily functions or placed resident at risk of injury in the last seven days) to both lower extremities and that Resident 8 used a motorized wheelchair as a mobility device. It further showed that Resident 8 was cognitively intact with a BIMS score of 15. In an interview and observation on 09/09/2025 at 1:04 PM, Resident 8 stated that they went out to the community un-supervised and that they used their motorized wheelchair to visit family and to get food. An observation of Resident 8's room showed a parked motorized wheelchair. In a follow-up interview on 09/11/2025 at 11:29 AM, Resident 8 stated that they independently used their motorized wheelchair outside of the facility 3 to 4 days out of the week. Review of a comprehensive care plan printed on 09/05/2025 did not show documentation of Resident 8's use of a motorized wheelchair. Further review did not show documentation of Resident 8's preference and/or ability for independent community outings. In an interview on 09/11/2025 at 11:47 AM, Staff J, Certified Nursing Assistant (CNA), did not identify Resident 8 when asked to identify Unit 700 residents who used a motorized wheelchair.In an interview on 09/11/2025 at 11:52 AM, Staff I, Licensed Practical Nurse (LPN), stated nobody used a motorized wheelchair in Unit 700. When asked if Resident 8 used a motorized wheelchair, Staff I stated, Oh yes, you're [ you are] right, and that most of the time [Resident 8 stayed in their] room and Resident 8 had not left their room lately. When asked if Resident 8 left the facility using their motorized wheelchair, Staff I stated [Resident 8] does, and that Resident 8 had not gone out in the last 3 weeks] due to an incident where Resident 8 bumped [themselves] in the store.In an interview and joint record review on 09/12/2025 at 11:20 AM, Staff H, LPN Unit Manager, stated that Resident 8 was alert and oriented and could sign in and out of the facility for community outings. Staff H stated that leaving the facility independently posed a risk to residents' safety to include cars, accidents, and falls. When asked if Resident 8 was identified by nursing to be at risk for falls and accidents, Staff H stated, Yes. A joint record review of Resident 8's comprehensive care plan did not show a care plan for Resident 8 leaving the facility independently and that Staff H expected there to be a care plan. When asked if assistive devices and equipment were important to be included in a resident's care plan, Staff H stated, yes, we include wheelchairs and walkers and that motorized wheelchairs were considered an assistive device. Joint record review of Resident 8's care plan did not show documentation of Resident's 8's use of a motorized wheelchair. Staff H stated that wheelchair was mentioned, but it doesn't [does not] say electric wheelchair. It should be there. When asked if Resident 8's safety interventions related to their use of a motorized wheelchair were identified and included in their care plan, Staff H stated, It should be there.In an interview on 09/12/2025 at 2:08 PM, Staff B, Director of Nursing, was asked if leaving the facility independently posed a risk to residents, Staff B stated, not necessarily if the resident was mobile. When asked if residents who were mobile could be at risk for accidents and hazards, Staff B stated, Yes. When asked if Resident 8's care plan included safety interventions related to leaving the facility independently, Staff B stated, Not everyone can go out independently, it depends on the situation, and that I have to see what [Resident 8's] particular situation is. Staff B further stated that they expected Resident 8's care plan would include their use of a motorized wheelchair and leaving the facility independently. RESIDENT 4Review of a face sheet showed Resident 4 admitted to the facility on [DATE] with diagnosis that included anxiety disorder (feeling of constant worrying), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and dementia (impaired thinking and memory). Review of the facility's compiled documents titled, Investigative Summary, [Resident 4], dated 08/26/2025, showed it was completed by Staff B. It showed, It appears [Resident 4] does not like to be bothered at times, leading to the allegations. However, leaving resident soiled will be detrimental to [Resident 4's] skin and general well-being.Staff educated to inform nurse if [Resident 4] refuses to be changed [incontinent care] and [Resident 4's representative] will also be called to try and encourage [Resident 4].In an interview and joint record review on 09/12/2025 at 12:00, Staff H stated staff would re-approach residents whenever residents refused any kind of care and that with the resident's initial refusal of care, staff would find out why, so that staff can accommodate the resident's needs. Staff H further stated that if the refusal of care was identified to be consistent [same way every time] for a resident, they would expect identified approaches to address the refusal of care to be included in the resident's care plan. Staff H stated that refusal of care posed a risk for residents. When asked if Resident 4 consistently refused care, Staff H stated that Resident 4 refuses medications and incontinent care, and that skin breakdown was a risk for refusing incontinent care. A joint record review of Resident 4's Electronic Health Record (EHR) did not show documentation of Resident 4's refusal of incontinent care included in their care plan. Staff H stated that Resident's refusal of incontinent care and intervention to notify Resident 4's representative was not included in their care plan. In an interview on 09/15/2025 at 2:42 PM, Staff B stated that they concluded that Resident 4 refused incontinent care at certain times from completing their investigation dated 08/26/2025. When asked if Resident 4's care plan included Resident 4's refusal of incontinent care and the intervention to notify Resident 4's representative, Staff B stated, I have to check. A follow-up joint record review and interview on 09/16/2025 at 2:39 PM, showed Resident 4's care plan did not include Resident 4's refusal of incontinent care and the intervention to notify Resident 4's representative, and Staff B stated, I don't [do not] see it. Reference: (WAC) 388-97-1020 (1) (2)(a)(b).

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure monitoring for latent (hidden or not active yet) signs of injury and prompt medical evaluation for treatment was provided in accordance with professional standards of practice for 1 of 1 resident (Resident 8), reviewed for change of condition. These failures disallowed an opportunity to promptly evaluate the resident for a change in condition, which resulted in a delay of medical services, and placed the resident at risk for adverse consequences, related complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Change in a Resident's Condition, dated 10/01/2021, showed that the facility will promptly notify the resident's physician/practitioner of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been an accident or incident involving the resident.The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's policy titled, Charting and Documentation, dated 10/01/2021, showed that All services provided to the resident.or changes in the resident's medical, physical, functional, or psychological condition, will be documented in the resident's medical record.The following information is to be documented in the resident medical record.Events, incidents, or accidents involving the resident.Review of a face sheet showed Resident 8 initially admitted to the facility on [DATE] with diagnosis that included generalized (not specific) muscle weakness and cauda equina syndrome (medical condition that affects the bundle of nerves at the bottom of the spinal cord).Review of an admission MDS dated [DATE] showed that Resident 8 was cognitively intact with a Brief Interview for Mental Status (BIMS -a cognitive screening tool) score of 15 (highest possible score). It further showed that Resident 8 used a motorized wheelchair for mobility.In an interview on 09/11/2025 at 11:29 AM, Resident 8 stated that on 08/21/2025, they used their motorized wheelchair at a clothing store when they injured their right foot. Resident 8 further stated that the tip of their right Ankle-Foot Orthosis (AFO-type of brace designed to support the ankle and foot) got caught on a store display while maneuvering down a narrow isle, which caused their right leg to flip around. When asked if they returned to the facility independently after the incident, Resident 8 stated, Yes, and that they initially reported the incident to a Physical Therapist (PT) to take a look at my leg and that Resident 8 felt like they sprained their right ankle. Resident 8 further stated that a Certified Nursing Assistant (CNA) later helped them take off their right AFO which resulted in Resident 8 having pain. Resident 8 stated that the CNA notified the Nurse. Review of a nursing progress note dated 08/21/2025 at 8:00 PM, showed Resident 8 was given oxycodone (strong pain medication) 10 mg (milligrams-a unit of measurement) that was instructed to be given every six hours as needed for severe pain. Review of a nursing progress note dated 08/21/2025 at 8:54 PM, showed [Resident 8] reported pain at around 8 pm [8:00 PM] on right ankle and wants oxycodone, [Resident 8] stated, I pumped my right ankle on my power w/c [wheelchair] while out for shopping to [a clothing store] this morning. It showed, [Resident 8] unable to move [their] leg r/t [related to] paralyze. [Resident 8] placed on a/c [alert charting - communication tool used for monitoring a resident's change of condition] for monitor. It further showed that the medical provider was notified via communication book and that Report given to incoming nurse.Review of a nursing progress notes showed Resident 8 was given additional doses of oxycodone 10 mg for severe pain on the following dates and times:- On 08/21/2025 at 11:03 PM- On 08/22/2025 at 3:07 PMReview of Resident 8's nursing progress notes did not show documentation of alert charting and/or medical provider assessment of Resident 8's complaint of right ankle pain on 08/22/2025, 08/23/2025 and on 08/24/2025 [three days following Resident's 8 change of condition].Review of Resident 8's August 2025 Medication Administration Record showed that Resident 8 was documented to receive non-pharmacological pain interventions on the following dates and nursing shifts:-On 08/21/2025, Rest for all shifts and Cold/Ice during the evening and night shifts.-On 08/22/2025, Rest for all shifts and Cold/Ice during the day and evening shifts.-On 08/23/2025, Rest for all shifts and Cold/Ice during the day and evening shifts.-On 08/24/2025, Rest for the day and evening shifts and Cold/Ice during the day and evening shifts. -On 08/25/2025, Rest for the day and evening shifts.Review of a medical provider's encounter note dated 08/25/2025 showed Resident 8 was assessed for a chief complaint of right ankle sprain. It showed that mechanism for Resident 8's complaint of right ankle pain was that ankle twisted at [a clothing store] when [their AFO] brace caught on display edge. It further showed that Resident 8 reported a pain score of eight out of 10 when moved, and that right leg pain was reported as pretty bad. It further showed that an ankle x-ray [used to check for broken bones] was ordered. Review of a progress note dated 08/26/2025, written by Staff H, Licensed Practical Nurse (LPN), Unit Manager, showed X-ray result of fracture [broken bone] on right distal [lower part of] tibia [shinbone], and provider plan to send [Resident 8] to emergency [Emergency Room].Review of discharge MDS dated [DATE] showed Resident 8's discharge from the facility was unplanned and that return to the facility was anticipated.Review of Resident 8's hospital Discharge summary dated [DATE] showed that Resident 8 Presents several days after a mechanical incident, [Resident 8's] right leg got stuck on display at a store while [Resident 8] was using [their] motorized scooter.For pain [Resident 8] has been using as needed oxycodone in the hospital. [Resident 8] is needing higher doses than [Resident 8] was on previously. At this point, [Resident 8] would like to try oral Dilaudid (a very strong painkiller that is prescribed to someone experiencing severe pain, like after major surgery or a serious injury) to see if it is more effective.Review of a face sheet showed Resident 8 readmitted to the facility on [DATE] with diagnosis that included non-displaced fracture of right tibia, acute embolism (blood clot) and thrombosis (blood clot forms inside a blood vessel that can block the flow of blood) of unspecified deep veins of lower left extremity. Record review of a provider progress note titled, Provider Readmit Visit (72 hours) note, dated 09/01/2025 showed Resident 8 was assessed by Staff G, Nurse Practitioner. It showed that The patient initially sustained a right tibial fracture after twisting [their] foot while manipulating [their] wheelchair. An X-ray on August 26 [2025] confirmed the fracture. Subsequently [after that] [Resident 8] was admitted to the hospital where [they] were diagnosed with left leg DVT and acute pulmonary embolism. She was stabilized and discharged on August 31 [2025] for continued medical management and therapy. It further showed, Assessment/Plan included Acute embolism and thrombosis of other specified deep vein of left lower extremity Left leg DVT [Deep Vein Thrombosis] and acute pulmonary embolism - blood clot likely due to immobilization following tibial fracture.In an interview on 09/11/2025 at 11:52 AM, Staff I, LPN, stated, nobody used a motorized wheelchair in Unit 700. When asked about Resident 8 regarding the use of a motorized wheelchair, Staff I stated, Oh yes, you're [you are] right, and that most of the time [Resident 8 stayed in their] room and Resident 8 had not left their room lately. When asked if Resident 8 left the facility using their motorized wheelchair, Staff I stated, [Resident 8] does, and that Resident 8 had not gone out in the last 3 weeks] due to an incident where Resident 8 bumped [themselves] in the store. Staff I further stated that prior to that incident [08/21/2025], [Resident 8] was going out. In an interview on 09/11/2025 at 12:15 PM, with Staff F, Rehabilitation Director, and Staff K, PT, Staff K stated that Resident 8 had reported the incident on 08/21/2025 to them and that they performed passive range of motion [PROM-moving a person's body part for them, without them doing any of the work], of Resident 8's right leg. Staff K stated that [Resident 8 was not] on case load [therapy services], so I [did not] feel comfortable doing more than PROM. When asked if Staff K notified Nursing of Resident 8's reported 08/21/2025 incident, Staff K answered, No and that they typically [do not] touch [work] with residents who are not on case load. In an interview on 09/12/2025 at 10:31 AM, Staff G stated that they were notified of Resident 8's 08/21/2025 incident on 08/25/2025. Staff G stated that Resident 8 was assessed to have pain and difficulty with mobility to their right foot. Staff G stated that Resident 8 goes out [of the facility] frequently via their motorized wheelchair. Staff G then stated that Resident 8 was assessed at the Emergency Department following the x-ray result of Resident 8's right ankle fracture. When asked if Resident 8 had a tibial fracture before the 08/21/2025 incident, Staff G stated, No. When asked if the incident on 08/21/2025 caused Resident 8 to stay in bed or become immobile due to right ankle pain, Staff G stated, I believe so and that Resident 8 was personally deciding not to [get out of bed]. Staff G confirmed that they wrote the readmission visit note dated 09/01/2025. When asked if Resident 8's 08/21/2025 incident resulted in Resident 8's hospitalization and new diagnosis of right tibial fracture, left leg DVT and Pulmonary embolism, Staff G stated that Resident 8 was found to have them [new diagnosis] when Resident 8 was admitted to the hospital for the fracture. Staff G further stated that a DVT and pulmonary embolism can occur when a resident is immobile for long periods and not on blood thinners. When asked if this was the case for Resident 8, Staff G stated, It could have been and that because of previous injuries, [Resident 8] did not have great sensation to lower extremities.In a follow-up interview on 09/12/2025 at 10:52 AM, Staff F stated that the Therapy department was part of the interdisciplinary team that provided services to residents. When asked if Resident 8 should have communicated Resident 8's initial report of the 08/21/2025 incident to the Nursing department, Staff F stated that Staff K said that they did not notify nursing staff on 08/21/2025 and that Resident 8 was on case load at the time of the incident. Staff F stated that they expected Therapy to notify Nursing of the reported incident on 08/21/2025 and for myself to follow-up with the physician to ensure Resident 8 was assessed for pain. Staff F further stated that If it's [is not] documented, I can't [cannot] say it [communication between Therapy and Nursing] happened. Review of a facility document titled, [Facility Name] Therapy Minutes Report, dated 07/01/2025 through 08/26/2025, did not show that Resident 8 received therapy services on 08/22/2025, 08/23/2025 and 08/24/2025. Review of Resident 8's document titled, Occupational Therapy Treatment Encounter Notes, dated 08/25/2025, showed that Resident 8 refuses to get EOB [Edge of Bed] due to pain in ankle, and that Resident 8 performed therapy exercises while lying in bed. In a follow-up interview on 09/12/2025 at 11:05 AM, Resident 8 stated that they experienced pain and difficulty with movement following the 08/21/2025 incident and that I wasn't [was not] able to transfer, I wasn't able to move it [right leg], any movement of my body, even trying to roll side to side for brief changes was extremely painful. When asked if Resident 8 was able to perform activities out of bed after the incident to include participating in Therapy, Resident 8 stated, No, absolutely not. Resident 8 further stated that It was definitely hard, my main priority for choosing this facility is their therapy program and that I was very sad to not go to Physical Therapy. My goal is to go home. In an interview and joint record review on 09/12/2025 at 11:20 AM, Staff H stated that the facility placed residents on alert charting whenever there was a change of condition that required ongoing monitoring. When asked if a resident's new report of pain required ongoing monitoring, Staff H stated, Yes. A joint record review of Resident 8's nursing progress note dated 08/21/2025 showed that Resident 8 reported the 08/21/2025 incident to a nurse and that Resident 8 complained of right foot pain. Further joint record review of Resident 8's progress notes for 08/22/2025, 08/23/2025, and 08/24/2025 did not show documentation of alert charting for Resident 8's change of condition. Staff H stated, I don't [do not] see that, and that Resident should have continued to be monitored for signs and symptoms of changes related to their complaint of right ankle pain following the 08/21/2025 incident. In an interview on 09/12/2025 at 09/12/2025 at 2:08 PM, Staff B, Director of Nursing, stated the facility placed residents on alert charting if there was a change of condition and that included anything outside of the ordinary. Staff B stated that they expected residents placed on alert charting would have follow up documentation. A joint record review of Resident 8's nursing progress note dated 08/21/2025 showed Resident 8 reported an incident that resulted in a new complaint of right ankle pain. It did not show documentation of alert charting for 08/22/2025, 08/23/2025, and 08/24/2025. Staff B stated, Yes, I am aware of that situation, that was brought to my attention after the resident was in the hospital. Staff B stated that Resident 8 should have continued to be monitored for changes in signs and symptoms related to their right ankle pain and that the provider should have followed up promptly. Staff B further stated that they completed an internal investigation of the 08/21/2025 incident.Review of the facility document titled, Internal Investigation Summary, [Resident 8], dated 08/29/2025, showed it was completed by Staff B. It showed Internal Investigation due to [Resident 8] currently hospitalized and discharged from facility. Was informed by RCM [Resident Care Manager/Nurse Unit Manager] on 08/27 [2025] at clinical stand-up meeting that [Resident 8] was transferred to hospital yesterday, and this was due to a fracture of her right foot. Per RCM, [Resident 8] informed a nurse last week when [Resident 8] returned from outing that she had bumped her ankle, and that nurse called the on-call [provider] and also referred to provider. However, per RCM provider did not order any x-rays until day before yesterday [08/25/2025] and that upon results showing a fracture, instructed a transfer to hospital. RCM stated he was unaware of incident because the nurse did not place [Resident 8] on alert [charting]. It further showed, The nurse who was informed when resident returned from outing (08/21/2025) regarding bumping her foot and that this nurse failed to place resident on alert or 24-hour report which would have alerted other nurses to follow up. Although she documented referral to provider, there is no evidence of provider follow up. In follow-up interview and joint record review on 09/15/2025 at 2:38 PM, Staff B was asked if the 08/21/2025 incident caused Resident 8 to become immobile due to right ankle pain, Staff B stated, There weren't [were not] any changes to [Resident 8's] usual routine. Staff B stated that they gathered this information by asking the RCM When asked if there were documentation from nursing staff assessments related to Resident 8's no changes in routine following the incident, Staff B stated, No. A joint record review of Resident 8's provider readmission visit note dated 09/01/2025 showed Staff G documented, Blood clot likely due to immobilization following tibial fracture. Staff B stated, I [do not] have anything to say about it. In an interview on 09/16/2025 at 2:09 PM, Staff C, Administrator, stated that they expected Resident 8 would have been monitored for ongoing changes related to the incident on 08/21/2025 and their complaint of right ankle pain. Reference: (WAC) 388-97-1060 (1) .

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide/replace a pressure relieving bed mattress (Dolphin Mattress-a type of mattress that alternated fluid through the mattress) as recommended by the wound consultant to prevent and protect skin/wounds from further breaking down for 1 or 3 residents (Resident 3), reviewed for pressure ulcers. This failure placed the resident at risk for related medical complications, a decrease in healing potential, and a diminished quality of life.Findings included.Review of the National Pressure Injury Advisory Panel (NPIAP - leading expert in pressure injuries/wounds), dated February 2025, defined pressure injury stages as follows: -Stage 4 Pressure Injury is a full-thickness loss of skin and tissue with exposed or directly palpable fascia (layer of tissue covering the muscle), muscle, tendon (a cord or band of dense, tough, inelastic, white, fibrous tissue, serving to connect a muscle with a bone or part), ligament (a tough fibrous band of connective tissue that supports internal organs and holds bones together at the joints. It connects bones to other bones and helps hold organs in place), cartilage (a strong, flexible connective tissue that protects the joints and bones acting as a shock absorber throughout the body) or bone in the ulcer. Slough (is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and/or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible.Review of the facility's undated Pressure Injury and Prevention Management Policy showed, If a referral is made to a wound consultant, the wound consultant will provide timely and accurate information to the facility on the status of the pressure ulcer/injury and will provide recommendation for change in treatment and care of the pressure ulcer/injury.Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool) dated 07/28/2025 showed Resident 3 readmitted to the facility on [DATE]. Further review of the MDS dated [DATE] showed Resident 3 required assistance with bed mobility and transfers.Review of the Electronic Health Record (EHR) showed Resident 3 had history of pressure injuries that included Stage 4 pressure injuries to the right and left hip and Osteomyelitis (bone infection) of the right femur (leg), the EHR further showed the Stage 4 pressure injuries and Osteomyelitis had a chronic (long) history of healing and reopening.Review of a physician order in the EHR dated 03/20/2025 showed Resident 3 had orders to be followed by a wound care clinic outside of the facility.Review of a wound care clinic notes dated 08/28/2025, showed Resident 3's mattress was not sufficiently offloading pressure, and Resident 3 needed a Dolphin Mattress to prevent and protect skin/wounds from further breaking down.In an interview on 08/26/2025 at 12:13 PM, Collateral Contact 1 (CC1), stated, We made several phone calls and sent so many recommendations to the nursing staff at the facility to please arrange to get this Dolphin Mattress for Resident 3. We informed them that the current mattress that they replaced with when the Dolphin Mattress broke was not sufficient for offloading pressure. CC1 stated Resident 3 had a long history of pressure injuries and that they recommended this mattress to prevent and assist in healing of pressure injuries.Observation on 09/08/2025 at 2:21 PM, Resident 3 had a MATT-EASY AIR mattress [a type of mattress that alternated air through the mattress] on their bed that was not the Dolphin Mattress as CC1 recommended in the wound care note dated 08/28/2025.In an interview on 09/09/2025 at 11:36 AM, CC2 stated the difference between the two mattresses were that the Dolphin Mattress functioned by alternating fluid in the mattress to relieve pressure and MATT-EASY AIR mattress functioned by alternating air to relieve pressure. CC2 further stated that the Dolphin Mattress was highly recommended for pressure reduction, healing, and prevention of pressure ulcers.In an interview on 09/15/2025 at 1:37 PM, Staff E, Registered Nurse, Unit Manager, stated that when Resident 3 returned from the wound care clinic the orders and recommendations were faxed over and that they noted the new orders and recommendations and made sure all were taken care of. Staff E stated that the Dolphin Mattress broke, and they informed the previous administration staff about the recommendation for it. Staff E stated that the MATT-EASY AIR mattress was ordered and placed on Resident 3's bed on 08/05/2025 despite the wound care recommendations for Dolphin Mattress. Staff E further stated the Dolphin Mattress was never replaced and had informed the previous administration regarding Resident 3's multiple wound care notes that recommended the Dolphin Mattress.In an interview on 09/15/2025 at 3:29 PM, Staff B, Director of Nursing, stated, I know the previous Administrator was working with our corporation to get the Dolphin Mattress replaced, I am not sure, but I think they did not want to pay to fix or replace the bed, so another mattress was ordered for Resident 3.In an interview on 09/16/2025 at 5:11 PM, Staff C, Administrator, stated that the mattresses should function the same, if one worked by alternating fluid, the one that it was replaced with should also function by alternating fluid.Reference: (WAC) 388-97-1060(3)(b).

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 2 of 2 residents (Residents 3 and 17) were free from significant medication errors. The failure to provide intravenous (IV- administered through a vein) antibiotic medications (to treat infection) placed the residents at risk for a decline in their medical condition, a life-threatening infection, and a diminished quality of life.Findings included .RESIDENT 3Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 07/28/2025 showed Resident 3 was readmitted to the facility on [DATE] and had intact thinking.In an interview on 09/08/2025 at 2:32 PM, Resident 3 stated, a few weeks ago I missed the antibiotic [medication] I was supposed to take for the infection in my wounds and bone, it was an IV the nurses told me they did not have it and that they were trying to get it delivered from the pharmacy. After I missed a few doses, I started to feel like I had a fever and chills. When the aides took my temperature, it was normal, but I still felt like I had a fever and chills from missing the antibiotics.Review of August 2025 Medication Administration Record (MAR) in the Electronic Health Record (EHR) showed orders for Meropenem (antibiotic-medication used to treat infection) 1 gram (gm-a unit of measurement) IV every 8 hours for Pelvic (hip) Osteomyelitis (bone infection) with a date to start on 07/28/2025 and a date to stop on 08/28/2025. Further review of the MAR dated 08/24/2025 at 2:00 PM and at 10:00 PM and on 08/25/2025 at 6:00 AM and at 2:00 PM, showed the medication was not administered. Medication Meropenem 1 gm IV was not administered four times from 08/24/2025 to 08/25/2025.Review of the nursing progress notes in the EHR dated 08/24/2025 showed Resident 4 missed doses of Meropenem 1 gm IV at 2:00 PM, 10:00 PM and on 08/25/2025 at 6:00 AM and 2:00PM.RESIDENT 17Review of the admission MDS dated [DATE] showed Resident 17 was admitted to the facility on [DATE].Review of a nursing admission progress note in the EHR dated 08/22/2025 showed Resident 17 admitted to the facility with right hip peri-prosthetic joint infection (an infection that occurred around the replaced right hip joint) and had a suspected joint infection and was admitted to the facility for intravenous antibiotic therapy.Review of the physician's orders in the EHR dated 08/23/2025 showed orders for Daptomycin (medication used to treat infection) IV 500 milligrams (mg-unit of measurement) at 10:00 AM for infection for 41 days and Ertapenem 1 gram IV at 10:00 AM for 6 weeks. Review of the MAR dated 08/23/2025 showed Daptomycin IV use 500 mg at 10:00 AM for infection or Ertapenem 1 gram IV at 10:00 AM was not administered to Resident 17.Review of a progress note in the EHR dated 08/23/2025 showed Resident 17 was transferred to a local hospital at 12:50 PM due to the pharmacy's inability to deliver the residents IV antibiotic medications.In an interview on 09/12/2025 at 1:31PM Staff D, Registered Nurse (RN), stated, we don't know where to get IV medications anymore, there has been a change, we don't know who to call. The pharmacy here doesn't do IVs anymore. They won't deliver IV medication here now. If I had a resident that had physicians orders for IV medication, I would have to ask the Director of Nursing Services (DNS) what to do. In an interview on 09/12/2025 at 1:46 PM Staff T, RN stated, the pharmacy does not do IVs, they will deliver all the other medications, just not the IVs. I don't know who to call if I get IV medication delivered here for the residents if they need it. I would have to ask the DNS; it's not the same pharmacy that we had for IVs, the pharmacy we have now will deliver all other medications, just not IVs.In an interview on 09/15/2025 at 1:07 PM Staff E, RN, Unit Manager stated, the previous pharmacy was called to deliver the IV antibiotic medication for Resident 3, and we were told they did not deliver IV medication to the facility anymore because their contract ended with the facility. Resident 3 missed three or four doses of their antibiotic IV. We informed the physician, and they wanted Resident 3 to be monitored here at the facility. I think Resident 17 was transported back to the hospital because we could not get their IV medication here. We have a new pharmacy that will bring IV medication to the facility now.In an interview on 09/15/2025 at 3:29 PM Staff B, DNS, stated there was an issue with the previous pharmacy when they stopped delivering IV medication to the facility. We notified the physician of Resident 3 when the IV antibiotic medication (Meropenem) was not administered, the physician ordered for the resident to be monitored in the facility. Staff B stated Resident 3 missed three or four doses of the IV antibiotic. Staff B stated there was another resident, Resident 17 was admitted to the facility and had to be transported back to the hospital the day after they were admitted because Resident 17 had physician orders for antibiotic IV's and they could not get the IV antibiotic medication delivered from the pharmacy to the facility. Staff B stated Resident 17 missed two doses of antibiotic medication before they were transported back to the hospital the day after admission. Staff B further stated those were significant medications that Resident 3 and Resident 17 missed, and now the facility had a pharmacy that would deliver IV medication to the facility.In an interview on 09/16/2025 at 5:16 PM, Staff C, Administrator, stated the previous pharmacy would not deliver the IV medications which caused Resident 3 and Resident 17 to miss those IV medications.Reference: (WAC) 388-97-1060(3)(k)(iii).

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure aerosol contact precautions (safety steps used to keep germs from spreading) that included keeping the door closed at all times and proper use of Personal Protective Equipment (PPE - gown, gloves, N95 [respirator -medical face mask that filters out at least 95% of tiny particles in the air] and face shield) were followed for 2 of 2 staff (Staff X & Z), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications.Findings included.Review of the facility's undated policy titled, Coronavirus Disease (COVID-19) [respiratory disease caused by a virus]-Infection Prevention and Control Measures, showed This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility, It further showed that IPC measures to address COVID-19 included identifying and managing ill residents.optimizing engineering controls [keeping isolation room doors closed] and indoor air quality.STAFF XReview of the facility document titled, admission Nursing Collection Tool, dated 09/12/2025, showed Resident 24 tested positive for COVID and required isolation precautions [or aerosol contact precautions] and appropriate PPE per policy. It further showed that Resident 24 admitted to the facility's Transitional Care [TCU, room [ROOM NUMBER]].Review of an admission Nursing Collection Tool, dated 09/13/2025, showed that Resident 25 tested positive for COVID and required isolation precautions and appropriate PPE per policy. It further showed that Resident 24 admitted to the Transitional Care [TCU, room [ROOM NUMBER]].Observation on 09/15/2025 at 3:32 PM, showed a sign posted on the closed double-door entrance to the TCU that indicated, All staff and visitors, N95 is required beyond this point. It further showed that an aerosol contact precaution sign was posted on room [ROOM NUMBER]'s door and that the door was not closed. In an interview and joint record review on 09/15/2025 at 3:37 PM, Staff X, Nursing Assistant Certified (NAC), stated that the double doors to the TCU were kept closed because Resident 24 and Resident 25 were positive with COVID-19. A joint record review of the aerosol contact precaution sign posted on room [ROOM NUMBER]'s door indicated that the door remains closed. Staff X stated, It [room [ROOM NUMBER]'s door] should be closed. In an interview on 09/15/2025 at 3:39 PM, Staff Y, Licensed Practical Nurse (LPN), stated that Resident 24 and 25 were on aerosol contact precautions for COVID-19. Staff Y stated that both residents were located in room [ROOM NUMBER] and that the door should be closed all the time. In an interview on 09/15/2025 at 4:35 PM, Staff N, Registered Nurse Unit Manager, stated that the facility admitted residents who tested positive for COVID-19 and that Residents 24 and Resident 25 were admitted to the facility with active COVID-19. Staff N stated that they expected staff to wear appropriate PPE and kept isolation door rooms closed when aerosol contact precautions were implemented. STAFF ZObservation on 09/16/2025 at 10:03 AM showed room [ROOM NUMBER]'s door was open and that Staff Z, NAC, was inside the room with a resident. It further showed Staff Z exited room [ROOM NUMBER] wearing a surgical mask. It did not show Staff Z used appropriate PPE according to aerosol contact precautions (N95, gown, mask, eye protection and gloves). In an interview on 09/16/2025 at 10:08 AM, Staff Z, NAC, stated that they entered room [ROOM NUMBER] to remove used glasses [for drinking]. A joint observation of the aerosol contact sign posted on the door of room [ROOM NUMBER] showed instructions to keep the door closed and for staff to wear appropriate PPE. Staff Z stated they should have worn appropriate PPE and kept room [ROOM NUMBER]'s door closed. In an interview on 09/16/2025 at 10:15 AM, Staff M, LPN, stated they expected staff would follow precautions indicated on the aerosol contact precaution sign when it was posted and that staff would wear N95 while working in the TCU. In an interview on 09/16/2025 at 3:30 PM, Staff B, Director of Nursing, stated that the facility admitted residents with active COVID-19 infection. Staff B stated that they expected staff would wear appropriate PPE to include N95 mask on the COVID Unit [TCU]. Staff B further stated that they expected room doors would remain closed as much as possible, when aerosol contact precautions were indicated. Reference: (WAC) 388-97-1320 1(a)2(a).

CONCERN (E) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a thorough investigation and/or include a corrective action to prevent reoccurrence of an incident for 3 of 4 residents (Resident 4, 1 & 2), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents and unidentified abuse.Findings included… Review of the facility's policy titled, “Abuse Investigation and Reporting,” dated 10/01/2021, showed that all reports of abuse, neglect and mistreatment were thoroughly investigated by “facility management.” Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events . Federal law requires the nursing home to do a thorough investigation of the incident. In order for a facility to provide evidence of the thoroughness of the investigation the information must be recorded.” It further showed that “the investigation is done to determine, as far as possible: what occurred; and to make necessary changes to the provision of care and services to prevent reoccurrence…The investigation should end with the identification of who was involved in the incident and what, when, where, why and how the incident happened during the probable or reasonable cause.” RESIDENT 4Review of a face sheet showed Resident 4 admitted to the facility on [DATE] with diagnosis that included anxiety disorder (feeling of constant worrying), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and dementia (impaired thinking and memory). Review of the facility's compiled documents titled, “Investigative Summary, [Resident 4], dated 08/26/2025, showed it was completed by Staff B, Director of Nursing. It showed that the facility was made aware of an allegation of abuse on 08/21/2025. The contents of the investigation included the investigation summary and staff statements from Staff U, Certified Nursing Assistant (CNA) and Staff V, CNA, did not show that the investigation ended with the identification of when the alleged incident happened. Further review of Resident 4's investigative summary documents showed resident interviews were completed on 08/26/2025 by Staff W, Social Worker. Review of interviews completed with Residents 8, 18, 19, 20, 21, 22 and 23 showed that these residents answered, “Yes,” to the question, “Do you have concerns about your safety?” It did not show documentation of Staff W completing a follow-up regarding residents' concern about their safety. In an interview and joint record review on 09/10/2025 at 3:52 PM, Staff B stated that Staff W did not “ask” the resident interview questions on 08/26/2025 correctly for Residents 8, 18, 19, 20, 21, 22 and 23. Staff B further stated that there was “follow-up” completed with residents who answered, “Yes” to having safety concerns. A joint record review of the documents provided by Staff B showed, “8/26 [2025] – f/u [follow-up] on safety concerns question. Resident had no safety concerns, [Staff B initials]” was documented on the back of the resident interview forms for Resident 8, 18, 19, 20, 21, 22 and 23. When asked who completed the follow-up with the residents, Staff B stated, “I asked either the [Nurse Unit Manager] or Social Worker, I don't [do not] remember.” When asked if they expected Staff W to have completed an immediate follow-up with the residents while conducting the interviews, Staff B stated “Yes.” When asked if they expected staff who were tasked with investigation interviews would be trained to conduct interviews correctly, Staff B stated, “Yes.” When asked if Staff W completed the investigation interviews correctly, Staff B stated, “based on this [resident interview forms], no.” Review of a quarterly Minimum Data Set (MDS – an assessment tool) dated 06/05/2025 showed that Resident 22 had a Brief Interview for Mental Status (BIMS – short test used to check how well a person's memory and thinking skills are working) score of four. This indicated severe cognitive impairment (major trouble with memory, thinking, and understanding). Review of a quarterly MDS dated [DATE] showed that a BIMS was not attempted with Resident 23 due to “resident is rarely/never understood.” In an interview on 09/11/2025 at 10:34 AM, Staff W stated that they were trained on the facility's process for investigating allegations of abuse and that, “I know how to do it and I've [I have] read the [facility] policies.” When asked how investigation resident interviews were conducted, Staff W stated that “Questions are printed on a document that is taken to the resident to be used for the interview, the resident is asked to sign the interview form afterwards.” Staff W stated that they wrote up the resident interview questions used for Resident 4's investigation on 08/26/2025. A joint record review of resident interview forms dated 08/26/2025 for Residents 8, 18, 19, 20, 21, 22 and 23 showed that these residents answered “Yes,” to the question, “Do you have concerns about your safety?” Staff W stated that they asked the question incorrectly. When asked if they were asked by Staff B to complete a follow-up for the resident interviews for Residents 8, 18, 19, 20, 21, 22 and 23. Staff W stated, “I didn't [did not] follow up because I didn't know I made the error. [Staff B] saw it and I don't [do not] know if [Staff B] followed up.” When asked how residents were selected for resident interviews, Staff W stated they selected residents based on their cognition (ability to remember and understand things) and those who have knowledge of the staff identified in an investigation. Staff W stated that residents who could not be interviewed due to poor cognition would require their representative to be interviewed. Staff W stated that they referred to the BIMS score in MDS assessments to determine a resident's ability to be interviewed. A joint record review of Resident 22 and 23's interview questionnaires completed on 08/26/2025 showed signatures from both residents. Staff W stated that they should have interviewed Resident 22 and 23's representatives and that these residents should not have been interviewed. In an interview on 09/15/2025 at 2:42 PM, Staff B stated that the facility referred to the BIMS score to determine a resident's cognition and ability to be interviewed. Staff B was asked if Resident 22 and 23 were appropriate to be interviewed [by Staff W] on 08/26/2025 and Staff B stated, “I don't [do not] have an answer for that.” Staff B stated that the facility followed guidance from the Purple Book for completing investigations. When asked if Resident 4's investigation determine the specific date and/or time of the alleged incident, Staff B stated, “I don't [do no] have an answer.” Review of the facility's policy titled, “Abuse,” revised on 10/20/2022, showed the organization would maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. This would include analysis of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. The policy showed that if an alleged allegation was verified appropriate corrective action must be taken. The policy further showed that resident's plan of care would be revised to reflect interventions to minimize reoccurrence and to treat any injury or harm identified through assessment of the resident. RESIDENT 1 & RESIDENT 2 INCIDENTReview of Resident 1 and Resident 2's investigation dated 08/22/2025, showed a Resident-to-Resident Investigation was completed. The “Summary of Events,” showed that on 08/22/2025 administration was notified that Resident 1 was attempting to push another resident back to their room, when Resident 2 tried to intervene. The summary showed that “In intervening, [Resident 1] became agitated and scratched and hit [Resident 2's] arms.” The investigation showed that the residents were immediately separated. The investigation further showed witness statements that saw Resident 1 “holding (in squeeze form),” Resident 2's arm and stopped once they saw the staff member and “yelled” at them in sign language. Further review of the investigation showed a care plan for Resident 1 and Resident 2. The investigation and care plans did not show a new or revised intervention was addressed or evaluated to prevent reoccurrence from the incident that occurred between Resident 1 and Resident 2 on 08/22/2025. On 09/05/2025 at 9:47 AM, Resident 2 stated that a “deaf” person (Resident 1) grabbed their friend's wheelchair and yelled at them (Resident 2) and said, “no, no, no.” Resident 2 stated that they did not know that they (Resident 1) were “deaf,” and did not know what they were saying, and they grabbed Resident 2's arm. Resident 2 lifted her left sleeve up to show three circular shaped bruises on their left forearm, indicating where Resident 1 had grabbed them. Resident 2 stated, “she [Resident 1] makes me nervous.” Resident 2 stated that staff heard her and Resident 1 yelling and separated them. In an interview and joint record review on 09/15/2025 at 11:36 AM, Staff E, Registered Nurse Unit Manager, stated the purpose of an investigation was to determine the cause of the incident and make a plan to correct the incident to prevent reoccurrence. Staff E stated that on 08/22/2025, they were informed by a nurse that Resident 1 grabbed Resident 2's arm and that had caused bruising. When asked what corrective action was taken related to the incident, Staff E stated, “separate the residents,” and “more supervision I guess, and don't [do not] sit them next to each other in the dining room.” When asked how staff would know what corrective action was taken, Staff E stated staff would know through verbal nursing report and alert charting (communication tool used for monitoring a resident's change of condition). When asked if they would expect the resident's care plan to reflect their behaviors, Staff E stated, “Yeah I guess it should, at that time [Resident 2] preferred to eat in her room,” and that “[Resident 2] still didn't [did not] want to see [Resident 1] I guess.” Staff E stated that Resident 1 could get “easily agitated” if you did not understand them and had a history of grabbing staff. A joint record review of Resident 1's mood and behavior care plan revised on 06/28/2024, showed Resident 1 had a behavior of grabbing staff, pushing them and locking them in an office. When asked if there was anything in Resident 1's care plan that addressed grabbing other residents, Staff E stated that they did not see any and that grabbing another resident would be a behavior, and that Staff E “could add that.” Staff E further stated that it was important to add Resident 1's behaviors in their care plan so that staff were aware. A joint record review of Resident 2's care plan printed on 09/15/2025, showed no care plan monitoring or interventions that addressed how Resident 2 would be protected from potential reoccurrence of the 08/22/2025 incident with Resident 1. Staff E further stated that there were no interventions. On 09/15/2025 at 4:59 PM, Staff B stated on 08/22/2025 the immediate action was to separate Resident 1 and Resident 2. When asked what the corrective action was, Staff B stated to keep Resident 1 and Resident 2 separated. When asked how the staff were aware of this, Staff B stated the kitchen and nursing staff had been “told,” and there was no documentation of that. Staff B further stated that they would expect Resident 1's behavior of grabbing another resident to be in their care plan. When asked if they would expect there to be a care plan or intervention for Resident 2 to address what happened on 08/22/2025 and how the facility would protect Resident 2, Staff B stated, “I don't [do not] have an answer for that.” On 09/16/2025 at 2:00 PM, Staff C, Administrator, stated the purpose of an investigation was to keep residents safe, find out the root cause of why the incident occurred, and prevent it from happening in the future. When asked if abuse or neglect was substantiated on the investigation for the incident on 08/22/2025 between Resident 1 and Resident 2, Staff C stated that the abuse was physical. When asked what corrective action was taken based on the investigation, Staff C stated that Resident 1 and Resident 2 were placed on alert and separated and were interviewed on whether they felt safe. When asked if there were any new/revised interventions as part of the investigation for Resident 1 and Resident 2's care plan, Staff C stated, “I could not find any other interventions, other than being separated.” Reference: (WAC) 388-97-0640 (6)(a)

CONCERN (E) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure bathing/showers were consistently provided for 4 of 6 residents (Residents 2, 6, 3 & 5), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decreased self-esteem, and a diminished quality of life.Findings included . Review of the facility's policy titled, “Activities of Daily Living (ADLs),” dated 10/01/2021, showed, “Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.” The policy showed if a resident refused care the resident and/or representative would be informed of the risks and benefits, offered an alternative intervention to minimize further decline, and the refusal and information would be documented in the resident's clinical record. The policy further showed each resident would receive a tub or shower baths as often as needed, but not less than twice weekly or as required by law. RESIDENT 2Review of the ADL self-care needs care plan initiated on 04/14/2025, showed Resident 2 required extensive assistance by one staff with bathing/showering. Review of Resident 2's Electronic Health Record (EHR), under task- ADL Bathing/Showering, showed they were scheduled for a shower on Thursday evenings and as needed. The task showed a lookback of 30 days from 08/12/2025 to 09/10/2025. The task showed two showers were given during this time: one on 08/22/2025 and on 09/01/2025. The task further showed documentation for the remaining days were documented as, “Not Applicable,” and did not show whether Resident 2 was offered a shower or if they declined a shower. Review of Resident 2's progress notes from 08/12/2025 to 09/10/2025 did not show whether Resident 2 was offered a shower or if they declined a shower during the time. RESIDENT 6Review of Resident 6's face sheet printed on 09/05/2025 showed they admitted to the facility on [DATE]. Review of a care plan printed on 09/16/2025 did not show the amount of assistance Resident 6 required with their showers/bathing. Review of Resident 6's EHR, under task- “*GG- Shower/Bathe Self Every Thursday day shifts and PRN [as needed],” showed Resident 6 was scheduled for a shower on Thursday. The task showed a lookback of 30 days from 08/26/2025 to 09/04/2025. The task showed one shower was given during this time: on 09/03/2025 (11 days after their admission). The task further showed documentation for the remaining days were documented as, “Not Applicable,” and did not show whether Resident 6 was offered a shower or if they declined a shower. Review of Resident 6's progress notes did not show whether Resident 6 was offered a shower or if they declined a shower during the time from 08/22/2025 to 09/08/2025. A joint record review and interview on 09/10/2025 at 1:20 PM, with Staff E, Unit Manager Registered Nurse, showed Resident 2's EHR under task- ADL Bathing/Showering revealed two showers on 08/22/2025 and on 09/01/2025 were given during a lookback of 30 days from 08/12/2025 to 09/10/2025. The task further showed documentation for the remaining days were documented as, “Not Applicable.” When asked if there was documentation to show whether Resident 2 was offered or refused a shower on the remaining days, Staff E stated, “I don't [do not] see it here.” When asked if there was any documentation to show whether Resident 6 was offered or declined a shower Staff E stated, “If there is no documentation then it means that it was not done. They [staff] should have offered a shower.” Staff E further stated it was important for a resident to be offered or receive a shower/bath for their dignity and comfort. On 09/11/2025 at 3:19 PM, Staff B, Director of Nursing, stated they would expect staff to document whether a resident received or refused their shower, and that “Not Applicable” documentation did not show whether a resident was offered a shower. When asked when Resident 6 received their first shower, Staff B stated, “It looks like due to documentation,” on 09/03/2025. When asked how many days Resident 6 went without a shower Staff B stated, “From 08/22/2025 to 09/03/2025.” Staff B stated that Resident 6 should have been offered a shower/bath prior to 09/03/2025. RESIDENT 3Review of a care plan for “Activity of Daily Living,” revised on 01/07/2025 showed Resident 3 required limited assistance of one staff member with bathing/showering. The care plan further showed Resident 3 preferred to take bed baths. Review of Resident 3's EHR, under task- ADL Bathing/Showering, showed Resident 3 was scheduled for a shower/bath every Sunday and Thursday evening and as needed. The task further showed Resident 3 did not receive bed baths from 08/13/2025 to 08/25/2025. Review of Resident 3's progress notes did not show whether Resident 3 was offered a bed bath or if they declined a bed bath during the time from 08/13/2025 to 08/25/2025. In an interview and joint record review on 09/11/2025 at 2:43 PM. Staff E stated Resident 3 was scheduled to receive two bed baths a week. A joint record review of Resident 3's EHR under task did not show that Resident 3 received bed baths from 08/13/2025 to 08/25/2025. Staff E stated refusals should be documented. Further joint review of the task record dated 08/13/2025 to 08/25/2025 with Staff E showed no documented refusals of the bed baths and did not show that Resident 3 received bed baths during the time of 08/13/2025 to 08/25/2025. RESIDENT 5Review of a care plan for bathing, initiated on 08/13/2025 showed Resident 5 was dependent on staff for bathing. Review of Resident 5' s EHR, under task-ADL Bathing/Showering, showed Resident 5 was scheduled for a shower/bath every Monday evening and as needed. The task further showed Resident 5 received one shower on 08/26/2025 during the time frame of 08/12/2025 to 09/08/2025. Review of Resident 5' s nursing progress notes dated 08/12/2025 to 09/08/2025 showed no documental refusals of showers. In an interview and joint record review on 09/11/2025 at 2:58 PM, Staff E stated Resident 5 was scheduled to receive a shower once a week, on Monday. A joint record review with Staff E of Resident 5's EHR under task, showed that Resident 5 received one shower on 08/26/2025 during the time frame of 08/12/2025 to 09/08/2025. Staff E stated refusals should be documented, further joint review of the task record dated 08/12/2025 to 09/08/2025 with Staff E showed no documented refusals of the showers, Staff E then stated the documentation showed that Resident 5 received one shower during the time of 08/12/2025 to 09/08/2025. In an interview and joint record review on 09/11/2025 at 3:28 PM, Staff B stated the task record showed Resident 5 received a shower on 08/26/2025, and nothing else was documented about a shower for Resident 5 during the time frame of 08/12/2025 to 09/08/2025. In an interview on 09/15/2025 at 4:01 PM, Staff C, Administrator, stated, “If Resident 3 or Resident 5 refused care like bed baths or showers it should be documented as a refusal, otherwise the expectation was for Resident 3 and Resident 5 to receive bed baths and showers as scheduled, and as needed.” Reference: (WAC) 388-97-1060 (2)(c)

CONCERN (E) 📢 Someone Reported This

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

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 7 of 10 days (09/01/2025, 09/02/2025, 09/03/2025, 09/04/2025, 09/05/2025, 09/09/2025 & 09/10/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included .Review of the nursing staff posting forms dated 09/01/2025, 09/02/2025, 09/03/2025, 09/04/2025, 09/05/2025, 09/09/2025 and 09/10/2025 did not show actual nursing hours worked. In an interview on 09/16/2025 at 3:46 PM, Staff O, Receptionist stated the nurse staffing form was posted every morning for day shift and then the evening and night shift was added to the form in the afternoon. Staff O further stated, I never do the actual hours worked. I just put up the staff hours that the nursing staff were scheduled to work. I never seen the actual hours worked completed on the form. The nursing forms were given to the staffing coordinator to save and file.In an interview on 09/16/2025 at 3:52 PM, Staff P, Staffing Coordinator, stated that the previous administration staff would fill in the actual hours worked on the nursing staff posting forms the next day. It was never done on the same day, so you would not know the actual hours worked until the next day or later if they did not get filled out.In an interview on 09/16/2025 at 5:10 PM Staff C, Administrator, stated the actual nursing hours should be posted on the same day to inform visitors and residents of the actual nursing hours worked.No Reference WAC .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foods were served at proper temperature for 1 of 7 nursing units (Transitional Care Unit [TCU]), and 4 of 4 residents (Residents 3, 5, 6 & 16), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included .FOOD TEMPERATURES-TCUDuring a joint observation and interview on 09/10/2025 at 12:11 PM, Staff Q, Dietary Manager, used the facility's kitchen thermometer to check the temperatures of the meal that was delivered to the TCU. The plate that had food on it was removed from a plastic tray; the serving plate sat on a round plate warmer and was covered with a round plastic top that covered the entire plate. Staff Q stated, the meal being served was baked beans, hamburgers, corn on the cob and chicken noodle soup. The following food items' temperature were noted as follows:-Baked beans temperature showed 133 degrees Fahrenheit (F-a unit of measurement),-Hamburger patty's temperature showed 124 degrees F-Corn on the cob's temperature showed 113 degrees F-Chicken noodle soup's temperature showed 105 degrees FInterview on 09/10/2025 at 12:18 PM, Staff Q stated the baked beans, hamburger patty, corn on the cob and the chicken noodle soup should have tested at 140 degrees F, and the temperatures were low for the food that was tested. Staff Q stated that when the food leaves the kitchen, the temperature should remain at 140 degrees F for up to forty minutes. Staff Q further stated the food did not hold the temperature for forty minutes and that the temperatures of the meal that was just tested left the kitchen less than ten minutes ago.FOOD TEMPERATURES AND PALATIBILITYRESIDENT 3Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 07/28/2025 showed the resident did not have impaired thinking or problems with their memory.In an interview on 09/08/2025 at 2:21 PM, Resident 3 stated, the food is always cold; to get a good meal I have to get it from outside of here and delivered to me. I haven't done it yet. I am trying to get all that figured out now.RESIDENT 5Review of the quarterly MDS dated [DATE] showed the resident did not have impaired thinking or problems with memory.In an interview on 09/09/2025 at 1:21 PM, Resident 5 stated that the food is cold, and it tastes terrible. I have chicken noodle soup with my lunch every day and it is always cold; I eat it anyway because it helps my stomach to feel better. I wish I could at least have it warm, the whole lunch would taste better if it was at least warm.RESIDENT 6Review of the admission MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory.In an interview on 09/09/2025 at 1:14 PM, Resident 6 stated, every meal is served lukewarm to cold, breakfast, lunch and dinner. A nice warm bowl of oatmeal in the mornings would be so nice. I sometimes don't eat because the food is always served lukewarm to cold.RESIDENT 16Review of the admission MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory.In an interview on 09/09/2025 at 1:16 PM, Resident 16 stated, the food should never be served cold, that is not right. Every meal is served cold. It tastes terrible.In an interview on 09/12/2025 at 12:23 PM, Staff Q stated, I am aware that there were some residents that complained of their meals being served cold and not tasting good. I thought the food being placed on a warm plate, covered with a lid and placed in a closed food cart for delivery to the nursing units would help the meals to keep the temperatures at 140 degrees F when brought to the nursing units and served to the residents.In an interview on 09/15/2025 at 3:29 PM with Staff B, Director of Nursing Services, stated they knew the previous Administrator and the dietary manager were working together to resolve the residents' complaints about cold food and the food not tasting good, and that they were not sure of the outcome.In an interview on 09/16/2025 at 5:03 PM, Staff C, Administrator, stated the residents should have meals served at the proper temperatures.Reference: (WAC) 388-97-1100 (2).

CONCERN (E) 📢 Someone Reported This

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

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

Social Worker (Tag F0850)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 4 of 4 social workers (Staff L, M, N & O), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life.Findings included .Review of the Facility Assessment, updated on 07/10/2025, showed the facility was licensed to provide care for 211 residents.STAFF LReview of the facility staff list showed Staff L, Social Worker, was hired on 12/23/2024 and was employed per diem (works on an as-needed basis).STAFF MReview of the facility staff list showed Staff M, Social Worker, was hired on 08/04/2025 and was employed full time.On 09/16/2025 at 5:46 PM, Staff M stated that the facility was licensed to hold over 200 beds (or residents). When asked how many social workers were employed in the facility Staff M stated there were three full-time social workers, and that Staff L was per diem and was not at the facility every day. Staff M stated that they had a master's degree in theology (provides an advanced academic study of a religion from academic, historical, and philosophical perspectives, and can prepare individuals for various careers in ministry, teaching, and further doctoral studies). Staff M stated that they did not have a degree in social work or in a human service field. When asked if they met the qualifications for a social worker in a facility with over 120 licensed beds, Staff M stated, I guess not, further stating Theology dealt with Christian studies and was not a human service field.STAFF NReview of the facility staff list showed Staff N, Social Worker, was hired on 12/23/2024 and was employed full time.On 09/16/2025 at 6:24 PM, Staff N stated that they had been employed with the previous company and had worked at the facility for three years. Staff N stated that they had an associate's degree and did not have a bachelor's degree in social work or in a human services field. When asked if they met the qualifications for a social worker in a facility with over 120 licensed beds, Staff N stated, I do not have it at this time.STAFF OReview of the facility staff list showed Staff O, Social Worker, was hired on 08/19/2025 and was employed full time.Review of an email exchange with Staff C, Administrator, on 09/16/2025 (2:47 PM) showed a request for the facility's social workers' certifications/qualifications. Another email exchange on 09/16/2025 (7:08 PM) with Staff C, Staff A, Interim Administrator, and Staff B, Director of Nursing, showed an additional request for completed documents for the facility's social worker(s) certifications/qualifications.In an interview on 09/16/2025 at 7:29 PM with Staff A and Staff C, Staff A stated the facility was licensed for 211 beds. Staff A stated the facility employed three full time social workers and that Staff L was per diem or as needed/ on-call. Staff C stated that they would expect to have a qualified social worker that met the requirements for their facility. When asked if they were familiar with the required qualifications for a social worker for the facility, Staff C stated, well apparently not as well as I should be. Staff C stated that Staff M had a master's degree in theology and was not applicable to social work or a human service field. Staff C further stated that Staff N had certifications [was not provided], and that they had been reaching out to Staff O all day and had not got back to me.An additional email exchange with Staff C on 09/17/2025 (10:02 AM) showed a request for all the facility's employed social worker's certifications/qualifications/degrees, any resume showing at least one year experience working as a social worker in a healthcare setting, and the facility's job requirements and description or policy for a social worker. The facility did not provide qualifications for Staff L, Staff M, Staff N, or Staff O or a job description or policy for a social worker as requested.In a follow-up email on 09/17/2025 at 11:56 AM, from Staff A showed they were unable to get any information regarding the 3rd social workers [Staff O] qualifications.Reference: (WAC) 388-97-0960 (2)(a)(b).

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) included a completed facility-based and community-based risk assessment, the facility resources to include a list of medical and non-medical equipment description, and contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations. This failure placed the residents at risk for unmet care needs.Findings included .Review of the facility's policy titled, Facility Assessment, dated 10/01/2025, showed that A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for the residents during day-to-day operations.Review of the facility's document titled Facility Assessment, dated 07/10/2025, did not show inclusion of a completed facility-based and community-based risk assessment, a list of medical and non-medical equipment description and contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations. It further showed that [Facility name] does not admit active COVID-19 patients. In an interview on 09/16/2025 at 4:15 PM with Staff A, Interim Administrator, and Staff C, Administrator, Staff C stated the facility could admit active COVID-19 residents and that the facility assessment needed to be updated to reflect that. Joint record review of the facility assessment dated [DATE] showed that a list of medical and non-medical equipment description was referred to be outlined in Appendix 1. It further showed that contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations were referred to be outlined in Appendix 2. Staff C and Staff A stated, No, we can't [cannot] find it [documentation of Appendix 1 and 2]. When asked if the facility assessment included a completed facility-based and community-based risk assessment, Staff C stated, No, but I can include it. No associated WAC.

Jun 2025 28 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to inform a resident and/or their representative about risks and benefits of positioning a bed against the wall for 1 of 3 residents (Resident 93), reviewed for accidents. The failure to conduct an assessment, evaluation and/or providing information regarding bed positioning prevented the resident and/or their representative to exercise their right to make an informed decision. Findings included . Review of the undated facility's policy titled, Resident Rights, showed, The Resident has the right to be fully informed of, and participate in, his or her treatment including: the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to his or her medical condition. The policy further showed, The Resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. Review of a face sheet printed on 06/02/2025 showed Resident 93 was admitted to the facility on [DATE] with diagnosis that included dementia (memory impairment and/or decline). Review of the quarterly minimum data set (an assessment tool) dated 04/03/2025 showed Resident 93 had severe cognitive impairment. Further review of the MDS assessment showed Resident 93 was unable to walk and had limited range of motion in both lower legs. Review of the facility's Electronic Health Record (EHR) did not show Resident 93 was assessed, evaluated or informed about the risk and benefits of positioning their bed against the wall. Observation on 05/30/2025 at 8:56 AM, showed Resident 93's bed was positioned against the wall. In a follow-up observation on 06/02/2025 at 10:54 AM and on 06/03/2025 at 9:02 AM, Resident 93 was lying in bed, and their bed was positioned against the wall. In an interview and joint record review on 06/04/2025 at 1:29 PM, Staff J, Registered Nurse (RN), stated that Resident 93's bed was positioned against the wall. Staff J stated that there should be a [physician] order if the bed is against the wall. A joint record review of the EHR did not show a physician order about Resident 93's bed position. Further joint record review of the EHR did not show Resident 93 was assessed, evaluated or informed regarding the risks and benefits of having their bed positioned against the wall. Staff J stated that they did not know if Resident 93's representative had been informed about Resident 93's bed position. In an interview and joint record review on 06/04/2025 at 2:11 PM, Staff E, RN Unit Manager, stated that they were aware that Resident 93's bed was positioned against the wall. A joint record review of the EHR did not show Resident 93 had been assessed, evaluated, and/or informed about risks/benefits of having their bed positioned against the wall. Staff E stated that they were not able to assess, evaluate and inform Resident 93 and/or their representative about the risks and benefits of positioning their bed against the wall. In an interview on 06/05/2025 at 2:51 PM, Staff B, Director of Nursing, stated they expected Resident 93 and/or their representative to have been assessed, evaluated and informed about risks and benefits of having their bed positioned against the wall. Reference: (WAC) 388-97-0260(2) (a-d) .

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident choices/preferences regarding shower/bathing were honored for 2 of 3 residents (Residents 41 & 10), reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk of being unable to exercise their rights, not having their choices/preferences honored, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Resident Rights, showed, The Resident has a right to a dignified existence, self-determination . The policy further showed that, The Resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice . Review of the facility's undated policy titled, Shower/Tub Bath, showed that residents would be offered at least two full baths or showers per week. The policy further showed that resident preference for type and frequency of baths would be taken into consideration and honored. RESIDENT 41 Review of a quarterly Minimum Data Set (MDS-an assessment tool) dated 04/17/2025, showed Resident 41 had moderate cognitive impairment, and shower/bathing was not attempted due to environmental limitations. The MDS assessment further showed that it was very important for Resident 41 to choose between a tub bath, shower, bed bath, or sponge bath. Review of the ADL care plan initiated on 08/02/2022 showed Resident 41 preferred to have a shower two times a week. Review of the May 2025 ADL Task showed Resident 41 had received bed baths on 05/09/2025, on 05/30/2025 and on 05/31/2025. The May 2025 ADL task showed Resident 41 had received tub baths on 05/08/2025 and on 05/19/2025, and from 05/11/2025 to 05/17/2025, Resident 41 did not have a shower for a week. The May 2025 ADL records did not show Resident 41 refused a shower. In an interview on 05/29/2025 at 12:38 PM, Resident 41 stated, There [are] not enough staff. Resident 41 further stated they prefer showering twice a week, but I never got it more than once a week. In an interview on 06/03/2025 at 10:23 AM, Staff K, Certified Nursing Assistant (CNA), stated that Resident 41 liked to have a shower twice a week but now gets [shower/bath] once a week because there is no regular shower aide. In an interview and joint record review on 06/03/2025 at 10:41 AM, Staff L, Licensed Practical Nurse, stated Resident 41 preferred to have showers. A joint record review of the ADL care plan showed Resident 41 preferred shower two times a week. A joint record review of the May 2025 ADL Task showed Resident 41 received three bed baths, two tub baths for the month of May 2025. Further joint review of the May 2025 ADL task did not show Resident 41 refused a shower from 05/11/2025 to 05/17/2025. Staff L stated that Resident 41's shower preferences and care plan should have been followed. In an interview and joint record review on 06/03/2025 at 11:16 AM, Staff D, Registered Nurse [RN] Unit Manager (RNUM), stated that they considered and followed residents' shower/bathing preferences and their care plan. A joint record review of Resident 41's ADL care plan showed Resident 41 preferred shower two times a week. A joint record review of the May 2025 ADL task showed Resident 41 did not have a shower from 05/11/2025 to 05/17/2025. Resident 41 was given bed baths or tub baths instead of showers two times a week. Further joint record review of the May 2025 ADL task did not show Resident 41 refused a shower. Staff D stated that they expected staff to have followed Resident 41's shower preferences and care plan. RESIDENT 10 Review of a significant change MDS dated [DATE], showed Resident 10 had intact cognition. The MDS assessment further showed that it was very important for Resident 10 to choose between a tub bath, shower, bed bath, or sponge bath. Review of the comprehensive care plan revised on 01/07/2025, showed Resident 10 preferred a bath twice a week. Review of the May 2025 ADL task showed Resident 10 did not have a bath and/or shower from 05/11/2025 to 05/17/2025 and had a tub bath once from 05/18/2025 to 05/24/2025. Further joint record review of the May 2025 ADL task did not show Resident 10 refused a shower. In an interview on 05/30/2025 at 10:24 AM, Resident 10 stated, I used to get two showers a week. I used to soak my legs, but I [did not] get showers or bath like I used to. Resident 10 further stated that with [current management] shower aides were given floor work assignment. In an interview on 06/03/2025 at 10:04 AM, Staff I, CNA, stated that Resident 10 preferred shower or bath two times a week. Staff I stated that Resident 10 usually gets [shower/bath] two times a week at the time of [previous management] but now it [shower/bath] is once a week. In an interview and joint record review on 06/03/2025 at 1:41 PM, Staff J, RN, stated that Resident 10 preferred shower/bath two times a week. A joint record review of the ADL care plan showed Resident 10 preferred a tub bath two times a week. A joint record review of the May 2025 ADL task showed Resident 10 did not have a shower/bath from 05/11/2025 to 05/17/2025 and had a tub bath from 05/18/2025 to 05/24/2025. Staff J stated that Resident 10's care plan should have been followed, and their [twice a week] bathing preferences honored. A joint record review and interview on 06/03/2025 at 2:43 PM with Staff D, showed Resident 10's ADL care plan included their preference for a twice a week tub bath. A joint record review of the May 2025 ADL task showed Resident 10 did not have a shower/tub bath from 05/11/2025 to 05/17/2025 and had a bath 05/18/2025 to 05/24/2025. Staff D stated that they expected staff to have followed Resident 10's care plan and honored their [twice a week] shower/bathing preferences. In an interview on 06/04/2025 at 2:42 PM, Staff B, Director of Nursing, stated that they expected staff to have followed Resident 41 and Resident 10's care plan and should have honored their shower/bathing preferences. Staff B further stated that they expected Resident 41 and Resident 10 to have received shower and/or bathing two times a week. Reference: (WAC) 388-97-0900 (1) .

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure privacy and confidentiality of medical information were maintained during a medical provider visit for 2 of 3 residents (Resident 42 & 51), reviewed for confidentiality of records. This failure placed the residents at risk for having their medical and personal information not kept confidential and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Attending Physician Responsibilities, showed that, The Physician/NPP [Non-Physician Practitioner], will maintain a courteous and professional level of interaction with facility residents. RESIDENT 42 An observation on 06/04/2025 at 1:02 PM, showed several residents were gathered in the Memory Care Unit (MCU) Television (TV) room area and that Staff U, Advanced Registered Nurse Practitioner, was interacting with Resident 42. It further showed that Staff U asked about specific medical conditions and discussed medical laboratory results with Resident 42, while Resident 42 was in the company of other residents. In an interview on 06/04/2025 at 1:22 PM, Staff G, Registered Nurse, stated that she observed Staff U visiting with Resident 42 while in the company of other residents. Staff G further stated that Staff U did not provide privacy during the visit with Resident 42 and that they should have taken them to their room for privacy. In an interview on 06/04/2025 at 1:50 PM, Staff B, Director of Nursing, stated that they considered the MCU TV room as a common area and that they expected provider visits would be conducted in private. RESIDENT 51 An observation on 06/04/2025 at 1:02 PM, showed Staff U visited with Resident 51 while they were seated on a bench that was placed between the MCU nurse's station and MCU dining room. It showed that Resident 51 was asked about specific medical conditions and that Resident 51 pushed away when Staff U attempted to place a stethoscope on their chest. In an interview on 06/04/2025 at 1:22 PM, Staff G stated that she observed Staff U visiting with Resident 51 near the nurse's station. Staff G further stated that Staff U did not provide privacy during the visit with Resident 51 and that they should have taken them to their room for privacy. In an interview on 06/04/2025 at 1:50 PM, Staff B, Director of Nursing, stated that they expected provider visits would be conducted in private. Reference (WAC): 388-97-0360 (1)(b)(e) .

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 2 residents (Resident 101), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences .All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect. Review of the facility's policy titled, Abuse, revised on 10/20/2022, showed, This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation .Designated staff will immediately review and investigate all allegations or observations of abuse. Review of a face sheet printed on 06/02/2025 showed Resident 101 admitted to the facility on [DATE]. In an interview on 05/29/2025 at 8:42 AM, Resident 101 stated, They're not providing the necessary resources to take care of us and that they would run out of trash bags, briefs, moisturizers and wipes. Resident 101 further stated that they thought this was a form of elderly abuse. Review of Resident 101's investigation report dated 05/29/2025 showed, Actions Taken: -Reported to State Agency -Administrator [Staff A]/Director of Nursing [Staff B] notified -Interview of resident -Care plan revision -Review of supply invoices which shows that supplies are being ordered regularly -Resident room and supply rooms checked and are fully stocked. Further review of the investigation report showed that interviews with other residents and staff members were not conducted. In an interview on 06/06/2025 at 10:21 AM, Staff A stated that they would report and investigate abuse/neglect allegations. Staff A stated that they and Staff B completed the investigations. Staff A reviewed Resident 101's investigation report and stated that they did not see documentation that other residents and staff were interviewed. Staff A stated, No, I'm not seeing it in the summary of events. When asked if the investigation was completed thoroughly, Staff A stated, we could have done more and that their usual format would be to interview other residents and staff members. Staff A further stated, We should have done a more thorough investigation like we usually do. Reference: (WAC) 388-97-0640 (6)(a) .

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) for 1 of 3 residents (Resident 76), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.19.1, dated October 2024, showed that the nursing home is required to complete an SCSA when the resident comes off hospice (a service that provides quality of life care for chronic conditions) benefit (revokes). The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election revocation. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar days). Review of a face sheet printed on 06/02/2024 showed Resident 76 was readmitted to the facility on [DATE] with diagnoses to include worsening renal (related to kidneys, including their function responsible for filtering blood, regulating fluid balance and waste management through urine production) failure. Review of Resident 76's nursing progress notes dated 06/12/2024 showed that resident was admitted to hospice on 06/12/2024. Review of the hospice provider note dated 05/02/2025 showed Resident 76 was discharged from hospice services on 05/02/2025. Review of the SCSA MDS dated [DATE] showed that the MDS was completed on 05/29/2025 (13 days late). A joint record review and interview on 06/03/2025 at 3:16 PM with Staff CC, Registered Nurse, showed that Resident 76 was discharged from hospice on 05/02/2025. Staff CC stated that the MDS coordinator was responsible for updating the SCSA MDS after a significant change of condition. In an interview and joint record review on 06/05/2025 at 1:27 PM, Staff Q, MDS Coordinator, stated that they followed the RAI manual for completion of MDS assessments. A joint record review of the hospice provider note dated 05/02/2025, showed Resident 76 was discharged from hospice on 05/02/2025. Staff Q stated that the SCSA MDS was late. In an interview and joint record review on 06/06/2025 at 11:36 AM, Staff B, Director of Nursing, stated it was their expectation that MDS assessments were completed timely and, in this case, Resident 76's SCSA MDS was completed late. Reference: (WAC) 388-97-1000(3)(b)(5)(e)(ii) .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess 3 of 20 residents (Residents 1, 97 & 90), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments for oral/dental status, medications, and hospice care (support for end-of-life care) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. It further showed, .Hospice Services is a program for terminally ill persons [people] where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare [government-run health insurance] program as a hospice provider. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). RESIDENT 1 Review of a quarterly MDS dated [DATE] showed Resident 1 readmitted to the facility on [DATE]. Further review of the MDS showed, Section N (Medications) was marked as they were taking an antidepressant (medications to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). Review of the April 2025 Medication Administration Record (MAR) showed Resident 1's order for an antidepressant medication was discontinued on 04/15/2025. It further showed that Resident 1 last received an antidepressant medication on 04/15/2025. In an interview and joint record review on 06/05/2025 at 11:09 AM, Staff Q, MDS Registered Nurse (RN), stated that they followed the RAI manual and when they completed Section N, they would review physician orders, and the MAR. Staff Q stated that the look back period for Section N was seven days. A joint record review of Resident 1's quarterly MDS dated [DATE], showed that it was coded for antidepressant use. A joint record review of Resident 1's April 2025 MAR showed they last received an antidepressant medication on 04/15/2025. Staff Q stated that Section N was not coded accurately and should have been. RESIDENT 97 Review of the admission MDS dated [DATE] showed Resident 97 admitted to the facility on [DATE]. It further showed that Section L (Oral/Dental Status) was marked none of the above were present and that they were not marked for No natural teeth or tooth fragment(s) (edentulous [toothless]). Review of the Nutritional at Risk Assessment dated 03/13/2025 showed Resident 97 was edentulous. An observation and interview on 05/29/2025 at 12:23 PM, showed Resident 97 was edentulous. Resident 97 stated that they had all their teeth pulled out. In an interview and joint record review on 06/05/2025 at 11:16 AM, Staff Q stated that when they completed Section L, they would try to examine the resident's mouth if allowed, spoke with staff and reviewed documentation. Staff Q stated that Section L had a seven-day look back period. A joint record review of Resident 97's admission MDS dated [DATE], showed it was not marked for No natural teeth or tooth fragment(s) (edentulous). A joint record review of the nutrition assessment dated [DATE], showed Resident 97 was edentulous. Staff Q stated that based on the documentation reviewed, Section L should have been coded accurately for edentulous. In an interview on 06/05/2025 at 1:53 PM, Staff B, Director of Nursing, stated that they expected MDS assessments to be completed accurately. Review of a face sheet printed 06/05/2025, showed Resident 90 was admitted to the facility on [DATE]. Review of Resident 90's quarterly MDS dated [DATE] showed that hospice care was marked in Section O0110 (Special Treatments, Procedures and Programs), which indicated that Resident 90 received hospice services while a resident at the facility. Review of Resident 90's physician's orders, printed on 06/03/2025, did not show orders for hospice services. In an interview on 06/06/2025 at 8:46 AM, Staff G, RN, stated that Resident 90 was not under a hospice program and that Resident 90 had services for just comfort care. A joint record review and interview on 06/06/2025 at 11:27 AM with Staff R, MDS RN, showed that hospice care was marked in Section O0110 of Resident 90's quarterly MDS dated [DATE]. Staff R stated that there was no supporting documentation of Resident 90 having received hospice services in their electronic health record. Staff R further stated that hospice care should not have been marked and that they expected MDS would be completed accurately. In an interview on 06/06/2025 at 11:44 AM, Staff B stated that the facility followed the RAI Manual for coding accuracy and that they expected MDS assessments would be completed accurately. Reference: (WAC) 388-97-1000(1)(b) .

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 101 Review of a face sheet printed on 06/02/2025, showed Resident 101 admitted to the facility on [DATE]. Review of Resident 1's Level I PASARR dated 02/12/2025 showed that Section IV (Service Needs and Assessor Data) was marked No level II evaluation indicated at this time due to exempted hospital discharge. Level II must be completed if discharge does not occur. Review of the census tab in the EHR printed on 06/02/2025, showed Resident 101's status was active. In an interview and joint record review on 06/02/2025 at 2:21 PM, Staff F, Social Worker, stated that if a resident was marked for hospital exempted discharge on their Level I PASARR that was completed prior to their admission, they would have to complete a new Level I PASARR if the resident was in the facility for more than 30 days. A joint record review of Resident 101's Level I PASSAR dated 02/12/2025, showed it was marked for No level II evaluation indicated at this time due to exempted hospital discharge. Level II must be completed if discharge does not occur. Staff F stated that they did not see a new Level 1 PASARR completed in Resident 101's EHR after their 30 days stay and that a new Level I PASARR should have been completed. In an interview on 06/04/2025 at 3:50 PM, Staff A stated that they expected staff to follow their policy and that a new Level I PASARR for Resident 101 should have been completed after their 30 days stay. Reference: (WAC) 388-97-1975 (1)(3)(5) Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions [RC] are not inappropriately placed in nursing homes for long-term care) Level II PASARR referral was made for 1 of 5 residents (Resident 102), reviewed for PASARR screening. In addition, the facility failed to complete Level I PASARR screening form for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 5 residents (Resident 101). These failures placed the residents at risk of not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, admission Criteria, dated 10/01/2021, showed that all new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid PASARR process. The policy further showed, If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD [Related Disorders], he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. RESIDENT 102 Review of a face sheet printed on 06/04/2025 showed Resident 102 admitted to the facility on [DATE]. Review of Resident 102's Level I PASARR dated 03/11/2025 showed that a diagnosis of mood disorders (a mental health condition that affects a person's emotional state, causing persistent feelings of sadness, irritability, or extreme mood swings) was marked. Further review of the Level I PASARR showed, resident recently had a decline with mood, adjustment disorder [a mental health condition that occurs when a person struggles to cope with a stressful life event, leading to emotional or behavioral symptoms]). In an interview and joint record review on 06/04/2025 at 10:19 AM, Staff O, Social Worker, stated that Resident 102 was admitted to the facility with a negative Level I PASARR. Staff O stated that the new Level I PASARR was completed on 03/11/2025 due to Resident 102's decline with their mood. Staff O stated that Resident 102's Level II PASARR referral was made. A joint record review of Resident 102's Electronic Health Record (EHR) showed that there was no documentation that a referral was made. Staff O stated, I believe I faxed the referral, but I do not have the fax cover sheet or the documentation to confirm. In an interview on 06/05/2025 at 2:02 PM, Staff A, Administrator, stated that when a residents' Level I PASARR screening indicated they met the criteria, they should be referred for a Level II PASARR evaluation. Staff A further stated that Resident 102's Level II PASARR referral should have been made and there should have been documentation for it.

CONCERN (D)

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

Deficiency F0646 (Tag F0646)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the State PASARR (Pre-admission Screening and Resident Review-an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities [ID], or related conditions are not inappropriately placed in nursing facility for long term care) Coordinator after a significant change in condition for 3 of 8 residents (Residents 76, 1 & 10), reviewed for PASARR. This failure placed the residents at risk for unmet mental health services necessary to obtain the resident's highest level of psychosocial well-being and diminished quality of life. Finding included . Review of an online document title, Preadmission Screening and Resident Review, dated 02/14/2020, showed that According to Medicaid, as part of the PASARR process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD/SMI) or ID has a significant change in their physical or mental condition. Referral to the State Mental Health (SMH) or ID authority should be made as soon as the criteria indicative of a significant change are evident. RESIDENT 76 Review of a face sheet printed on 06/05/2025 showed Resident 76 readmitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder (MDD- a mental health condition characterized by persistent feelings of sadness, low mood, and loss of interest in activities that were once pleasurable), and Post-Traumatic Stress Disorder (PTSD-a mental health condition that can develop after experiencing or witnessing a traumatic event). Review of a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) dated 05/26/2025 showed Resident 76 had diagnoses of MDD, anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life) and PTSD. Review of the hospice provider note dated 05/02/2025 showed Resident 76 was discharged from hospice services on 05/02/2025. A joint record review and interview on 06/03/2025 at 3:16 PM with Staff CC, Registered Nurse, showed hospice provider note included Resident 76 discharged from hospice care on 05/02/2025. Staff CC stated that Resident 76 needed an SCSA to be completed. In an interview on 06/06/2025 at 10:40 AM, Staff F, Social Worker, stated that if a significant change of condition was identified for a resident with MD or ID, then the resident needed to be referred for PASARR Level II for evaluation. Staff F stated a referral completed on 06/05/2025, and it was late. In an interview on 06/06/2025 at 11:36 AM, Staff B, Director of Nursing, stated that it was their expectation that staff would notify the mental health authority or the State PASARR Coordinator after a resident had a significant change in condition. RESIDENT 1 Review of a face sheet printed on 06/05/2025, showed Resident 1 readmitted to the facility on [DATE] with diagnoses that included anxiety disorder, and MDD. Review of Resident 1's Level I PASARR dated 04/04/2024, showed Section IV (Service Needs and Assessor Data) was marked for Level II evaluation referral required for significant change. Review of Resident 1's Electronic Health Record (EHR) did not show documentation for a completed Level II PASARR evaluation. A joint record review and interview on 06/03/2025 at 3:03 PM with Staff F, showed Resident 1's Level I PASARR dated 04/04/2024 was marked for Level II evaluation referral required for significant change. Staff F stated that they were not able to see that a Level II evaluation was completed and that there's nothing after that date. Staff F further stated that they would double check with the PASARR Coordinator. When asked how often they followed up with the PASARR Coordinator, Staff F stated, quarterly. In a follow up interview on 06/04/2025 at 3:39 PM, Staff F stated that they had followed up with the PASARR Coordinator and that they were told that they did not have Resident 1's referral. Staff F further stated that they did not see documentation that a follow up was made to the PASARR Coordinator. In an interview on 06/04/2025 at 3:45 PM, Staff A, Administrator, stated that they expected staff to follow up on Level II PASARR evaluation referrals. RESIDENT 10 Review of a face sheet printed on 06/02/2025 showed Resident 10 was admitted to the facility on [DATE] with a diagnosis that included bipolar disorder (a mental illness characterized by intense mood swings). Review of the MDS look up tab showed Resident 10 had an SCSA MDS dated [DATE]. Review of the EHR showed Resident 10 had a Level I PASARR dated 03/12/2018. Further review of the EHR did not show Resident 10 had a new and/or updated PASARR. An additional review of the EHR did not show documentation that the State mental health authority or PASARR Coordinator had been informed of Resident 10's significant change in condition. A joint record review and interview on 06/03/2025 at 2:14 PM with Staff F, showed Resident 10 had a Level I PASARR dated 03/12/2018. A joint record review of the EHR did not show a new or updated PASARR completed for Resident 10. Staff F stated, there was no new PASARR or referral for a Level II completed for [Resident 10]. There should have been one completed and the PASARR Coordinator was not notified [about Resident 10's significant change in status]. In an interview on 06/05/2025 at 1:57 PM, Staff A stated that they expected a new Level I PASARR should have been completed and the PASARR Coordinator notified when Resident 10 had a significant change in their status. Reference: (WAC) 388-97-1975 (7) .

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were revised timely and accurately to reflect changes in care related to discontinuation of hospice (a service that provides quality of life care for chronic conditions) services, initiation of comfort care or end-of-life care, and/or discontinuation of medication for 3 of 7 residents (Residents 76, 90 & 1), reviewed for care planning. These failures placed residents at risk for unidentified and unmet care needs, and a diminished quality of life. RESIDENT 76 Review of a face sheet printed on 06/02/2025 showed Resident 76 was readmitted to the facility on [DATE]. Review of a nursing progress note dated 06/12/2025 showed Resident 76 was admitted to hospice services on 06/12/2024. Review of Resident's 76's comprehensive care plan initiated on 06/12/2024 showed Resident 76 was on hospice for end-of-life/comfort care. Review of a hospice provider note dated 05/02/2025 showed Resident 76 was discharged from hospice services on 05/02/2025. In an interview and joint record review on 06/03/2025 at 3:16 PM, Staff CC, Registered Nurse (RN), stated that Resident 76 was discharged from hospice on 05/02/2025. Further review of the care plan showed it was not revised to reflect that Resident 76 was discharged from hospice care. Staff CC stated that the care plan should have been revised in a timely manner to reflect discharge from hospice care services. In an interview on 06/06/2025 at 11:42 AM, Staff B, Director of Nursing, stated that it was their expectation that once a resident was discharged from hospice, the care plan should have been reviewed and updated promptly to reflect the resident's change in status. Staff B further stated Resident 76's care plan should have been revised in a timely manner. RESIDENT 1 Review of a face sheet printed on 06/05/2025, showed Resident 1 readmitted to the facility on [DATE] with diagnoses that included major depressive disorder (persistent feelings of sadness and loss of interest, significantly impacting daily life). Review of the physician's order printed on 06/02/2025, showed Resident 1 did not have an order for an antidepressant (medication for depression or depressive disorder). Review of the April 2025 Medication Administration Record showed Resident 1's antidepressant medication was discontinued on 04/15/2025. Review of Resident 1's mood care plan revised on 02/21/2023, showed, He takes a low dose of [an] anti-depressant medication routinely. In an interview and joint record review on 06/05/2025 at 8:08 AM, Staff J, RN, stated that they did not think Resident 1 was on an antidepressant medication. A joint record review of Resident 1's physician orders did not show an order for antidepressant medication. Staff J stated that if a residents' antidepressant medication was discontinued, it should have been reflected on their care plan. In an interview and joint record review on 06/05/2025 at 8:15 AM, Staff E stated that care plans were reviewed quarterly and as needed and if there were any changes to their plan of care. Staff E stated if residents were no longer on an antidepressant medication, and if they were informed about it, they would remove it from their care plan. A joint record review of Resident 1's physician orders showed that they did not have an order for antidepressant medication. Staff E stated, Resident 1 used to be [on antidepressant] but not anymore. A joint record review of Resident 1's mood care plan showed, He takes a low dose of an anti-depressant medication routinely. Staff E stated that Resident 1's care plan should have been updated. In an interview on 06/05/2025 at 1:55 PM, Staff B stated that they expected resident care plans to have been revised on admission, quarterly, and when there was a change in their care. Staff B further stated that they expected Resident 1's care plan to have been revised. Reference: (WAC) 388-97-1020 (2)(a)(5)(b) RESIDENT 90 Review of a face sheet printed on 06/05/2025, showed Resident 90 was admitted to the facility on [DATE]. Review of a progress note dated 08/23/2024 showed Staff F, Social Worker, wrote, [Resident 90] has had a decline in condition this assessment period r/t [related to] start of [Collateral Contact 2's] end-of-life comfort care program (similar to hospice). In an interview on 06/06/2025 at 8:46 AM, Staff G, RN, stated that Resident 90 received comfort care. Review of Resident 90's care plan, printed on 06/06/2025, did not show that their care plan was revised to include their transition to end-of-life comfort care program. A joint record review and interview on 06/06/2025 at 11:11 AM with Staff E, RN Unit Manager, did not show that Resident 90's care plan was revised to include end-of-life comfort care. Staff E stated that there was no care plan addressing end of life goals or treatments, and that they would expect the care plan to have been revised. In an interview on 06/06/2025 at 11:46 AM, Staff B stated they expected Resident 90's care plan to have been revised to include the focus of comfort care/end-of-life comfort care.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there was an ongoing activity program to meet the needs of 1 of 1 resident (Resident 95), reviewed for activities. This failure placed the residents at risk for unmet activity pursuit, social isolation, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities Programs, dated 10/01/2021, showed that the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. The policy showed that activities were available daily and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. The policy further showed that the resident's participation in activities was documented in the resident's medical record. Review of a face sheet printed on 06/04/2025 showed Resident 95 admitted to the facility on [DATE]. Review of the admission Minimum Date Set (MDS-an assessment tool) dated 04/25/2025, showed that Resident 95 was cognitively intact. The MDS assessment further showed that it was very important for Resident 95 to listen to the music they like, keep up with the news, do their favorite activities and go outside to get fresh air when the weather is good. Review of Resident 95's care plan dated 04/22/2025, showed that the facility would encourage, support and assist Resident 95 with family phone/virtual/in-person visits and invite, encourage and assist Resident 95 to attend group activities. The care plan further showed that Resident 95 would be provided one on one visit as needed for emotional support and provide assistance and access to leisure activity supplies in room (magazines, newspaper, mystery books, TV [Television] News, Sports (hockey, soccer, football baseball), channel 4/5, Price is Right game show, movies, country music, puzzles .). In an interview on 05/29/2025 at 1:01 PM, Resident 95 stated that they like to do activities such as going out. When asked if they were doing activities in the facility, Resident 95 stated No, I am supposed to have activities, but I have never seen any. Resident 95 further stated that they liked going out, and they only went out once when their collateral contact visited them. Multiple observations on 05/29/2025 at 1:01 PM, on 06/02/2025 at 9:33 AM, and on 06/03/2025 at 8:45 AM, showed that Resident 95 was awake, lying in bed and did not have any leisure activity supplies in their room such as magazines, newspaper and mystery books. In an interview and joint record review on 06/03/2025 at 9:24 AM, Staff V, Activities Director, stated they expected the residents to participate in activities and that after they participated or refused, it should be documented. Staff V stated that they did not believe Resident 95 was coming to group activities, That is probably because [Resident 95] does not want to come. Staff V stated that Resident 95 was definitely doing activities independently, but for group activities, I do not see it on the chart. Staff V further stated, I do not think [Resident 95] had one on one. We should have let [Resident 95] participate in activities as planned in their care plan. I do not think everything listed on [Resident 95's] care plan was being implemented. A joint record review of activities progress notes from 04/21/2025 to 06/03/2025 did not show Resident 95 had documentation for their activity participation. Staff V stated that there should have been documentation indicating Resident 95 was participating in activities of their choice. In an interview on 06/05/2025 at 2:02 PM, Staff A, Administrator, stated that it was their expectation that residents should be offered activities to enhance their well-being and social engagement in the facility. Staff A further stated that Resident 95 should have been offered activities of their choice and that each instance of participation or refusal should have been documented to ensure proper tracking. Reference: (WAC) 388-97-0940(1)(2) .

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform skin evaluations, implement appropriate monitoring and treatment after sustaining a skin injury, and/or failed to monitor and obtain daily weights for a resident on diuretic (water pill) therapy in accordance with professional standard of practice for 2 of 7 residents (Residents 21 & 98), reviewed for quality of care. These failures placed the residents at risk for unmet care needs and diminished quality of life. Findings Included . SKIN INJURY RESIDENT 21 During an observation and interview on 06/02/2025 at 10:43 AM, Resident 21 had two scabs (a dry protective) on their left knee and another two scabs on their right shin. Resident 21 stated that their skin injuries occurred due to a fall and that they were not receiving treatment. Review of the weekly skin assessment dated [DATE] showed that Resident 21 skin was intact. A joint observation and interview on 06/05/2025 at 10:34 AM with Staff KK, Registered Nurse (RN), showed Resident 21 had had two scabs on their left knee and another two scabs on their right shin. Staff KK was palpitating around the edges of the scabs/wounds, Resident 21 stated, it hurts. When asked about Resident 21's skin injury, Staff KK stated they were not aware of it. In an interview and joint record review on 06/05/2025 at 10:38 AM, Staff KK stated that for any skin injury, nursing staff were expected to provide first aid, notify the physician, family, document the injury in the skin assessment, and follow the provider's treatment recommendations. A joint record review of Resident 21's weekly skin assessments showed that the two scabs on their left knee and another two scabs on their right shin were not previously assessed. Staff KK stated that the scabs on Resident 21's left knee and right shin were not previously documented. In an interview on 06/06/2025 at 11:18 AM, Staff B, Director of Nursing, stated that skin assessments were completed weekly and during shower or sponge baths. Staff B further stated it was their expectation that all skin injuries to be documented, reported to the provider and family, and treated according to the physician's order. WEIGHT MONITORING RESIDENT 98 Review of a face sheet printed on 06/05/2025 showed Resident 98 was readmitted to the facility on [DATE]. Review of the May 2025 Medication Administration Record printed on 06/04/2025 showed Resident 98 received two diuretic medications. Review of a daily weight documentation printed on 06/05/2025 showed that Resident 98's daily weights were not recorded for the following dates: 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025 and 05/05/2025. In an interview on 06/05/2025 at 3:55 PM, Staff II, Admissions RN, stated that residents' weights should be obtained at admission or readmission and that daily weights should have been recorded if the resident was on diuretic therapy. In an interview and joint record review on 06/06/2025 at 11:14 AM, Staff B, Director of Nursing, stated that resident weights were required on admission and weekly thereafter. A joint record of Resident 98's daily weights showed no documentation from 04/30/2025 to 05/05/20225. Staff B stated that residents receiving diuretics should be weighed daily. Staff B further stated that Resident 98's weights should have been recorded daily. Reference: (WAC) 388-97-1060 (1)(3)(b)(4) .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a prescribed therapeutic diet of small, portioned meals for 1 of 3 residents (Resident 36), reviewed for nutrition/hydration. This failure placed the resident at risk for unintended weight loss, medical complications, and a diminished quality of life. Findings included . A review of the facility's policy titled, Therapeutic Diets, dated 10/01/2021, showed that, Therapeutic Diet, meant a diet ordered by a physician or delegated registered/licensed dietician as part of treatment for a clinical condition. It further showed that therapeutic diets were prescribed to support the resident's treatment and plan of care in accordance with his or her goals and preferences. Review of a face sheet printed on 06/05/2025, showed that Resident 36 admitted to the facility on [DATE] with diagnoses that included gastroparesis (a condition where the stomach muscles do not work properly to move food through the stomach, which can lead to vomiting and trouble digesting food) and Type I diabetes mellitus (a chronic condition that affects blood sugar levels). Review of Resident 36's care plan, printed on 06/04/2025 showed, Special instruction: INFO [information]: Give smaller meals more frequently: 4-5 small meals a day versus 3 large meals. Small particle diet for Gastroparesis. Observations on 05/30/2025 at 8:54 AM, on 06/03/2025 at 9:13 AM and on 06/05/2025 at 8:39 AM showed Resident 36's main entrée portions were fully covering the surface of their plate [served with regular portions]. Observation and interview on 06/04/2025 at 12:41 PM, showed Resident 36 was eating their lunch. Resident 36's lunch entrée consisted of uncoated strips of white meat, unpeeled potato slices and a serving of mixed corn kernels, peas, carrots, and lima beans. It further showed that Resident 36 was slowly chewing their food in between bites. Resident 36 stated that they asked staff to turn off their wall-mounted fan, because it takes so long to chew that my food gets cold .then it's just tasteless. In an interview on 06/04/2025 at 1:19 PM, Staff M, Certified Nursing Assistant, stated that Resident 36 received three regular meals delivered from the kitchen. Staff M further stated that Resident 36 received regular portions, not smaller portions. A joint record review and interview on 06/04/2025 at 1:35 PM with Staff G, Registered Nurse, showed Resident 36's EHR had instructions to receive smaller meals. Staff G stated that Resident 36 did not receive small meal portions and that, They look regular to me. Review of Resident 36's EHR weight records printed on 06/05/2025, showed that Resident 36 weighed 184.0 pounds (lbs. -unit of measurement) on 04/29/2025 and weighed 173.0 lbs. on 05/29/2025. It showed that Resident 36 had a significant weight loss in 30 days (more than five percent loss of body weight in one month). In an interview on 06/05/2025 at 1:05 PM, Staff N, Registered Dietician, stated that Resident 36 was supposed to have small frequent meals and that it was related to Resident 36's diagnosis of gastroparesis. Staff N further stated that Resident 36 has had a significant weight loss from 04/29/2025 through 05/29/2025 and that they would, have to see how [Resident 36] is eating. A joint of observation and interview on 06/05/2025 at 1:12 PM with Staff N, showed Resident 36's lunch tray had regular sized portions. Staff N stated, It looks like regular portions, and that the kitchen should have provided entrée portions using a smaller scoop. Staff N further stated that Resident 36 should have been receiving three small-portioned meals along with snacks in between meals. A joint record review and interview on 06/05/2025 at 1:27 PM with Staff H, Dietary Manager, did not show that Resident 36's meal slip, dated 06/05/2025, indicated small-portioned meals. Staff H stated that Resident 36 received regular serving portions. A joint record review and interview on 06/05/2025 at 4:09 PM with Staff B, Director of Nursing, showed Resident 36's nutritional care plan had instructions to receive smaller meals more frequently: 4-5 small meals a day versus 3 large meals. Small particle diet for Gastroparesis. Staff B stated that they expected nursing staff would follow those orders. In an interview on 06/06/2025 at 8:16 AM, Staff A, Administrator, stated that they considered Resident 36's diet of small-portioned meals to be a therapeutic diet and that they expected staff would follow the diet. Reference: (WAC): 388-97-1100(1) .

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of respiratory equipment, and document oxygen (O2) saturation (the amount of O2 in the blood) for 1 of 3 residents (Resident 98), reviewed for respiratory care. These failures placed the resident at risk for respiratory infection, related complications, and a diminished quality of life. Findings Included . Review of the facility's undated policy titled, Oxygen Administration, showed that during O2 setup or adjustment, staff were instructed to check the mask, tank, humidifying (that increase humidity/moisture in the air) jar [container], to ensure they were in good working order and securely fastened. The policy further instructed staff to document the date and time the setup was performed. Review of a face sheet printed on 06/05/2025 showed Resident 98 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a progressive lung disease that makes it difficult to breathe) and acute hypoxic respiratory failure (a condition characterized by low levels of O2 in the blood). Review of Resident 98's May 2025 Medication Administration Record (MAR), printed on 06/03/2025 showed an order for two liters (unit of measurement) of O2 continuously at night, off during the day, and use of Bilevel Positive Airway Pressure (BIPAP- a device that helps people with breathing difficulties) at night. Review of Resident 98's physician order dated 01/02/2025, showed instructions for staff to check Resident 98's O2 saturation each shift and to notify the provider [medical team] if the saturation fell to 90 percent or lower. Review of the May 2025 MAR printed on 06/05/2025 did not show documentation of Resident 98's O2 saturation during night shift on the following dates: 04/03/2025, 05/02/2025, 05/19/2025, 05/20/2025, 05/24/2025, 05/25/2025 and 05/29/2025. Observations of Resident 98's O2 equipment on the following dates showed: - On 05/29/2025 at 10:37 AM, the O2 humidifier bottle was not dated. The BiPAP tubing nose piece was observed laying on the nightstand table and was not properly stored. - On 05/30/2025 at 9:22 AM, the O2 humidifier bottle was not dated. - On 05/30/2025 at 2:31 PM, the humidifier bottle was not dated and the BiPAP tubing nose piece was not properly stored. - On 06/02/2025 at 10:59 AM, the O2 nasal cannula (a flexible tubing that delivers O2 through the nose) was observed laying on the floor, not properly stored. The humidifier bottle was unlabeled. A joint observation and interview on 06/02/2025 at 11:12 AM with Staff DD, Licensed Practical Nurse, showed Resident 98's nasal cannula tubing was not properly stored, it was laying on the floor. Staff DD stated that the tubing should not be laying on the floor and that it should be stored in a bag. Staff DD were observed picking it up and placed it on top of the O2 concentrator without properly cleaning and/or storing it. Staff DD was asked whether the O2 humidifier bottle was labeled, Staff DD stated, No, it should be [labelled]. A joint observation and interview on 06/04/2025 at 8:56 AM with Staff D, Register Nurse Unit Manager, showed that the nasal cannula was not properly stored, it was laying on the floor. Staff D stated, It's [it is] not supposed to be laying on the floor. In an interview on 06/06/2025 at 11:22 AM, Staff B, Director of Nursing, stated that it was their expectation that all O2 tubing and humidifier bottles should have been dated and initialed, and that O2 saturation have been documented per the physician's order. Staff B further stated that nasal cannula should be stored in a clear plastic bag when not in use. Reference: (WAC) 388-97-1060 (3)(j)(vi) .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure physician orders were followed and/or clarified in accordance with professional standards of practice for 3 of 9 residents (Residents 16, 321 & 219), reviewed for medication administration. This failure placed the residents at risk for receiving incorrect medication dosage and formulation, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, [Company name] Medication Administration Policy, showed, This policy establishes the guidelines for the safe and effective administration of medications . The policy further showed that the .right medication, right dose . must be confirmed . during medication administration. In addition, the policy showed, This policy ensures that medications are administered safely and effectively . maintaining compliance with regulatory standards and best practices. RESIDENT 16 Review of Resident 16's June 2025 physician orders showed, Calcium 600+D3 [cholecalciferol-type of Vitamin D-a supplement] Oral [by mouth] Tablet 600-10 MG [milligram-unit of measurement]-MCG [microgram-unit of measurement] (Calcium Carbonate [type of calcium]-Cholecalciferol-a supplement) one time a day, started on 03/03/2025. Observation on 06/05/2025 at 8:33 AM, showed Staff Z, Registered Nurse (RN), administered a Citracal + D Calcium citrate [brand name, type of calcium supplement] - Vitamin D3 315 MG-250 IU [international unit-unit of measurement] Tablet to Resident 16 instead of the prescribed order above. In an interview and joint record review on 06/05/2025 at 8:44 AM, Staff Z stated that they administered a tablet of Citracal + D Calcium citrate - Vitamin D3 315 MG-250 IU to Resident 16. Staff Z stated that the prescribed medication was the same as the medication they administered to Resident 16. A joint record review of Resident 16's physician order showed, Calcium 600+D3 Oral Tablet 600-10 MG-MCG (Calcium Carbonate-Cholecalciferol). A joint record review of the medication administered to Resident 16 showed, Citracal + D Calcium citrate - Vitamin D3 315 MG-250 IU Tablet. Further joint record review of the physician order and the medication administered showed the medications were two different types of calcium (carbonate and citrate). Staff Z stated that Resident 16 had received different dosages of calcium and Vitamin D3. Staff Z further stated that the order should have been clarified with the pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs). In an interview and joint record review on 06/05/2025 at 12:15 PM, Staff E, RN Unit Manager, stated that they expected staff to administer medications as prescribed by the physician. A joint record review of Resident 16's physician order showed Calcium 600+D3 Oral Tablet 600-10 MG-MCG (Calcium Carbonate-Cholecalciferol). Staff E was shown an empty packet of the medication administered to Resident 16. A joint record review of the medication administered to Resident 16 showed Citracal + D Calcium citrate - Vitamin D3 315 MG-250 IU Tablet. Further joint record review of the physician order and the medication administered showed the medications were two different types/dosages of calcium (carbonate and citrate) and Vitamin D. RESIDENT 321 Review of Resident 321's June 2025 physician order showed, Calcium Carbonate-Vitamin D Oral Tablet 600-5 MG-MCG (Calcium Carbonate-Vitamin D) one tablet by mouth two times a day for bone health, started on 05/19/2025. A joint record review and interview on 06/05/2025 at 9:39 AM with Staff AA, Licensed Practical Nurse, showed Resident 321's June 2025 electronic Medication Administration Record (e-MAR) had orders for Calcium Carbonate-Vitamin D Oral Tablet 600-5 MG-MCG (Calcium Carbonate-Vitamin D). Staff AA stated that they had administered Resident 321 with the above prescribed order in the morning. When asked to show a sample of the medication administered to Resident 321, Staff AA pulled out a Caltrate [brand name] + D Calcium Carbonate-Vitamin D3 600 MG (1,500 MG)-400 IU from Resident 321's medication bin, and stated, this is what [they] received. A joint record review of Resident 321's physician order and the medication they had indicated they were not the same dosage. Staff AA stated that they should have clarified the order with the physician and the pharmacist. RESIDENT 219 Review of Resident 219's June 2025 physician order showed, Calcium Carbonate-Vitamin D Oral Tablet 600-5 MG-MCG (Calcium Carbonate-Vitamin D) two tablets by mouth two times a day for bone health, started on 05/13/2025. A joint record review and interview on 06/05/2025 at 9:39 AM with Staff AA, showed Resident 219's June 2025 e-MAR had orders for Calcium Carbonate-Vitamin D Oral Tablet 600-5 MG-MCG (Calcium Carbonate-Vitamin D). Staff AA stated that they had administered Resident 219 with the above prescribed order in the morning. When asked to show a sample of the medication administered to Resident 219, Staff AA pulled out a Caltrate + D Calcium Carbonate-Vitamin D3 600 MG (1,500 MG)-400 IU from Resident 219's medication bin, and stated, this is what I gave [them]. A joint record review of Resident 219's physician order and the medication they had were not the same dosage. Staff AA stated that they should have clarified the order with the physician and the pharmacist. A joint record review and interview on 06/05/2025 at 12:35 PM with Staff E, showed Resident 321 and Resident 219's had physician order of Calcium Carbonate-Vitamin D Oral Tablet 600-5 MG-MCG. A joint record review with Staff AA and Staff E showed the sample of the medication administered to Resident 321 and Resident 219 had different dosages of Vitamin D than what was prescribed by the physician. Staff E stated that they expected staff to have clarified the residents' medications with the physician and the pharmacist. In an interview and joint records review on 06/05/2025 at 12:59 PM, Staff X, Consultant Pharmacist, stated that their pharmacy was in-house and they packaged and dispensed medications prescribed by the physician. Staff X was shown the medications administered to Resident 16, Resident 321 and Resident 219. Staff X stated that the medications were dispensed by their pharmacy. A joint record review of the physician orders and the medications dispensed by the pharmacy showed Resident 16, Resident 321 and Resident 219 received medications with different dosages of calcium and Vitamin D3 than what was prescribed by their physician. Staff X stated that the medication orders should have been clarified with the physician prior to dispensing. In an interview on 06/05/2025 at 1:30 PM, Staff B, Director of Nursing, stated that they expected staff to have clarified Resident 16, Resident 321 and Resident 219's medications with their physician. Staff B further stated that they expected the pharmacist to have dispensed medications as prescribed by their physician. Reference: (WAC) 388-97-1300(1)(b)(ii) .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dental services were offered and/or provided for 1 of 1 resident (Resident 36), reviewed for dental services. This failure placed the resident at risk for unmet dental care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Dental Services, dated 10/01/2021, showed that Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. It further showed that routine dental services were provided through a referral to community dentists (tooth doctor), to the resident's personal dentist, referral to community dentists and/or referral to other health care organizations that provide dental services. Review of a face sheet printed on 06/05/2025, showed that Resident 36 admitted to the facility on [DATE]. In a phone interview on 05/29/2025 at 2:30 PM, Resident 36's representative stated that Resident 36 had a broken a tooth, and that they notified facility staff of it. Resident 36's representative further stated that they had not received an update regarding Resident 36 receiving dental services. An observation and interview on 06/04/2025 at 12:41 PM, showed Resident 36 was lying in bed and eating their meal. Resident 36's lunch entrée consisted of uncoated strips of white meat, unpeeled potato slices and a serving of mixed corn kernels, peas, carrots, and lima beans. It further showed Resident 36 was slowly chewing in between bites of their meal. Resident 36 stated that they asked staff to turn off their wall-mounted fan, because it takes so long to chew that my food gets cold .then it's just tasteless. In an interview on 06/05/2025 at 8:49 AM, Staff F, Social Services, stated that, I was not informed of the broken tooth in the [nursing] progress note on 05/10/2025. When asked if Resident 36 had been referred to dental services, Staff F stated that they would confirm and refer to the list of residents who were referred to the in-house dental hygienist (a health professional who specializes in preventative dental care). Review of a nursing progress note dated 05/10/2025 showed it was labeled as a late entry, and that Resident 36's representative had notified staff in-person regarding Resident 36's broken tooth. It did not show that Resident 36 was referred to dental services regarding the broken tooth. In an interview on 06/05/2025 at 10:42 AM with Staff G, Registered Nurse (RN) and Staff D, RN Unit Manager, Staff G stated that they were aware of Resident 36's broken tooth. Both Staff G and Staff D stated that Resident 36 had not been referred to dental services and that, because it's [it is] not bothering [Resident 36]. Both Staff G and Staff D stated, Yes, when asked if residents would be referred to dental services for preventative dental care. Both Staff G and Staff D further stated that they considered an assessment for a broken tooth as preventative care. In a follow up interview on 06/05/2025 at 11:53 AM, Staff D stated that Resident 36 had not been referred to dental services for their broken tooth and that Resident 36 should have been referred. In a follow up interview on 06/05/2025 at 12:01 PM, Staff F stated that they were unable to locate documentation indicating that Resident 36 had been referred to dental services related to the broken tooth. In an interview on 06/05/2025 at 4:06 PM, Staff B, Director of Nursing, stated that they expected a resident with a known broken tooth, would be referred to dental services and that Resident 36 should have been referred. Reference (WAC): 388-97-1060 (3)(vii) .

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure meal preferences were provided for 2 of 7 residents (Residents 35 & 10), reviewed for food preferences. This failure placed the residents at risk of not having their food choices honored, dissatisfaction with food served, and a diminished quality of life. Findings included . RESIDENT 35 Review of the annual Minimum Data Set (MDS-an assessment tool) dated 05/07/2025 showed Resident 35 had an intact cognition. In an interview on 05/29/2025 at 10:39 AM, Resident 35 stated that they were provided with a menu selection for their breakfast, lunch and dinner. Resident 35 stated that they would cross out the food items they did not want and circled or wrote down the ones they preferred to have. Resident 35 stated, I don't [do not] like the menu selection. Resident 35 further stated that the kitchen staff don't [do not] pay attention to what you like. Review of the lunch menu for 06/03/2025 at 10:32 AM, showed, Marinated [seasoned] chicken or glazed [coated with sweet ingredients and spices] ham, mashed potatoes, carrots, angel food cake [sponge cake with cream]. An observation and interview on 06/03/2025 at 12:05 PM, Resident 35's lunch meal tray showed a marinated chicken thigh, mashed potatoes, carrots, angel food cake, two cups of ice cream and two cups of hot chocolate. Resident 35 stated, Look, they gave me what I have crossed out [marinated chicken or the glazed ham, mashed potatoes and carrots]. They did not follow the menu and that they were annoyed. Resident 35 further stated that they did not like the marinated chicken or the glazed ham, mashed potatoes, and carrots. A joint record review and interview on 06/03/2025 at 12:11 PM, with Staff K, Certified Nursing Assistant, showed Resident 35's lunch menu selection ticket had crossed out the following: marinated chicken or glazed ham, mashed potatoes and carrots. Staff K stated that they were aware that Resident 35 had crossed out the food items on their lunch menu selection ticket. Staff K stated that they delivered Resident 35's lunch meal tray, which the kitchen staff had prepared and included the food items Resident 35 had crossed out. Staff K further stated that Resident 35's menu choices or preferences were not followed and that they should have done so. A joint record review and interview on 06/03/2025 at 12:15 PM, with Staff L, Licensed Practical Nurse, showed Resident 35's lunch menu selection ticket had crossed out the following: marinated chicken or glazed ham, mashed potatoes and carrots. Staff L stated that they expected staff to have followed Resident 35's meal choices and/or preferences before they provided Resident 35's meal tray. In an interview on 06/03/2025 at 12:18 PM, Staff D, Registered Nurse [RN] Unit Manager (RNUM), stated that they expected staff to have followed Resident 35's meal choices and/or preferences. RESIDENT 10 Review of a quarterly MDS dated [DATE] showed Resident 10 had intact cognition. In an interview on 05/30/2025 at 10:37 AM, Resident 10 stated, I don't [do not] get my menu sometimes, and sometimes the food was not appetizing. In an interview on 06/03/2025 at 8:49 AM, Resident 10 stated they had pizza for dinner and that they did not like the way it was served. Observation and interview on 06/04/2025 at 12:22 PM showed Resident 10 had a sandwich wrapped in transparent plastic on a plate and a can of root beer on their bedside table. Resident 10 were not in their room. Another observation at 12:58 PM showed an uneaten tuna sandwich without dressing or condiments with half of its bread flap open on Resident 10's bedside table. Resident 10 were not in their room; they were observed on the phone at the unit nursing station. Staff J, RN, was observed outside of Resident 10's room. Staff J stated that Resident 10 had told the kitchen staff that they did not get the sandwich they had asked for and was upset about their tuna sandwich. Another observation and interview on 06/04/2025 at 1:09 PM, showed Resident 10 was teary-eyed. Resident 10 stated, I specifically asked them for tuna salad sandwich with celery and green onions chopped up with mayonnaise mixed with tuna on a good bread. Resident 10 further stated that they called the kitchen and spoke to a staff. A joint observation and interview on 06/04/2025 at 1:16 PM, Staff H, Dietary Manager, delivered Resident 10 a tuna salad sandwich on a plate covered with a transparent wrap. Resident 10 stated, It [tuna sandwich] should have been like this. Staff H stated that they prepared the tuna salad sandwich themselves. When Staff H was shown the tuna sandwich that was delivered earlier, Staff H stated, It should [not have] been prepared like that and that Resident 10's menu choice and/or preference should have been followed. Another interview on 06/04/2025 at 1:31 PM, Staff J stated that residents had the daily menu in the morning and they choose the menu for lunch and dinner. Staff J stated that Resident 10 did not get the meal they had chosen, and it was not the first time it had happened, and that Resident 10 had spoken about it during the food committee [meeting]. In an interview on 06/04/2025 at 2:27 PM, Staff E, RNUM, stated that they expected residents' meal choices and/or preferences to be honored and followed by the facility. Staff E stated that Resident 10's meal choices and preferences should have been followed by staff. In an interview on 06/04/2025 at 2:47 PM, Staff B, Director of Nursing, stated, I expected staff to honor or follow residents' choices and preferences about their meals. Reference: (WAC) 388-97-1120 (3)(a) .

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure clinical or medical records were complete and accurate for 1 of 3 residents (Resident 118), reviewed for resident records. The failure to document resident health condition (assessment and evaluation) placed the resident at risk for incomplete and inaccurate medical records and unmet care needs. Findings included . Review of a face sheet printed on [DATE] showed Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Minimum Data Set (an assessment tool) look up page showed a completed Death in Facility assessment dated [DATE]. Review of the [DATE] nursing progress notes printed on [DATE] did not show documentation about Resident 118's clinical status or condition on [DATE]. Review of vital signs (measurable overall health status that included blood pressure (BP), heart rate (HR) and breathing rate) data for Resident 118, showed that their BP, HR and breathing rate were last documented on [DATE]. Review of the Electronic Health Record (EHR) did not show documentation of Resident 118's clinical status on [DATE]. In an interview and joint record review on [DATE] at 12:43 PM, Staff AA, Licensed Practical Nurse, stated they were working on day shift on [DATE], and that they were assigned to Resident 118. A joint record review of the vital signs did not show documentation of Resident 118's BP, HR and breathing rate on [DATE] and [DATE]. A joint record review of Resident 118's nursing progress note showed the last documentation was dated [DATE] and had no documentation about Resident 118's clinical status on [DATE]. Staff AA stated there was no information for Resident 118's BP, HR and breathing rate on [DATE] and [DATE] and that the last nursing note was dated [DATE]. Staff AA stated that they did not write a progress note about Resident 118's clinical status on [DATE]. In a telephone interview on [DATE] at 2:17 PM, Resident 118's Collateral Contact (CC2) stated that Resident 118 went to the hospital on [DATE] for a planned diagnostic (the process of identifying illness, condition or injury) procedure and had a cardiac arrest (sudden loss of heart function) during the procedure. Resident 118's CC2 stated, They tried to do CPR [Cardio-Pulmonary Resuscitation-emergency lifesaving procedure] but [Resident 118] did not make it. [Resident 118] expired [died] on [DATE]th [[DATE]] at around 11:30 [AM] in the morning. In an interview and joint record review on [DATE] at 2:52 PM, Staff B, Director of Nursing, stated that Resident 118 was known to them and that Resident 118 went out for a medical appointment/planned procedure on [DATE] and did not die here [in the facility]. A joint record review of Resident 118's EHR did not show documentation about their medical appointment or planned procedure or Resident 118's clinical status on [DATE]. Staff B stated that there was no documentation about Resident 118 leaving the facility for the planned procedure or medical appointment. Staff B stated that there was no documentation about Resident 118's clinical status and/or about their death in their medical record. Staff B further stated, I expected that there should have been forms of documentation about [Resident 118]'s clinical status or their death. Reference: (WAC) 388-97-1720 (1)(a)(i)(ii)(4)(b)(i)(ii)(iii) .

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) and influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were offered for 1 of 5 residents (Resident 54), reviewed for immunizations and infection control. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and influenza disease. Findings included . Review of the facility's undated policy titled, Pneumococcal Vaccine, showed, Residents will be offered pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infection. It further showed, Re-vaccinations of the pneumococcal vaccine will be administered to those residents who are deemed appropriate by the physician. Review of the facility's policy titled, Influenza Vaccine, dated 08/10/2023, showed, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. It further showed, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. Review of a face sheet printed on 06/05/2025 showed Resident 54 admitted to the facility on [DATE]. Review of Resident 54's immunization record printed on 06/06/2025 showed that they received an influenza vaccine on 11/14/2023 and Pneumovax [pneumococcal vaccine] Dose 2 on 04/08/2020. Further review did not show that Resident 54 received the annual influenza vaccine and the most current pneumococcal vaccine. Review of the Electronic Health Record (EHR) showed no documentation that Resident 54 was offered the annual influenza vaccine, pneumococcal vaccine or was informed about the risks and benefits. In a telephone interview on 06/05/2025 at 2:40 PM, Staff W, Infection Preventionist, stated that they had access to the state immunization database and would go there to check if residents' were up to date on their vaccinations. Staff W stated that on admission, they would offer the influenza and pneumococcal vaccine and if they refused, they would explain the risk and benefits and would document it. If the resident accepted the vaccination, they would give the consent form to the pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs) who would administer the vaccine. In an interview and joint record review on 06/06/2025 at 11:17 AM, Staff E, Registered Nurse Unit Manager, stated that they offered the influenza vaccine annually. A joint record review of Resident 54's immunization record did not show documentation that they received the annual influenza vaccine and that they received the Pneumovax Dose 2 on 04/08/2020. Staff E stated there was no documentation that the vaccines were given unless he refused and that it would have been documented in their EHR or it wound be documented in the vaccination consent form. Staff E stated that they were not able to find documentation that Resident 54 received the first dose of the pneumococcal vaccine or documentation that they had refused it. Staff E further stated they would ask the pharmacy as they usually had residents' vaccination records. Review of Resident 54's WA IIS [Washington State Immunization Information System]-Patient Vaccination record dated 06/05/2025, showed that they were Past Due for pneumococcal and influenza vaccine. In an interview and joint record review on 06/06/2025 at 11:59 AM, Staff X, Consultant Pharmacist, stated nursing staff would provide them with the consent form for the vaccine and that they would administer it. If residents' refused, they would document it. Staff X stated that they did not have a record that they had administered the annual influenza vaccine to Resident 54 and that they may not have gotten a consent form to administer the vaccine. A joint record review of Resident 54's immunization record showed that Resident 54 received Pneumovax Dose 2 on 04/08/2020. Staff X stated that Resident 54 was eligible for the Prevnar 20 (a vaccine that protects against 20 strains of bacteria that cause pneumococcal disease) and based on the information they had, they would recommend that for Resident 54. In an interview on 06/06/2025 at 1:54 PM, Staff B, Director of Nursing, stated that they offered the influenza vaccine annually and that pneumococcal vaccines offered to residents' depended on what the pharmacy recommended and what vaccine they needed. Staff B stated that Staff W ensured residents' were up to date on their vaccines and if they were not, they would be offered the vaccine. Staff B stated that they did not see the annual influenza vaccine record for Resident 54 and that it should have been offered to them. Staff B further stated that Resident 54 should have been offered the recommended pneumococcal vaccine. Reference: (WAC) 388-97-1340 (1)(2) .

CONCERN (E)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure the survey result binder included the recent recertification survey results and associated plan of correction for 2 of 3 years (November 2022 and February 2023), reviewed for availability of survey reports. This failure prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plan of correction. Findings included . Review of the facility's undated policy titled, Examination of Survey Results, showed, A copy of the most recent and three preceding years of standard surveys, including any subsequent extended surveys, follow-up revisit reports, complaint surveys, etc., along with state-approved plans of correction of noted deficiencies, are accessible in an area frequented by residents, resident representatives, and visitors. A review of a binder labelled, Annual Recertification Survey on 05/29/2025 at 10:18 AM, on 05/30/2025 at 2:17 PM, and on 06/02/2025 at 2:05 PM, showed the binder contained the 2024 annual recertification survey results and associated plan of correction. Further review of the binder showed that the 2022 and 2023 recertification survey results and their associated plan of correction for 11/03/2022 and 02/20/2023 were not the binder. During a joint record review and interview on 06/02/2025 at 2:17 PM with Staff B, Director of Nursing, showed that the binder contained the 2024 recertification survey and its associated plan of correction. Further review of the binder showed the 2022 and 2023 survey results were not included in the binder. Staff B stated the binder should have the 2022 and 2023 survey results and their associated plan of correction and made accessible to residents and their representatives. In an interview on 06/02/2025 at 2:23 PM, Staff A, Administrator, stated they were responsible for maintaining and updating the recertification survey results binder. Staff A further stated that the 2022 and 2023 survey results were missing and that they were required to maintain the previous three-year survey result and its associated plan of correction. Reference: (WAC) 388-97-0480(1)(a)(c)(4) (5)(a) .

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and/or renew guardianship papers, and/or failed to offer assistance in formulating an Advance Directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA] for health care) for 3 of 4 residents (Residents 43, 77 & 102), reviewed for Advance Directives. These failures placed the residents and/or their representatives at risk of 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, dated [DATE], showed, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. It further showed, If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. RESIDENT 43 Review of the annual Minimum Data Set (an assessment tool) dated [DATE] showed Resident 43 readmitted to the facility on [DATE] and had a diagnosis of unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently). In an interview on [DATE] at 10:30 AM, Resident 43 stated that they had a guardian. Review of Resident 43's guardian and conservator (an individual appointed by the court to look after the well-being of a minor or a person who is mentally incapacitated due to an illness or accident) papers showed an expiration date of [DATE]. In an interview and joint record review on [DATE] at 2:01 PM, Staff F, Social Worker, stated that Social Workers and Staff S, Business Office Manager, managed the residents' guardianship papers and that Social Workers initiated it. Staff F stated that the Business Office ensured guardianship papers were up to date and that sometimes they would keep an eye on them but were not high on their list. Staff F stated that if the guardianship papers were expired, they would try to get an updated copy. A joint record review of Resident 43's guardianship papers showed an expiration date of [DATE]. Staff F stated that they may be able to get an updated copy from Resident 43's representative. Staff F stated that they usually checked on it for their assigned residents and that they were not sure who was responsible in ensuring the guardianship papers were up to date and ensuring the current copy was in the residents' Electronic Health Record (EHR). Staff F further stated that if residents' had an updated guardianship paper, they should have had a copy in their EHR. In an interview on [DATE] at 3:27 PM, Staff S stated that guardianship lawyers ensured that residents' guardianship papers were up to date and that the guardianship lawyers were the ones that were on top of it. When asked who ensured the guardianship papers were up to date in the residents' EHR, Staff S stated that no one was assigned to it. In an interview on [DATE] at 3:41 PM, Staff A, Administrator, stated that they did not know who ensured updated guardianship papers were in the residents' EHR and that they would have to refer to their policy. Staff A further stated that they expected guardianship papers to be up to date in Resident 43' EHR. RESIDENT 77 Review of a face sheet printed on [DATE] showed Resident 77 was admitted to the facility on [DATE]. Review of the quarterly minimum data set (an assessment tool) dated [DATE] showed Resident 77 had intact cognition. Review of Resident 77's EHR did not show documentation for advance directives. Further review of the EHR did not show documentation that an advance directive was discussed and/or offered to Resident 77. In an interview and joint record review on [DATE] at 2:15 PM, Staff F stated, if they [residents] have [advance directive] we ask them to send it to us to have it uploaded to our system. Staff F stated that they offered assistance for residents who chose to have an advance directive. A joint record review of Resident 77's EHR did not show advance directive was discussed and/or offered to Resident 77. Staff F stated, I don't [do not] see any documentation that it was discussed or offered to [Resident 77] and that it should have been discussed and offered to the resident. In an interview on [DATE] at 1:55 PM, Staff A stated that they expected staff to discuss or offer advance directive to Resident 77 upon their admission to the facility. RESIDENT 102 Review of a face sheet printed on [DATE] showed Resident 102 admitted to the facility on [DATE]. In an interview and joint record review on [DATE] at 12:51 PM, Staff O, Social Worker, stated that the facility followed a process in which they offer residents the opportunity to establish an advance directive if they did not have one. Staff O stated that Resident 102 was their own decision-maker and did not have an advance directive. Staff O stated that they spoke with Resident 102's collateral contact, and they were interested in serving as the resident's DPOA (a legal document that allows an appointed agent to make decisions on behalf of the principal, even if the principal becomes incapacitated). A joint record review of Resident 102's EHR showed no documentation that advance directive was discussed with the resident's collateral contact. Staff O stated that they did not document the conversation they had with Resident 102's collateral contact. In an interview on [DATE] at 8:22 AM, Resident 102 stated that they were their own decision maker. Resident 102 stated that they wanted to designate DPOA for their health care decisions. Resident 102 stated that the facility did not request a copy of advance directive if they had or offered them the option to establish one. Resident 102 stated that with their procedure appointment on [DATE] approaching, they were expected to have an advance directive in place. Resident 102 stated that they would be interested in having advance directive if they were given the opportunity. In an interview on [DATE] at 2:02 PM, Staff A stated that residents should be given an opportunity to delegate to DPOA upon admission and ensure their care preferences were documented. Staff A stated that these directives must be easily accessible to staff when needed. Staff A stated that Resident 102 should have been offered the option to establish an advance directive, and that Staff O should have documented all discussions they had regarding Resident 102's advance directive. Reference: (WAC) 388-97-0280 (3)(a)(d) .

CONCERN (E)

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

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 98 Review of a face sheet printed on 06/05/2025 showed Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's EHR showed a physician's order initiating an antidepressant (a drug used to treat mental health condition that causes a persistent feeling of sadness and loss of interest in activities, significantly impacting daily life) 7.5 milligrams (mg- unit of measurement) on 05/15/2025, and a dose increased to 15 mg on 05/20/2025. Review of Resident 98's May 2025 MAR, printed on 06/04/2025 did not show monitoring or documentation for target behaviors and potential adverse side effects. A joint record review and interview on 06/04/2025 at 10:52 AM with Staff D, showed Resident 98 had been taking an antidepressant since 05/15/2025. Staff D stated that adverse side effects and target behaviors were not monitored or documented and that they should have. In an interview on 06/06/2025 at 11:27 AM, Staff B stated it was their expectation that any resident taking antidepressants should have been monitored for adverse side effects and target behaviors and documented in the MAR. Staff B further stated this was missing in Resident 98's records. Review of a face sheet printed on 06/04/2025 showed Resident 54 was admitted to the facility on [DATE]. Review of the May 2025 physician's order summary report showed that Resident 54 had been on antipsychotic medication since 10/26/2023. Review of Resident 54's Abnormal Involuntary Movement Scale (AIMS- an assessment tool used to evaluate involuntary movements) assessment showed it was completed late on 09/25/2024 (two months and 10 days late). Review of a Consultant Pharmacist's Medication Regimen Review dated 04/02/2025 showed, Please consider document AIMS assessment every 6 [six] months since he is taking Quetiapine [antipsychotic medication] routinely so the facility may stay compliant. Last AIMS was on 9-25-24 [09/25/2024]. In an interview and joint record review on 06/04/2025 at 10:35 AM, Staff E, RNUM, stated that Resident 54 was on antipsychotic medication. Staff E stated that residents on antipsychotic medication should have had an AIMS assessment completed every three to six months. A joint record review showed that Resident 54's last AIMS assessment was completed on 09/25/2024. Staff E stated that Resident 54's AIMS assessment was overdue and should have been completed within six months. In an interview on 06/04/2025 at 1:36 PM, Staff B stated that residents on antipsychotic medication were expected to have an AIMS assessment completed every six months and as needed. Staff B further stated that Resident 54's AIMS assessment was late and should have been completed within six months. Reference: (WAC) 388-97-1060 (3)(k)(i)(4) Based on interview and record review, the facility failed to ensure adequate monitoring was in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 3 of 5 residents (Resident 6, 90 & 98), and failed to timely assess involuntary movements associated with psychotropic drug use for 1 of 3 residents (Resident 54), reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Antipsychotic Medication [used to treat mental health symptoms], showed that nursing staff will observe and document information regarding the effectiveness of any interventions, including antipsychotic medications. It further showed that nursing staff would monitor for and report to the attending physician, side effects and adverse consequences, to include involuntary movements associated with antipsychotic drug use. RESIDENT 6 Review of a face sheet printed on 06/05/2025, showed that Resident 6 readmitted to the facility on [DATE]. Review of Resident 6's Electronic Health Record (EHR) showed a physician's order for an antipsychotic medication that started on 08/15/2024. Further review did not show monitoring for side effects related to antipsychotic medication use. Review of Resident 6's Medication Administration Record (MAR) for May 2025, printed on 06/02/2025, did not show documentation of monitoring of side effects related to antipsychotic medication use. In an interview and joint record review on 06/04/2025 at 10:53 AM, Staff D, Registered Nurse [RN] Unit Manager (RNUM), stated that the facility monitored for side effects and target behaviors related to psychotropic drug use and that they expected to see documentation of monitoring in the MAR and in the physician's orders. A joint record review of Resident 6's EHR showed a physician's order for antipsychotic medication that started on 08/15/2024. Further joint record review of Resident 6's EHR did not show documentation of monitoring side effects related to antipsychotic medication use in the physician's orders, in May 2025 and in June 2025 MAR. Staff D stated that, I don't see it, I will put that in. Staff D further stated that they expected monitoring would have been in place. In an interview on 06/06/2025 at 11:48 AM, Staff B, Director of Nursing, stated that they expected residents who were prescribed psychotropic medications would have monitoring of side effects documented in the physician's orders and in the MAR. RESIDENT 90 Review of a face sheet printed on 06/05/2025, showed that Resident 90 was admitted to the facility on [DATE]. Review of Resident's 90's physician orders, printed on 06/03/2025, showed an order for an antipsychotic medication that was started on 07/18/2024. Further review did not show monitoring of side effects or target behaviors (observable behaviors that are intended to be addressed by medication) related to antipsychotic medication use. A joint record review and interview on 06/04/2025 at 11:03 AM with Staff D showed a physician's order for antipsychotic medication that started on 07/18/2024 in Resident 90's EHR. Further joint record review did not show documentation of monitoring side effects and target behaviors related to antipsychotic medication use in the physician's orders, in May 2025 MAR, and in June 2025 MAR. Staff D stated that they did not see documentation and that they expected monitoring for side effects and target behaviors would have been in place. In an interview on 06/06/2025 at 11:48 AM, Staff B stated that they expected residents who were prescribed psychotropic medications would have monitoring of side effects and target behaviors documented in the physician's orders and in the MAR.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NAIL CARE RESIDENT 76 Review of a quarterly MDS dated [DATE], showed Resident 76 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. Observation on 06/02/2025 at 11:55 AM, showed Resident 76's right thumb fingernail was long and had brown matter underneath them. The left great toenail had black discoloration, and the right great toenail had brown discoloration. Both great toenails were thick and had brown matter underneath them. Resident 76 stated they could not clip or clean their nails and had requested staff assistance and were told, We will get to it when we have [a] chance. A joint observation and interview on 06/06/2025 at 10:37 AM, Staff T, License Practical Nurse, showed Resident 76's right thumb fingernail was long and had brown matter underneath them. The left great toenail had black discoloration, and the right great toenail had brown discoloration. Both great toenails were thick and had brown matter underneath them. Staff T stated that staff were responsible for residents' nail care and/or refer them to the podiatrist (foot doctor) [as needed], who visited weekly. Review of a comprehensive care plan printed on 06/05/2025 showed Resident 76 had no care plan for nail care. Review of Resident 76's nursing progress note dated 12/16/2024 showed a podiatrist referral. Further review of Resident 76's EHR did not show documentation that Resident 76 was seen or scheduled for a visit with the podiatrist. A joint record review and interview on 06/06/2025 at 11:14 AM with Staff B, showed Resident 76's EHR did not include documentation that nail care was provided, a podiatrist visit was scheduled or had occurred, and a care plan for nail care developed or implemented. Staff B stated it was the staff's responsibility to provide nail care or refer residents to the podiatrist. Staff B further stated that during ADL care, staff should clip the residents' nails, identify who require podiatry services, and then put them on the list to be seen. Reference: (WAC) 388-97-1020(1), (2)(a)(b) TOILETING HYGIENE RESIDENT 27 Review of a face sheet printed on 06/02/2025 showed Resident 27 readmitted to the facility on [DATE] with diagnoses that included unspecified dementia (memory loss severe enough to impair daily life and independent function). Review of the quarterly MDS dated [DATE] showed Resident 27 was dependent on staff with toileting hygiene and was always incontinent with bladder and bowel. In an interview on 05/30/2025 at 9:11 AM, Resident 27 stated that they would not get toileting assistance on night shift and that the aides tell them they did not have time. Resident 27 stated that they had told staff that they did not mind being woken up to be changed because they have sensitive skin and needed to be changed. Review of the Activities of Daily Living Self Care Performance Deficit care plan, revised on 08/24/2017, showed, TOILET USE: [Resident 27] has been declining to use [the] toilet or BSC [beside commode]. She is incontinent B/B [bladder and bowel]. Offer to assist res [Resident 27] to [the] toilet upon rising in AM [morning], at HS [hour of sleep], and prn [as needed]. Requires assist with toilet transfer, hygiene, and clothing management. If res [Resident 27] declines toileting then check and change her q [every] 2-3 hrs [two to three hours]. Review of Resident 27's urinary incontinence care plan intervention, revised on 01/07/2025, showed, INCONTINENT: Offer/assist with toileting/incontinent care every 2-3 hours and prn (resident stated she wants to be WOKEN UP) per her request. Review of Resident 27's toileting hygiene task from 05/07/2025 through 06/05/2025, showed no documentation that toileting hygiene assistance was provided on night shift on 05/07/2025, 05/11/2025, 05/13/2025, 05/14/2025, 05/19/2025, 05/20/2025, 05/22/2025, 05/26/2025, 05/27/2025, 05/30/2025, 06/01/2025, and on 06/04/2025. Review of Resident 27's Documentation Survey Report, dated March 2025 through May 2025 showed, Toileting Hygiene, showed the following: -March 2025- 25 days out of 31 days with no documentation that toileting hygiene assistance was provided. -April 2025- 17 days out of 30 days with no documentation that toileting hygiene assistance was provided. -May 2025- eight days out of 31 days with no documentation that toileting hygiene assistance was provided. Review of Resident 27's nursing progress note from March 2025 through June 2025, did not show that they refused assistance with toileting hygiene. In an interview on 06/05/2025 at 5:54 AM, Staff P, Certified Nursing Assistant (CNA), stated that they provided toileting assistance at night and that if they provided the care, they would document it in their charting system. Staff P further stated that they assisted Resident 27 during the night and that Resident 27 never refuses care. In an interview and joint record review on 06/05/2025 at 8:25 AM, Staff E stated that they expected CNAs to provide toileting care every two to three hours on night shift and document it under task in their charting system. A joint record review of the toileting hygiene task from 05/07/2025 through 06/05/2025, showed 12 days of missing documentation for night shift. Staff E stated, technically if it's not charted, it's not done. Staff E further stated that staff should have provided toileting care at night unless Resident 27 refused. In an interview on 06/05/2025 at 1:57 PM, Staff B stated that they expected staff to provide toileting care per the residents' Kardex (care guide for CNAs), at least two to three hours or as needed. Staff B further stated that they expected staff to document the care provided every shift and if the resident refused, staff should document it. BED POSITIONING RESIDENT 93 Review of a face sheet printed on 06/02/2025 showed Resident 93 was admitted to the facility on [DATE] with a diagnosis of left lower leg fracture (break in the bone). Review of a quarterly Minimum Data Set (MDS-an assessment tool) dated 04/03/2025 showed Resident 93 had severe cognitive impairment. Further review of the MDS showed Resident 93 was unable to walk and had limited range of motion in their lower legs. Review of Resident 93's comprehensive care plan printed on 05/30/2025 did not include Resident 93's bed placement against the wall including its risks and benefits. An observation on 05/30/2025 at 8:56 AM showed Resident 93 was lying in bed and their bed was positioned against the wall. In an interview and joint record review on 06/04/2025 at 1:29 PM, Staff J, RN, stated that Resident 93's bed was positioned against the wall. A joint record review of the comprehensive care plan revised on 05/30/2025 did not include Resident 93's bed against the wall including its risks and benefits. Staff J stated that the unit manager was responsible for the care planning. In an interview and joint record review on 06/04/2025 at 2:11 PM, Staff E stated that they were aware that Resident 93's bed was positioned against the wall. A joint record review of the EHR did not show Resident 93 was assessed, evaluated and informed about the risks/benefits of having their bed against the wall. Staff E stated that Resident 93 did not have a care plan regarding placement of their bed against the wall and that it should have been. In an interview on 06/05/2025 at 2:51 PM, Staff B stated that they expected staff to have care planned Resident 93's bed placement against the wall including its risks and benefits. ACTIVITIES PROGRAM RESIDENT 95 Review of the facility's policy titled, Activities Programs, dated 10/01/2021, showed that the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. The policy showed that activities were available daily and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. The policy further showed that the resident's participation in activities was documented in the resident's medical record. Review of a face sheet printed on 06/04/2025 showed that Resident 95 admitted to the facility on [DATE]. Review of the admission MDS dated [DATE], showed Resident 95 was cognitively intact. The MDS further showed that it was very important for Resident 95 to listen to the music they like, keep up with the news, do their favorite activities and going outside to get fresh air when the weather was good. Review of Resident 95's care plan dated 04/22/2025, showed that the facility would encourage, support and assist [Resident 95] with family phone/virtual/in-person visits and invite, encourage and assist Resident 95 to attend group activities. The care plan further showed that [Resident 95] would be provided one on one visit as needed for emotional support and provide assistance and access to leisure activity supplies in room (magazines, newspaper, mystery books, TV (News, Sports [hockey, soccer, football baseball], channel 4/5, Price is Right game show, movies, country music, puzzles (fill in the blank) .). In an interview on 05/29/2025 at 1:01 PM, Resident 95 stated that they liked to do activities such as going out. When asked if they were doing activities in the facility, Resident 95 stated, No, I am supposed to have activities, but I have never seen any. Resident 95 further stated that they liked going out, and they went out once when their collateral contact visited them. Multiple observations on 05/29/2025 at 1:01 PM, on 06/02/2025 at 9:33 AM, and on 06/03/2025 at 8:45 AM, showed that Resident 95 was awake, lying in bed and did not have any leisure activity supplies in their room such as magazines, newspaper and mystery books. In an interview and joint record review on 06/03/2025 at 9:24 AM, Staff V, Activities Director, stated they expected the residents to participate in activities and that after they participated or refused, it should be documented. Staff V stated that they did not believe Resident 95 was coming to group activities, That is probably because [Resident 95] does not want to come. Staff V stated that Resident 95 was definitely doing activities independently, but for group activities, I do not see it on the chart. Staff V further stated, I do not think [Resident 95] had one on one. We should have let [Resident 95] participated in activities as planned in their care plan. I do not think everything listed on [Resident 95's] care plan was being implemented. A joint record review of activities progress notes from 04/21/2025 through 06/03/2025 did not show that Resident 95 had documentation for their activity participation. Staff V further stated that Resident 95's activity care plan should have been implemented. In an interview on 06/05/2025 at 2:02 PM, Staff A, Administrator, stated that their expectation was for residents to be offered activities that enhance their well-being and social engagement within the facility. Staff A further stated that Resident 95's activity care plan should have been implemented. Based on observation, interview, and record review, the facility failed to develop and/or consistently implement care plans for 6 of 20 residents (Residents 36, 6, 93, 95, 27 & 76), reviewed for comprehensive care plans. The failures to implement care plans for nutrition, dental care, pain management, bed positioning, activities program, toileting hygiene, and nail care, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Care Planning- Comprehensive Person-Centered, showed that The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) [A manual used to guide resident assessments] process . All reasonable efforts will be made to incorporate the resident's personal and cultural preferences in developing goals of care. It further showed that each resident's comprehensive care plan would describe services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. NUTRITION CARE PLAN RESIDENT 36 Review of a face sheet printed on 06/05/2025, showed that Resident 36 admitted to the facility on [DATE] with diagnosis that included gastroparesis (a condition where the stomach [part of the body where food goes after it is eaten] muscles don't work properly to move food through the stomach, which can lead to vomiting and trouble digesting food). Review of Resident 36's care plan, printed on 06/04/2025 showed, Special instruction: INFO [information]: Give smaller meals more frequently: 4-5 [four to five] small meals a day versus 3 [three] large meals. Small particle diet for Gastroparesis. Observations on 05/30/2025 at 8:54 AM, on 06/03/2025 at 9:13 AM and on 06/05/2025 at 8:39 AM showed Resident 36's main entrée portions were fully covering the surface of their plate [served with regular portions]. A joint record review and interview on 06/04/2025 at 1:35 PM with Staff G, Registered Nurse (RN), showed Resident 36's Electronic Health Record (EHR) profile had instructions for smaller meals more frequently: 4-5 small meals a day versus 3 large meals. Small particle diet for Gastroparesis. Staff G stated that Resident 36 did not receive small meal portions and that, They look regular to me. A joint record review and interview on 06/05/2025 at 4:09 PM with Staff B, Director of Nursing, showed Resident 36's care plan had instructions for smaller meals more frequently: 4-5 small meals a day versus 3 large meals. Small particle diet for Gastroparesis. Staff B stated that they expected Resident 36's special instructions should be implemented. DENTAL CARE PLAN Review of a nursing progress note dated 05/10/2025 showed it was labeled as a late entry, and that Resident 36's representative had notified staff in-person regarding Resident 36's broken tooth. It did not show that Resident 36 was referred to dental services regarding their broken tooth. Review of Resident 36's care plan, printed on 06/04/2025, showed that, Refer to dentist [doctor who takes care of teeth and gums] as indicated. In an interview on 06/05/2025 at 10:42 AM, Staff G stated that they were aware of Resident 36's broken tooth. In an interview and joint record review on 06/05/2025 at 11:53 AM, Staff D, RN Unit Manager (RNUM), stated that Resident 36 had not been referred to dental services for their broken tooth and that they should have been referred. A joint record review of Resident's 36's dental care plan showed, Refer to dentist as indicated. Staff D stated that Resident 36's dental care plan was not implemented. In an interview on 06/05/2025 at 4:06 PM, Staff B stated that they expected Resident 36's dental care plan would have been implemented. PAIN MANAGEMENT CARE PLAN RESIDENT 6 Review of a face sheet printed on 06/05/2025, showed that Resident 6 readmitted to the facility on [DATE] with diagnosis that included polyosteoarthritis (swelling and stiffness that affects multiple joints at the same time) and dorsalgia (back pain). Review of Resident 6's physician's orders, printed on 06/05/2025, showed orders for an analgesic (medication used to relieve pain) that was administered routinely and as needed for pain. Review of a care plan, printed on 06/06/2025, did not show a care plan was developed for pain management related to Resident 6's diagnosis of polyosteoarthritis and dorsalgia. A joint record review and interview on 06/06/2025 at 9:25 AM with Staff E, RNUM, showed Resident 6 had a diagnosis of polyosteoarthritis listed in their EHR. Further joint record review of Resident 6's EHR did not show that a pain management care plan was developed. Staff E stated that I don't [do not] see any care plan addressing pain or pain management, and that they expected a care plan to address Resident 6's pain management would have been developed. A joint record review and interview on 06/06/2025 at 11:55 AM with Staff B showed Resident 6 had a diagnosis of polyosteoarthritis and dorsalgia listed in their EHR. Further joint record review did not show that a pain management care plan was developed. Staff B stated, I don't [do not] see anything, and that they expected pain management would have been developed.

CONCERN (E)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed and posted with actual hours worked after the start of each shift for 7 of 7 days (05/29/2025, 05/30/2025, 06/02/2025, 06/03/2025, 06/04/2025, 06/05/2025 & 06/06/2025), reviewed for sufficient and competent staffing. This failure placed the residents and their representatives at risk of not being fully informed of current staffing levels, potentially affecting their understanding of staff availability and care delivery. Findings Included . Review of the facility's policy titled, Posting Nursing Staffing Policy, dated 10/06/2022, showed the facility was required to post the daily nurse staffing information in a prominent location accessible to residents and visitors. The policy further showed the posting must include the facility name, current date, resident census, total number and actual hours worked by staff, and reflect staff absences due to callouts and illness for each shift. Observation on 05/29/2025 at 2:42 PM, showed a posted staffing form outside the elevator on the wall of the 400 hallways. The form showed shift times as follows: - Day shift: 6:00 AM to 2:30 PM - Evening shift: 2:00 PM to 10:30 PM - Night shift: 10:00 PM to 6:30 AM Multiple observations of the posted daily staffing form showed the planned actual hours, and it did not show the actual hours worked on the following dates and times: - On 05/29/2025 at 2:42 PM - On 05/30/2025 at 1:28 PM - On 06/02/2025 at 3:02 PM - On 06/03/2025 at 11:13 AM - On 06/04/2025 at 2:06 PM - On 06/05/2025 at 1:02 PM - On 06/06/2025 at 8:23 AM In an interview and joint record review on 06/06/2025 at 9:54 AM, Staff EE, Staffing Coordinator, stated that total actual hours were updated in real time by the front desk secretary as staff clocked in. A joint record review of the posted daily staffing forms dated 05/29/2025, 05/30/2025, 06/02/2025, 06/03/2025, 06/04/2025, 06/05/2025 & 06/06/2025 did not show the actual hours worked. Staff EE stated that planned hours, callouts, and illness were documented in the schedule book and were not shown on the posted staffing form. In an interview and joint record review on 06/06/2025 at 11:02 AM, Staff B, Director of Nursing, stated that it was their expectation that the total number and actual hours worked by licensed and unlicensed nursing staff would be posted for each shift A joint record review of the posted daily staffing forms dated 05/29/2025, 05/30/2025, 06/02/2025, 06/03/2025, 06/04/2025, 06/05/2025 & 06/06/2025 did not show the actual hours worked. Staff B stated the posted daily nurse staffing form was missing a column showing actual hours worked and that it should have been included. In an interview on 06/06/2025 at 1:34 PM, Staff A, Administrator, stated that the posted daily nurse staffing form should have included both the total number and the actual hours worked per shift. Staff A further stated this information was not shown on the daily nurse staffing. No associated WAC .

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 1 Review of a face sheet printed on 06/05/2025, showed Resident 1 readmitted to the facility on [DATE]. Review of Resident 1's facility provided document titled, Note to Attending Physician/Prescriber, dated 03/05/2025, showed a copy of the recommendation to Please consider ordering a new BMP [Basic Metabolic Panel- a blood test that measures the levels of different substances in your blood]. Most BUN [Blood Urea Nitrogen-a blood test to measure kidneys [organs responsible for filtering blood, regulating fluid balance and waste management through urine production function] lab [laboratory] shows it abnormally high . It further showed that the Physician/Prescriber Response was not completed. In an interview and joint record review on 06/06/2025 at 1:11 PM, Staff B stated that the Registered Nurse Unit Managers (RNUM) managed the medication regimen review recommendations provided by the pharmacist consultant. Staff B stated that when they received the recommendation from the pharmacist, they would be given to the RNUM to review and those requiring to be reviewed/completed by the physician would be provided to them. When the physician was done reviewing/completing the recommendation, they would be given back to the RNUM to follow up on. Staff B stated that it would then be given to medical records to be scanned into the residents' EHR. A joint record review of Resident 1's Note to Attending Physician/Prescriber dated 03/05/2025, showed that it was not completed by the physician. Staff B stated that they expected that the physician would complete the pharmacist consultant recommendation form and that the form would be given to medical records to get scanned into the resident's EHR. Reference: (WAC) 388-98-1300 (4)(c) Based on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRR) were consistently completed for 3 of 5 residents (Resident 6, 90 & 1), reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications and a diminished quality of life. Findings included . Review of the facility policy titled, Medication Regimen Review [MRR-a comprehensive assessment of a patient's medications, performed by a pharmacist to identify and address potential problems], revised on 06/06/2025, showed that the Consultant Pharmacist [a person who is professionally qualified to provide expert advice on medication management, safety, and regulatory compliance to various healthcare settings] will perform an MRR for every resident in the facility. It further showed that routine reviews will be done monthly. RESIDENT 6 Review of a face sheet printed on 06/05/2025, showed that Resident 6 readmitted to the facility on [DATE]. Review of physician orders, printed on 06/05/2025, showed that Resident 6 had prescribed medications. Review of the facility's MRR binder for the year 2025 did not show documentation of Resident 6's MRR for the months of March and April of 2025. Review of Resident 6's Electronic Health Record (EHR) did not show documentation of completed MRRs for the months of March and April 2025. On 06/03/2025 at 8:19 AM and on 06/04/2025 at 9:44 AM written requests were submitted to Staff A, Administrator, for additional documentation of completed MRRs, including MRRs for Resident 6. Review of additional requested MRRs on 06/04/2025 at 2:04 PM, did not show documentation of completed MRRs for Resident 6 for the months of March and April 2025. RESIDENT 90 Review of a face sheet printed on 06/05/2025, showed that Resident 90 was admitted to the facility on [DATE]. Review of physician orders, printed on 06/03/2025, showed that Resident 90 had prescribed medications. Review of the facility's MRR binder for year 2025 did not show documentation of Resident 90s MRR for the months of March and April of 2025. Review of Resident 90's EHR did not show documentation of completed MRRs for the months of March and April 2025. On 06/03/2025 at 8:19 AM and on 06/04/2025 at 9:44 AM written requests were submitted to Staff A for additional documentation of completed MRRs, including MRRs for Resident 90. In an interview on 06/06/2025 at 8:12 AM, Staff A stated that they had provided all MRRs available as was requested. Staff A further stated that they expected MRRs would be completed monthly as per the facility's policy. In an interview on 06/06/2025 at 11:55 AM, Staff B, Director of Nursing, stated that they expected MRRs would be completed monthly, and that documentation would be available in the residents' EHR.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 300 UNIT MEDICATION STORAGE ROOM A joint observation and interview on 06/05/2025 at 9:09 AM with Staff D, RNUM, showed the following expired medical supplies: -Four unopened safety scalpels with an expiration date of 09/30/2023. -Two unopened disposable dermal (skin) curette (medical instrument used to scrape or remove unwanted tissue/skin) with an expiration date of 03/01/2023. -One unopened Bard-[NAME] (brand) scalpel with an expiration date of 07/31/2022. Staff D stated that they were expired and that they should have been discarded. Staff D stated that the Unit Managers checked the medication storage rooms and that the staff that used the medical supplies should have checked the five rights, which included to check for expiration date. In an interview on 06/06/2025 at 1:18 PM, Staff B stated that they expected expired medical supplies to be disposed of. Staff B further stated that they expected the medication room to be checked at least once a month and to dispose/discard expired medications/medical supplies. 500 UNIT MEDICATION ROOM REFRIGERATOR TEMPERATURE LOG A joint record review and interview on 06/05/2025 at 8:39 AM with Staff E, showed that the 500-unit medication room Quarterly Daily Refrigerator Temperature Record, dated May 2025 showed three days of missing entries and the June 2025 Refrigerator Temperature Record had two days of missing entries. Staff E stated that staff should have been checking the temperature of the medication room refrigerator daily. In an interview on 06/06/2025 at 1:18 PM, Staff B stated that staff should have checked the temperature of the 500-unit medication room refrigerator daily. Reference: (WAC) 388-97-1300(2) Based on observation, interview, and record review, the facility failed to appropriately label medication and ensure expired medications, laboratory/medical supplies and biologicals (diverse group of medicines made from natural sources) were disposed of timely in accordance with current accepted professional standards for 3 of 4 medication carts (200 unit, 600 unit & 400 unit) and for 1 of 3 medication rooms (300 unit), and failed to ensure refrigerator temperatures were monitored for 1 of 3 medication room refrigerators (500 unit), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications and medical supplies, possible infections, and adverse consequences. Findings included . Review of the facility's undated policy titled, Medication Storage, showed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy further showed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 200 UNIT MEDICATION CART During a joint observation and interview on 06/05/2025 at 9:48 AM, with Staff AA, Licensed Practical Nurse (LPN), showed the following items: -One undated opened Neomycin (brand name-antibiotic [medication to treat infection]) eye ointment, -One bottle of Milk of Magnesia (brand name-laxative [medication to soften stools]) with an expiration date of 03/2025 (March 2025), -One container of Hemoccult Sensa Developer (brand name- rapid test to check for blood in the stool) with an expiration date of 2023-06 (June 2023), -Five individually packed Sani-cloth (brand name) bleach germicidal (substance that kills germs or inhibit their growth) disposable wipes with expiration dates of 2021/05 (May 2021), - Four Bisacodyl (brand name-laxative) rectal (anus) suppositories (medication administered through the anus) with expiration dates of 01/2025 (January 2025), and -One tube of silver collagen wound gel (for wound healing) with an expiration date of 04/2025 (April 2025). Staff AA stated that they were expected to discard expired medications and medical supplies and that they should have done so. 600 UNIT MEDICATION CART During a joint observation and interview on 06/05/2025 at 10:48 AM, with Staff L, LPN, showed one unopened bottle of Nitroglycerin (brand name-drugs to treat chest pain) tablet with an expiration date of 03/2025 (March 2025). Staff L stated, it [Nitroglycerin bottle] should have been discarded or returned to the pharmacy. 400 UNIT MEDICATION CART During a joint observation and interview on 06/05/2025 at 11:46 AM, with Staff J, Registered Nurse (RN), showed three Bisacodyl rectal suppositories with expiration dates of 01/2025 (January 2025). Staff J stated that they should have discarded the expired suppositories. In an interview on 06/05/2025 at 12:04 PM, Staff E, RN Unit Manager (RNUM), stated that staff were expected to label and date when they first opened a medication. Staff E stated that medication and/or medical supplies with expired dates were either returned to the pharmacy or discarded. Staff E stated that they expected staff to have labeled/dated medication when they first opened it and that expired medications and/or medical supplies had been discarded or returned to the pharmacy. In an interview on 06/05/2025 at 1:41 PM, Staff B, Director of Nursing, stated that they expected staff to label/date opened medication and discard expired medications and/or medical supplies.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 dry storage room (Kitchen Dry Storage Room), 3 of 4 refrigerators (Kitchen Cooler A Refrigerator, Kitchen Cooler H Refrigerator and Kitchen Cooler D Refrigerator), 1 of 1 seasoning shelf (Kitchen Seasoning Shelf) and 5 of 6 dining room refrigerators (500 unit, 300 unit, 100 unit, 600 unit & 700 unit), reviewed for food services. The failure to date and discard expired food items and/or before use by date, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Receiving and Storage of Food, dated 10/01/2021, showed, Foods shall be received and stored in a manner that complies with safe food handling practices. The policy showed, All foods stored in the refrigerator or freezer will be covered, labeled and dated. The policy further showed that food items and snacks kept in the nursing units must be labeled with the resident's name, the item and the use by date. Review of the facility's policy titled, Date Marking for Food Safety, dated on 03/09/2023, showed, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The policy further showed, Prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. KITCHEN DRY STORAGE ROOM A joint observation and interview on 05/29/2025 at 8:10 AM with Staff H, Dietary Manager, showed that eight loaves of white bread, 12 loaves of raisin bread, 13 loaves of wheat bread, eight loaves of sourdough bread, and eight hamburger buns had no expiration or use by date. Staff H stated that the bread and/or loaves of bread were taken out of the freezer. Staff H stated that their process required bread removed from the freezer to be dated and then placed in the refrigerator. Staff H further stated that the bread/loaves of bread had been removed from the freezer a few days ago and should have been labeled to monitor their use-by date or discarding timeline. KITCHEN REFERIGATORS COOLER A A joint observation and interview on 05/29/2025 at 8:22 AM with Staff H, showed the following: -one opened Dijon Mustard with a use-by date of 05/13/2025 -one opened jar of cherry filling with a use-by date of 05/19/2025. -one opened jar of chicken base with no use by/expiration date. Further observation showed an opened date of 5/24 [05/24/2025]. -one opened jar beef base with no use by/expiration date. Further observation showed an opened date of 5/13 [05/13/2025]. -one opened jar of chopped garlic with no use by/expiration date. Further observation showed an opened date of 5/26 [05/26/2025]. Staff H stated that the Dijon Mustard and cherry filling should have been discarded. Staff H further stated that the chicken base, beef base and chopped garlic should have had a use-by date. COOLER H A joint observation and interview on 05/29/2025 at 8:35 AM with Staff H, showed two containers of half and half were opened on 5/27 [05/27/2025] and one almond milk was opened on 5/28 [05/28/2025]. Further observation showed that the food items did not have use-by dates. Staff H stated that the half and half and the almond milk should have been labeled with a use-by date. COOLER D A joint observation and interview on 05/29/2025 at 8:41 AM with Staff H, showed a container of cooked ham with a preparation date of 5/23 [05/23/2025]. Further observation showed the cooked ham did not have a use-by date. Staff H stated that it should have had a use-by date. KITCHEN SEASONING SHELF A joint observation and interview on 06/05/2025 at 9:18 AM with Staff H, showed one opened container of cinnamon, one opened container of whole thyme leaves, one opened container of herbs de [NAME], and one opened container of old bay with no opened and use-by dates. Further observation showed an opened container of ground coriander with use by date of 2/4 [02/04/2025]. Staff H stated that the cinnamon, whole thyme leaves, herbs de [NAME], and old bay should have had open and use-by dates. Staff H stated that ground coriander was expired and should have been discarded. DINING ROOM REFRIGATORS 500 UNIT DINNING ROOM REFRIGATOR A joint observation and interview on 06/05/2025 at 10:39 AM with Staff H, showed two opened jugs of milk, one opened carton of orange juice, and one opened carton of half and half with no opened/use by date. Staff H stated that the milk, orange juice, and half and half should have had opened and use-by dates. 300 UNIT DINING ROOM REFRIGATOR A joint observation and interview on 06/05/2025 at 10:49 AM with Staff H, showed one opened carton of half and half, one opened carton of soy milk, one opened jug of milk with no opened/use-by date. Staff H stated that the half and half, soy milk, and milk should have had opened and use-by dates. 100 UNIT DINING ROOM REFRIGATOR A joint observation and interview on 06/05/2025 at 10:55 AM with Staff H, showed one cranberry juice, opened on 05/28/2025, with a use-by date of 06/04/2025. Staff H stated that the opened cranberry juice was expired and should have been discarded. 600 UNIT DINING ROOM REFRIGATOR A joint observation and interview on 06/05/2025 at 12:54 PM with Staff H showed one opened jug of milk and one opened carton of half and half with no opened and use-by date. Further observation showed one opened carton of thickened apple juice labeled with open date of 05/20/2025 and it did not show a use by date. Staff H stated that the milk and half and half should have had an open and use-by date. Staff H stated that the thickened apple juice was expired and should have been discarded. 700 UNIT DINNING ROOM REFRIGATOR A joint observation and interview on 06/05/2025 at 12:57 PM with Staff H, showed that one opened carton of thickened lemon-flavored water, and one opened half and half did not have an opened and use by date. Further observation showed a sandwich, prepared on 5/30 [05/30/2025]. Staff H stated that the thickened lemon-flavored water, and half and half should have had an opened and use-by date. Staff H stated that the sandwich expired and should have been discarded. In an interview on 06/05/2025 at 2:02 PM, Staff A, Administrator, stated that they expected kitchen staff to check the food items regularly, to date when first opened, and discarded when expired/passed the use by date. Staff A further stated the food items that were undated/passed the use by date should have been dated and/or discarded. Reference: (WAC) 388-97-1100 (3) .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required, failed to handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) drainage bag appropriately for 1 of 2 residents (Resident 1), and failed to disinfect/sanitize medical equipment between resident use for 1 of 2 staff (Staff I), reviewed for infection control. In addition, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 2 of 8 residents (Residents 77 & 219). These failures placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's policy titled, Infection Control Program, dated 10/24/2022, showed, Infection control policies, procedures, and protocols will be reviewed at least annually. Review of the facility's undated policy titled, Urinary Catheter Care, showed, Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) Policy, dated 03/28/2024, showed, The purpose of this policy is to outline the guidelines for implementing Enhanced Barrier Precautions (EBP) in order to reduce the transmission of multidrug-resistant organisms (MDROs) within our facility. EBP will be utilized in conjunction with standard precautions (infection prevention practices used to prevent the transmission of infectious disease) to provide targeted gown and glove use during high-contact resident care activities [use Personal Protective Equipment (PPE) when transferring, dressing, bathing/showering]. INFECTION CONTROL POLICY-ANNUAL REVIEW Review of the IPCP policies and procedures showed that they have not been reviewed at least annually. The following policies were last reviewed and/or dated below: -Infection Control Program-reviewed on 10/24/2022 In a telephone interview on 06/05/2025 at 2:40 PM, Staff W, Infection Preventionist, stated that they reviewed IPCP policies every six months to annually and that they talked about it in Quality Approvement and Performance Improvement (a data driven and proactive approach to quality improvement) meetings. Staff W was informed of the Infection Control Program policy dated 10/24/2022, Staff W stated that it should have been reviewed every six months to annually. In an interview and joint record review on 06/06/2025 at 1:26 PM, Staff B, Director of Nursing, stated that IPCP policies were reviewed quarterly and when there was a change. A joint record review of the Infection Control Program policy showed that it was dated 10/24/2022. When asked if the IPCP policies should be reviewed annually, Staff B stated, yes. In an interview and joint record review on 06/06/2025 at 2:20 PM, Staff A, Administrator, stated that they typically reviewed all IPCP policies annually. A joint record review of the Infection Control Program, policy showed that it was dated 10/24/2022 and it further showed, Infection control policies, procedures, and protocols will be reviewed at least annually. Staff A stated that they expected IPCP policies to be reviewed annually. URINARY CATHETER CARE RESIDENT 1 Review of the quarterly Minimum Data Set (an assessment tool) dated 04/29/2025 showed Resident 1 readmitted to the facility on [DATE] and had a diagnosis of obstructive uropathy (a condition where urine flow is blocked). It further showed that Resident 1 had an ostomy (surgery to create an opening from an area inside the body to the outside). Observation on 06/04/2025 at 12:33 PM, showed Resident 1 was lying in bed with their urinary catheter drainage bag touching the floor. At 12:42 PM, Staff Y, Certified Nursing Assistant (CNA), entered Resident 1's room, delivered their lunch tray and left the room. Resident 1's urinary catheter drainage bag remained touching the floor. In an interview and joint observation on 06/04/2025 at 1:00 PM, Staff Y stated that Resident 1's urinary catheter drainage bag should not have been on the floor and that sometimes I find it on the floor, and I have to hang it. Staff Y stated they did not know what happened. A joint observation showed Resident 1's urinary catheter drainage bag was touching the floor. Staff Y stated that it should not have been on the floor. In an interview on 06/06/2025 at 11:40 AM, Staff E, Registered Nurse [RN] Unit Manager (RNUM), stated that they expected staff to ensure urinary catheter drainage bags were not touching the floor and that It's [it is] an infection control issue. Staff E further stated that Resident 1's urinary catheter drainage bag should not have been on the floor. In an interview on 06/06/2025 at 1:07 PM, Staff B stated that they expected staff to ensure urinary catheter drainage bags were not touching the floor. Staff B further stated that Resident 1's urinary catheter drainage bag should not have been on the floor. DISINFECTING MEDICAL EQUIPMENT STAFF I Review of the facility's policy titled, Cleaning and Disinfecting Resident Care Items and Equipment, dated 10/01/2021, showed, Resident-care equipment, including reusable items and durable medical equipment [reusable medical devices] will be cleaned and disinfected according to current CDC [Centers for Disease Control] recommendations for disinfection . The policy further showed, Durable medical equipment (DME) must be cleaned and disinfected before reuse [reused] by another resident. Observations on 06/04/2025 at 9:40 AM showed Staff I, CNA, took out the sit-to-stand lift (a medical device designed to assist individuals with limited mobility in transitioning from a seated position to a standing position) from Resident 67's room after Staff I assisted them in their wheelchair. Staff I did not clean or disinfect the sit-to-stand lift and moved it to Resident 9's room. Staff I then assisted Resident 9 to transfer them from bed to the toilet using the lift. At 10:13 AM, Staff I assisted Resident 9 to transfer to their wheelchair using the sit-to-stand lift. Staff I then moved the sit-to-stand lift and placed it alongside the unit hallway. Staff I proceeded to go outside unit and did not clean or disinfect the sit-to-stand lift. In an interview on 06/04/2025 at 10:25 AM, Staff I stated that they sanitized or disinfected the sit-to-stand lift after they used it. When asked if they had cleaned or disinfected the sit-to-stand lift between resident use, Staff I stated, Yes. I used the hand sanitizer and [the] paper towel. I also used the washcloth to sanitize it. Staff I showed a package labeled adult washcloth and stated, it [washcloth] has chemicals in there that can be used to clean, too. Staff I stated that they used the washcloth to wipe the handlebars of the sit-to-stand lift where [Resident 67 and Resident 9] placed their hands. When asked if they cleaned and disinfected the other parts of the lift equipment, Staff I stated, No, I only sanitized or wiped the handle. In an interview on 06/04/2025 at 11:43 AM, Staff J, RN, stated that staff were expected to clean and disinfect medical equipment after resident use. Staff J stated that they used the Microdot Minute [brand name] wipes (disinfectant wipes). Staff J further stated that this [microdot minute wipes] should have been used to clean and disinfect [the sit-to-stand lift]. USE OF PPE RESIDENT 77 An observation on 05/30/2025 at 10:56 AM, showed Staff FF, CNA, was in Resident 77's room (an EBP room) with Staff GG, Student Aide, they transferred Resident 77 to their wheelchair. Further observation showed Staff FF and Staff GG were not wearing gowns and gloves when assisting Resident 77 to their wheelchair. In an interview and joint record review on 05/30/2025 at 11:19 AM, Staff FF stated that Resident 77 was on EBP due to urinary catheter use. A joint record review of the EBP signage posted outside Resident 77's room showed, Wear gloves and a gown for the following high-contact Resident Care activities .transferring. When asked if they were wearing gloves and gown when transferring Resident 77 to their wheelchair, Staff FF stated, No. Staff FF further stated that they should have worn their gloves and gown when transferring Resident 77 to their wheelchair. In an interview on 06/02/2025 at 11:20 AM, Staff J stated that staff were expected to wear the required PPE when providing care with residents on EBP. Staff J stated that Staff FF should have worn their gloves and gown when they transferred Resident 77 to their wheelchair. In an interview on 06/04/2025 at 2:11 PM, Staff E stated that they expected staff to follow EBP and PPE guidelines and to clean and disinfect residents' equipment between residents' use. Staff E stated that they used Sani-cloth [brand name] disinfectant wipes and Microdot Minute wipes to sanitize or disinfect residents' equipment. Staff E stated that Staff FF should have worn proper PPE when transferring residents on EBP and that Staff I should have used the proper disinfectant for the sit-to-stand lift between resident use. In an interview on 06/04/2025 at 2:34 PM, Staff B stated that they expected staff to follow PPE guidelines for residents on EBP and to use proper disinfectants to clean, sanitize and disinfect residents' equipment between use. RESIDENT 219 Observations on 05/29/2025 at 8:53 AM and at 1:15 PM, showed that an EBP signage was posted outside Resident 219's Room (room [ROOM NUMBER]). Observation and interview on 05/29/2025 at 1:31 PM, showed Staff BB, CNA, transferred Resident 219 from their wheelchair to their bed without using gown and gloves. When Staff BB was done assisting Resident 219, they left the room without performing hand hygiene. Staff BB stated that they did not use PPE during the transfer and that they should have. Staff BB stated that they did not perform hand hygiene before and after they transferred the resident. Staff BB further stated that they forgot that Resident 219 was on EBP. In an interview on 06/04/2025 at 12:34 PM, Staff AA, Licensed Practical Nurse, stated that they expected staff to appropriately use PPE during resident care. Staff AA further stated that Staff BB should have followed the EBP procedure. In an interview on 06/04/2025 at 1:36 PM, Staff B stated that staff assisting residents in EBP rooms must follow the instructions displayed on the EBP signage. Staff B stated that Staff BB should have adhered to the EBP protocol and wore the required PPE. Staff B further stated that Staff BB should have performed hand hygiene. Reference: (WAC) 388-97-1320 (1)(a)(c) (5)(c) .

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0838 (Tag F0838)

Minor procedural issue · This affected most or all residents

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Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to include a contingency plan (to handle potential challenges or disruptions based on the findings from the facility assessment) and plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs. Findings included . Review of the facility's document titled, [Facility Name] Facility Assessment, updated on 04/25/2025, did not show documentation of the facility's contingency plan and plans to maximize direct care staff recruitment and retention. In an interview on 06/06/2025 at 10:59 AM, Staff A, Administrator stated that the facility's contingency plan and plans to maximize direct care staff recruitment and retention were not referenced in the facility assessment, updated on 04/25/2025. Staff A further stated that they would include them in the facility assessment. No associated WAC .

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary supervision for 1 of 3 residents (Resident 1), reviewed for elopement. The failure to provide the necessary supervision for Resident 1 resulted in an elopement and placed the resident at risk for injury. Findings included . Review of the facility's elopement policy, revised in March 2021showed, elopement occurs when a resident leaves a safe area without staff knowledge OR the patient enters an unsafe area without staff knowledge or presence. The policy further showed all residents were assessed for exit seeking, wandering behavior on admission, quarterly and as needed using the Elopement/Wandering Risk Assessment. Review of the admission Minimum Data Set assessment (a required assessment) dated 05/01/2025 showed the resident was admitted to the facility on [DATE], had impaired memory and required assistance to walk safely. Review of a nursing progress note dated 04/27/2025, showed Resident 1 was wandering in the nursing unit and was redirected from the front desk/lobby area two times by staff. The nursing progress notes documented that at 3:15 PM that day, Resident 1 was not observed on the nursing unit when Staff D, Licensed Practical Nurse, looked for them. Staff D went to the front desk, and Collateral Contact 1 (CC1) told Staff D they saw Resident 1 go out the front door and walk on the street outside the facility. The nursing progress notes further showed Resident 1 was found at 3:30 PM [that day on a busy street approximately a block away] from the facility. In an interview on 05/27/2025 at 3:25 PM Staff C, Front Desk Receptionist, stated that CC1 heard that we were looking for a resident and that they saw them go out the front door and walk down the street by themselves. Staff C further stated, I immediately went and told the nurse. In an interview on 05/27/2025 at 4:11 PM, Staff D stated that it was the beginning of their shift and Resident 1 was wandering back and forth around the nursing unit and I did not know they were able to go to the front desk by themself. I went to the front desk to ask if anyone had seen them and CC1 heard me and stated they saw Resident 1 walking down the street by themselves. In an interview on 05/27/2025 at 4:20 PM, CC1 stated that they heard the nurses were looking for a resident, and that they told the nurses they saw a person that fit the description walking outside by themself. CC1 further stated they did not think that person should be walking down that busy street alone, but they did not know they were a resident at the facility until they heard that the nurses were looking for resident. In an interview on 05/28/2025 at 3:30 PM Staff F, Corporate Nurse, stated the initial admission elopement risk assessment form dated 04/26/2025 showed Resident 1 had a history of elopement, wandering, and was at risk for elopement. In an interview on 05/28/2025 at 3:38 PM Staff B, Director of Nursing Services, stated Resident 1 did not receive the supervision they needed to prevent them from leaving the building. Reference: (WAC) 388-97-1060 (3)(g) .

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely and necessary assistance with Activities of Daily Living (ADL) for 2 of 3 residents (Residents 1 & 2), reviewed for ADLs. The failure to provide the residents who were dependent on staff with assistance with toileting, changing soiled clothing, and bed linens placed the residents at risk for skin impairments, low self-esteem, and a diminished quality of life. Findings included . Review of the undated facility's policy titled, ADL, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. RESIDENT 1 Review of the admission Minimum Data Set assessment (MDS-a required assessment) dated 04/01/2025 showed Resident 1 admitted to the facility on [DATE], had impaired thinking/memory, and was dependent on staff for all care. Review of Resident 1's care plan dated 03/27/2025, showed Resident is dependent on staff for all toileting needs. Resident is incontinent of bowel and bladder (involuntarily loss of urine and bowel). Review of the investigative summary form dated 04/01/2025 showed Resident 1 was found in a wet environment, that someone just changed their brief and left their whole bed wet of urine. In an interview on 05/12/2025 at 12:48 PM, Staff E, Therapist, stated it looked like they had not been changed for a while, they were soaked through to the layers of the bed linens. RESIDENT 2 Review of the admission MDS dated [DATE] showed Resident 2 admitted to the facility on [DATE], had moderately impaired thinking, and was dependent on staff for all ADL's. Review of Resident 2's care plan dated 03/12/2025 showed the resident required assistance with ADL's. Review of the investigative summary form dated 04/01/2025 showed Resident 2 had vomited on their clothing and bed linen and had not been changed for a significant amount of time. In an interview on 05/07/2025 at 12:51 PM, Staff C, Certified Nursing Assistant, stated I do rounds frequently on the residents to see if they need anything. It just depends on the residents and how much help they need, if they need a lot of help, I am always checking them. In an interview on 05/07/2025 at 12:22 PM, Staff D, Licensed Practical Nurse, stated the nursing staff should check on the residents frequently to provide and assist them with all their care needs. In an interview on 05/12/2025 at 4:56 PM Staff B, Director of Nursing Services, stated their expectation was for the nursing assistants to meet the needs of all the residents. Staff B further stated the nursing staff did not meet the needs of Resident 1 and Resident 2 and should have assisted them to meet their needs. Reference: (WAC) 388-97-1060 (2)(c) .

Apr 2024 27 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call light (an alerting device for staff to assist residents in need) was within reach for 1 of 2 residents (Resident 115), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Call Lights: Accessibility and Timely Response, showed that Staff will ensure the call light is within reach of resident and secured, as needed and The call system will be accessible to residents while in their bed. Resident 115 admitted to the facility on [DATE] with diagnoses that included hemiplegia (unable to move one side of the body) affecting their left side. Review of the falls care plan revised on 03/12/2024, showed the resident [Resident 115] needs a safe environment .a working and reachable call light. Observations on 04/22/2024 at 8:46 AM and on 04/22/2024 at 11:37 AM, showed Resident 115's call light was hung up on the wall and not within reach. Additional observations on 04/23/2024 at 9:16 AM and on 04/23/2024 at 11:26 AM, showed Resident 115's call light was hung up on the wall and not within reach. In an interview and joint observation on 04/23/2024 at 11:28 AM with Staff AAA, Certified Nursing Assistant, stated they would expect Resident 115's call light to be within reach on their strong side. Joint observation showed the call light was hung up on the wall. Staff AAA stated the call light should not be there but should be within reach. On 04/23/2024 at 11:37 AM, Staff W, Licensed Practical Nurse, stated that the call light should be within reach of residents and that staff should be checking frequently. Staff W stated they would not expect Resident 115's call light to be hung up on the wall and that it must have been forgotten. On 04/30/2024 at 2:14 PM, Staff B, Director of Nursing Services, stated they expected staff to be checking call light placement every time they go in a room and leave the room. Staff B further stated they expected the call lights to be within residents' reach and not be hung up on the wall. Reference: (WAC) 388-97-0860 (2) .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for health care) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 1 of 3 residents (Resident 120), 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 undated policy titled, Residents' Rights Regarding Treatment and Advance Directives, showed, On admission, the facility will determine if the resident has executed an advance directive and should the resident have an advance directive, copies will be made and placed on the chart. Resident 120 admitted to the facility on [DATE]. Review of Resident 120's clinical record did now show documentation that a copy of their advance directive was obtained. On 04/24/2024 at 9:46 AM, Resident 120's representative stated that Resident 120 had an advance directive and stated that I don't remember if they [the facility] asked for a copy of it or not. On 04/25/2024 at 1:17 PM, Staff BBB, admission Coordinator, stated that if a resident had an advance directive, they would request a copy of it and there should be a copy in the resident's medical record. Staff BBB reviewed Resident 120's clinical record and stated they did not see that there was a copy of an advance directive for Resident 120 in their medical records. Staff BBB further stated, If she [Resident 120's representative] said there is one [advance directive], we should request for it. On 04/30/2024 at 2:40 PM, Staff A, Administrator, stated, Admissions [admission Coordinator] is supposed to obtain one [advance directive] if a resident has one. Staff A stated that if a resident had an advance directive, they would expect there to be a copy of it in the residents' medical records. Reference: (WAC) 388-97-0280 (3)(a) .

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 1 of 3 residents (Resident 71), reviewed for hospitalization. This failure placed the resident at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's undated policy titled, Bed Hold, showed that the facility will hold a bed for a discharged resident who expected to return to the facility. It showed that if the resident's absence from the facility exceeds the grace period [3 days] the designated personnel will contact the resident or the resident's responsible party to offer a Bed-Hold to guarantee the resident's bed at time of discharge. It further showed that a copy of the Bed Hold policy will be sent with the resident's paperwork at time of discharge. Resident 71 admitted to the facility on [DATE]. Review of the progress notes dated 04/01/2024, showed Resident 71 was transferred to the hospital for further evaluation. Review of Resident 71's clinical record (electronic record and physical chart) did not show documentation that a bed-hold notice was provided to Resident 71 and/or their representative. In an interview and joint record review on 04/25/2024 at 1:01 PM with Staff L, Social Worker (SW), stated they were responsible for providing the bed-hold notice to residents. Joint record review of Resident 71's clinical record showed no documentation that a bed-hold was provided to Resident 71 and/or their representative. Staff L stated that there should have been one. Joint record review and interview on 04/25/2024 at 2:20 PM with Staff FFF, SW, showed no documentation that a bed-hold was provided to Resident 71 and/or their representative. Staff FFF stated they could not find any bed-hold documentation. On 04/30/2024 at 2:40 PM, Staff A, Administrator, stated that there should have been documentation that a bed-hold was provided to Resident 71 and/or their representative. Reference: (WAC) 388-97-0120 (4)(a)(b)(c) .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 2 of 27 residents (Residents 14 & 99), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate hospice and medication coding placed the residents at risk for unidentified or unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, code residents identified as being in a hospice program for terminally ill person where an array of services is provided for the palliation and management of terminal illness and related conditions. It further showed coding instructions to code all high risk drug class medications according to their pharmacological (drug's uses, effects, and modes of actions) classification and not how they are being used. It showed to check if the resident is taking any medication by pharmacological classification during the 7-day observation period. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). RESIDENT 14 Resident 14 admitted to the facility on [DATE]. Review of the nursing progress notes dated 03/10/2024 showed Resident 14 admitted to hospice. Review of the significant change in status (SCSA) MDS with an ARD of 03/18/2024, showed Resident 14 was not coded (marked) for hospice. In an interview and joint record review on 04/25/2024 at 11:37 AM, Staff G, MDS/Registered Nurse, stated that they followed the RAI manual for MDS completion. Joint record review showed Resident 14's SCSA MDS was not coded for hospice. Staff G stated that Resident 14's SCSA MDS should have been coded for hospice and that it would need to be modified. On 04/25/2024 at 12:12 PM, Staff B, Director of Nursing Services, stated they expected staff to complete the SCSA MDS per the RAI manual and that the MDS be completed accurately. Staff B further stated that Resident 14's SCSA MDS should have been coded for hospice. RESIDENT 99 Resident 99 admitted to the facility on [DATE]. Review of the March 2024 medication administration record showed Resident 99 was on insulin (a drug that lowers the level of glucose [a type of sugar] in the blood). Review of the quarterly MDS with an ARD of 03/15/2024, showed Resident 99's insulin was not coded under the MDS medication section. During an interview and joint record review on 04/29/2024 at 3:33 PM with Staff G, stated that Resident 99 was taking insulin during the look back period. Joint record review of Resident 99's quarterly MDS with an ARD of 03/15/2024, showed insulin was not coded under medication section for Hypoglycemic (medications that lowers or regulate blood sugar in the body) and stated that it should have been coded. On 04/30/2024 at 11:21 AM, Staff B stated they expected MDS assessments to be completed accurately. Reference: (WAC) 388-97-1000 (1)(b) .

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 42 Resident 42 admitted to the facility on [DATE]. Review of Resident 42's quarterly MDS dated [DATE], showed Resident 42 was cognitively intact. On 04/22/2024 at 11:12 AM, Resident 42 stated that they had not had a care conference and were waiting for something to happen. Interview and joint record review of Resident 42's electronic clinical record on 04/26/2024 at 11:01 AM, Staff DD, stated care conferences were offered to residents upon admission, twice a year, or anytime as needed. Staff DD stated that if a resident was offered a care conference, they would expect to have a care conference meeting within two weeks. Joint record review of the electronic clinical records showed Resident 42's last care conference meeting was in July 2023. Staff DD stated that there should have been a care conference for Resident 42 but were waiting for a legal guardian. Staff DD stated their guess was that Resident 42 declined a care conference, further stating, I can't prove that based on what I wrote. On 04/30/2024 at 1:12 PM, Staff B stated that they expected care conferences to take place quarterly, annually, and as needed. Staff B stated that if a resident did not have a legal guardian appointed, they would still expect a care conference to be made with the resident. Staff B further stated that Resident 42 should have had a care conference. Reference: (WAC) 388-97-0120 (2)(f)(4)(b) Based on interview and record review, the facility failed to ensure residents and/or their representatives were invited to participate in care plan meetings/care conferences for 2 of 2 residents (Residents 89 & 42), reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Care Planning-Care Conference-Resident Participation, showed it was the facility's policy to support the resident's right to be informed and participate in their care planning and treatment (implementation of care). The policy further showed that the facility will make an effort to schedule a care conference at the best time for the resident/representative and that if the resident/representative were determined not practicable for the development of the resident's care plan, an explanation would be documented in the resident's medical record. RESIDENT 89 Resident 89 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 01/26/2024, showed Resident 89 was cognitively intact. On 04/22/2024 at 2:15 PM, Resident 89 stated that the facility never included them in their care plan decision. Review of Resident 89's clinical records under assessments titled, Care Conference Summary showed that their last care conference was on 05/30/2023. On 04/29/2024 at 9:16 AM, Staff DD, Social Worker, stated that care conferences would be held on admission, change of conditions, every six months, and annually. Staff DD stated that during care conference resident or resident representative would be invited and participate. After reviewing Resident 89's electronic clinical record, Staff DD stated that Resident 89's last care conference was on 05/30/2023. On 04/30/2024 at 9:58 AM, Staff A, Administrator, stated that residents should be involved in their care plan decisions.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 2 of 8 residents (Residents 89 & 81), reviewed for ADLs. This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Activities of Daily Living (ADL's), showed, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The policy further showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. RESIDENT 89 Resident 89 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 01/26/2024, showed Resident 89 was cognitively intact and required substantial/maximal assistance (the helper does more than half the effort) with personal hygiene. Observation on 04/22/2024 at 8:52 AM, showed Resident 89's fingernails were long and had brown debris underneath the nails. Resident 89 stated, I would like to have them trimmed. Further observations on 04/23/2024 at 12:22 PM and on 04/24/2024 at 9:20 AM, showed Resident 89's fingernails were long and had brown debris underneath them. Review of the ADL care plan revised on 04/22/2024, showed Resident 89 required set up to one-person extensive assist with personal hygiene. On 04/25/2024 at 1:32 PM, Staff NN, Certified Nursing Assistant (CNA), stated fingernail care would be provided by the shower aid. On 04/26/2024 at 10:59 AM, Staff OO, CNA/Shower Aid, stated that fingernail care would be provided during shower unless the resident had diagnosis of diabetes (when a body doesn't make enough insulin [a hormone that lowers the level of glucose (a type of sugar)] in the blood or can't use it as well as it should). Staff OO further stated Resident 89 had refused fingernail care and they have had reported to nursing in the past. Joint observation and interview on 04/26/2024 at 11:05 AM with Staff OO, showed Resident 89's fingernails were long and had brown debris underneath them. Staff OO stated that the resident's fingernails were long and should have been trimmed. On 04/29/2024 at 1:33 PM, Staff PP, Resident Care Manager, stated shower aids and CNAs should provide fingernail care unless residents have diabetes. Staff PP further stated they were not aware of Resident 89's refusal of fingernail care. On 04/30/2024 at 9:23 AM, Staff B, Director of Nursing, stated they expected fingernail care to be provided during showers. RESIDENT 81 Resident 81 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (damage to the brain due to a loss of oxygen to the area), Hemiparesis (weakness or the inability to move on one side of the body), and Dysarthria (speech sound disorder). Review of the quarterly MDS dated [DATE], showed Resident 81 had severely impaired cognition and depended on staff for transfers. Review of the ADL care plan revised on 02/16/2024, showed Resident 81 required maximum assistance of two staff for transfers. Observation on 04/22/2024 at 11:22 AM, showed Resident 81 was lying in their bed and their collateral contact (CC) was sitting at the resident's bed side. Resident 81's CC stated that the resident was always in bed and that they have requested for the resident to be up on their wheelchair. Observations on 04/23/2024 at 8:33 AM and at 11:31 AM, on 04/24/2024 at 8:31 AM, at 11:33 AM, and at 1:35 PM, showed Resident 81 was lying in bed. On 04/24/2024 at 11:27 AM, Resident 81's CC was at bed side and stated that they have been asking staff for the last several days to have Resident 81 up on their wheelchair. Resident 81's CC further stated that the resident was never assisted out of their bed and into their wheelchair. On 04/24/2024 at 1:38 PM, Resident 81's CC stated that nobody came to the resident's room to transfer them onto their wheelchair. On 04/25/2024 at 1:33 PM, Staff NN, CNA, stated that Resident 81's CC requested to only get the resident up once a week in their wheelchair and Resident 81's CC did not ask them that day. In an interview and joint record review on 04/26/2024 at 10:50 AM, Staff EEE, CNA, stated that they would provide care for Resident 81 based on their care plan on the [NAME] (a care guide for CNAs). Staff EEE further stated that other staff told them that Resident 81 would get up on their wheelchair once a week. A joint record review of Resident 81's [NAME] showed no care plan to get Resident 81 up on their wheelchair once a week. On 04/29/2024 at 1:14 PM, Staff GGG, Registered Nurse, stated that Resident 81 should be up on their wheelchair daily. On 04/29/2024 at 1:33 PM, Staff PP stated Resident 81 should be up on their wheelchair when their CC requests it. On 04/30/2024 at 9:26 AM, Staff B, Director of Nursing, stated they expected staff to get Resident 81 up on their wheelchair unless they refused. Reference: (WAC) 388-97-1060 (1)(2)(c) .

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident environment remained free from accident hazards for 2 of 2 offices (Transitional Care Unit [TCU]/Resident Care Manager] RCM] office and the office next to the TCU/RCM office), reviewed for accident hazard. This failure placed residents at risk for avoidable accident and/or injury and a diminished quality of life. Findings included . Observation on 04/24/2024 at 9:42 AM, showed the TCU-RCM office and another office next to it were opened, and unsupervised. The offices had both powered and non-powered tools that included two saws, two drillers, electrical wiring, and a brazing (joining process that uses a filler metal to join two base metals together at temperatures above 840 degrees Fahrenheit) solder (a process that involves heating a specialized [NAME] composed of lead and tin to form a bond between two metals) machine. On 04/24/2024 at 9:44 AM, Collateral Contact 1 (CC1), stated that when they go for break or bathroom, they leave the doors open and unsupervised. CC1 stated that nobody informed them of the precautions they should take to keep residents safe during maintenance work. On 04/24/2024 at 9:49 AM, Collateral Contact 2 (CC2), stated, If we are going for break, bathroom or to bring things from somewhere we leave it open. CC2 stated that they did not know whether they needed to close the door and/or supervise the offices when they were away. On 04/24/2024 at 10:28 AM, Staff C, Facilities Director, stated CC1 and CC2 were doing air conditioning installation in two offices [TCU/RCM office and the office next to it]. Staff C stated that to leave those two offices open and unsupervised is not the ideal way to do it, that is not the way we expect them to do it. Staff C further stated that the offices should not have been left open and unsupervised. On 04/29/2024 at 11:43 AM, Staff B, Director of Nursing Services, stated that the two offices in repair should have been closed/supervised. On 04/30/2024 at 8:23 AM, Staff A, Administrator, stated those offices in repair should not have been left opened and/or unsupervised. Reference: (WAC) 388-97-1060(3)(g) .

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 3 residents (Residents 110 & 17), reviewed for urinary catheter. The failure to ensure urinary catheters were off the floor placed the residents at risk for infections and related complications. Findings included . Review of the facility's undated policy titled, Catheter Care/Bags, showed, It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. RESIDENT 110 Resident 110 admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked and causes the urine to flow backwards). Review of the admission Minimum Data Set (MDS- an assessment tool) dated 02/13/2024 showed Resident 110 had an indwelling foley catheter. Review of the urinary catheter care plan revised on 02/09/2024, showed a goal that Resident 110 will show no signs and symptoms of urinary infection (infection in the urine). Observation on 04/23/2024 at 9:11 AM, showed Resident 110's bed was in the low position and their catheter bag was hooked onto the bed frame with the bottom of the catheter bag touching the floor. In another observation on 04/25/2024 at 8:47 AM, showed Resident 110's catheter bag was partly covered with a blue privacy covering, and the bottom of the catheter bag was exposed and touching the floor. During a joint observation and interview on 04/25/2024 at 9:03 AM with Staff J, Certified Nursing Assistant (CNA), showed Resident 110's catheter bag was exposed and touching the floor. Staff J stated Resident 110's catheter bag should not be touching the floor. On 04/29/2024 at 11:20 AM, Staff E, Infection Preventionist, stated that Resident 110's catheter bag should not be touching the floor, and it should be covered with a protection [privacy] bag. On 04/29/2024 at 1:18 PM, Staff B, Director of Nursing, stated Resident 110's catheter bag should be covered for privacy and that their catheter bag should not have been touching the floor. RESIDENT 17 Resident 17 admitted to the facility on [DATE] with diagnosis that included neurogenic bladder (lack of bladder control due to a nerve problem in the brain or spinal cord) and had an indwelling urinary catheter. Observation on 04/24/2024 at 8:27 AM, showed Resident 17's bed was in a low position, their urinary catheter drainage bag was touching the floor, and the lower one-third part of the catheter drainage bag was not covered by a privacy bag. During a joint observation and interview on 04/24/2024 at 8:35 AM with Staff Q, Registered Nurse, showed Resident 17's urinary catheter drainage bag was touching the floor. Staff Q stated that the resident's urinary catheter drainage bag should was touching the floor, and it should not have been. On 04/30/2024 at 10:21 AM, Staff B stated that urinary catheter drainage bag should not be touching the floor. Reference: (WAC) 388-97-1060 (3)(c) .

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure tube feeding (a medical device used to provide nutrition into the stomach if resident is unable to swallow safely) supplies (tubing set) including the irrigation syringe were labeled/dated for 1 of 2 residents (Resident 4), reviewed for tube feeding management. This failure placed the residents at risk for infection and related complications. Finding included Review of the facility's undated policy titled, Care and Treatment of Feeding Tubes, showed it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Resident 4 admitted to the facility on [DATE] with diagnoses that included stroke (restriction of blood flow or sudden burst of blood vessel in the brain), dysphagia (difficulty swallowing), and protein-calorie malnutrition (a condition that result from lack of sufficient nutrients in the body). Review of the quarterly Minimum Data Set assessment (an assessment tool), dated 03/13/2024, showed Resident 4 was totally dependent with tube feeding management for nutrition/hydration. Observation on 04/22/2024 at 9:01 AM, showed Resident 4 was receiving Jevity (that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 Cal [calorically dense, fiber-fortified therapeutic nutrition] running at 50 milliliters per hour for a total of 18 hours. Further observation showed the tube feeding's set and irrigation syringe did not have a date or label when it was first used. During a joint observation and record review on 04/22/2024 at 12:30 PM with Staff II, Registered Nurse, showed the tubing and irrigation syringe were not labeled/dated. Staff II stated the tubing and irrigation syringe were not dated or initialed as it should have been. On 04/30/2024 at 10:21 AM, Staff B, Director of Nursing Services, stated that it was their expectation that the tube feeding set and/or the irrigation syringe should be dated, labeled, and initialed when new tubing and syringe were first used or opened. Reference: (WAC) 388-97-1060 (3)(f) .

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards of practice for 1 of 1 resident (Resident 90), reviewed for respiratory care. The failure to have an oxygen administration order, maintain, label/date, and properly store oxygen nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) properly placed the resident at risk for unmet care needs, respiratory infections, and related complications. Findings included . Review of the facility's undated policy titled, Oxygen Administration, showed oxygen is administered under orders of a physician, except in the case of an emergency. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. Staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Keep delivery devices covered in plastic bag when not in use. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. Resident 90 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 04/09/2024, showed Resident 90 was cognitively intact. Observation on 04/22/2024 at 10:56 AM, showed Resident 90 had an oxygen concentrator in their room that was not in use. Resident 90 had a long oxygen tubing connected to the concentrator and the nasal canula was sitting in the resident's nightstand drawer. Further observation showed the oxygen tubing was not labeled/dated and not stored in a bag. Resident 90 stated that they used oxygen once or twice a day. Observation on 04/23/2024 at 10:11 AM, on 04/24/2024 at 12:57 PM, and on 04/25/2024 at 8:18 AM, showed Resident 90's oxygen was not in use and the nasal canula was hanging down from the resident's nightstand. The oxygen tubing was not labeled or stored in a bag when not in use. On 04/24/2024 at 1:03 PM, Resident 90 stated that due to their shortness of breath during the night, they were using oxygen by themselves. Observation on 04/26/2024 at 8:00 AM, showed Resident 90 was using their oxygen. Resident 90's oxygen concentrator was on and running at 1.5 liters per minute. Review of Resident 90's physician's order printed on 04/24/2024, showed Resident 90 had no oxygen order. In an interview on 04/26/2024 at 8:02 AM, Staff HHH, Licensed Practical Nurse, stated that Resident 90 had an oxygen concentrator in their room, but they had never seen them using it. Staff HHH stated Resident 90 had no physician's order for oxygen use. Joint observation and interview on 04/26/2024 at 8:07 AM with Staff HHH, showed Resident 90 was using oxygen at 1.5 liters per minute, and the oxygen tubing was not labeled or dated. Staff HHH stated that Resident 90 was using oxygen, and the tubing was not labeled. On 04/26/2024 at 10:15 AM, Staff PP, Resident Care Manager, stated that a resident should have an oxygen order before use. Staff PP also stated that oxygen tubing should be changed weekly and labeled with the date it was changed. Staff PP further stated that Resident 90 had no oxygen order. On 04/30/2024 at 9:35 AM, Staff B, Director of Nursing Services, stated that they would expect a resident to have an oxygen order prior administering it. Staff B stated oxygen tubing should be changed and labeled weekly. Reference: (WAC) 388-97-1060 (3)(j)(vi) .

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to comprehensively assess and evaluate the need for bed rails for 1 of 3 residents (Resident 95), 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's undated form titled, Process for halos [a type of bed rail shaped like a ring], bed rails, showed a nursing assessment was required regardless of prior function or use. Resident 95 admitted to the facility on [DATE]. Review of Resident 95's physician's order showed an order initiated on 02/23/2024 for Halos/Bed Enabler- Bilateral [both] for bed mobility. Review of a nursing progress notes dated 02/23/2024 at 12:40 PM, showed, halos requested by Resident 95's representative for bed mobility and support. Observations on 04/22/2024 at 12:44 PM and on 04/24/2024 at 9:15 AM, showed Resident 95's bed rails were loose, the left rail was looser than the right rail. Joint record review and interview on 04/24/2024 at 1:31 PM with Staff II, Registered Nurse, showed Resident 95's Initial Device Assessment dated 02/23/2024 [and was printed on 04/24/2024], did not have documentation that previous interventions/alternatives were attempted prior to the use of bed rails. Staff II stated that there should have been documentation. On 04/30/2024 at 10:03 AM, Staff RR, Rehab Director, stated that there should be a safety evaluation/assessment done prior to installation or use of bed rails. Staff RR stated that they did not see documentation for a safety evaluation/assessment for Resident 95 and that it should have been documented prior to bed rail use. During an interview and joint record review on 04/30/2024 at 12:32 PM with Staff B, Director of Nursing Services, stated that they expected staff to complete an assessment and consent prior to installing the bed rails. Staff B stated that the assessment should address safety and that Resident 95's assessment did not specify whether that was assessed. Joint record review of Resident 95's Initial Device Assessment dated 02/23/2024, showed there were new interventions added to the assessment. Staff B stated that they should have been documented prior to installation of the bed rails. Reference: (WAC) 388-97-1060 (3)(g) .

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the appropriate competencies, skills set and proficiencies to apply a condom catheter (external flexible tube that is used to collect urine from the body) for 1 of 5 nursing staff (Staff S), reviewed for competent nursing staffing. This failure placed the resident at risk for infection, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Competency Evaluation, showed, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. The policy further stated that checklists were to be used to document training and competency evaluations. Review of the facility's undated policy titled, Condom Catheter Care Policy, showed, It is the policy of this facility to ensure that condom catheters are applied appropriately, cared for and removed consistent with current standards of practice. Staff S, CNA, was hired on 02/14/2022. Review of facility provided employee training file for Staff S did not show a condom catheter competency skills assessment. On 04/25/2024 at 9:13 AM, Staff S, wore gloves to assist Resident 39 with peri-care (cleaning of private parts) in the resident's bathroom. Staff S with the same used gloves, pulled the resident's pants up and transferred Resident 39 into their wheelchair while touching multiple surfaces of the wheelchair. Staff S touched Resident 39's bedside table, their hand, the TV remote control, bedside drawer, wheelchair brakes, and walker. Staff S assisted Resident 39 to transfer from their wheelchair into their bed. Staff S then assisted Staff II, Registered Nurse, with applying a condom catheter on Resident 39. Staff S stretched the condom catheter and applied it to Resident 39. Staff S did not do hand hygiene and/or changed their used gloves in between task, after assisting Resident 39 in the bathroom or after assisting the resident back into their bed. On 04/25/2024 at 10:24 AM, Staff S stated they should have removed their used gloves and washed their hands after assisting Resident 39 in the bathroom. Staff S stated they should have applied new gloves to assist the resident with transfers, and then completed hand hygiene and changed their gloves prior to assisting with the condom catheter. Staff S further stated that the nurse was responsible for changing the resident's condom catheter, but if the nurses were not around then CNAs could do it. On 04/30/2024 at 1:05 PM, Staff B, Director of Nursing Services, stated that under the direction of a nurse a CNA was able to apply a condom catheter. Staff B further stated that Staff S did not have staff training and competency evaluation for condom catheters in their skills check list and that there should have been one. Reference: (WAC) 388-97-1680 (2)(b) .

CONCERN (D)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed the total number of staff and actual number of hours worked for each shift for 1 of 7 days reviewed for posted nurse staffing information. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's undated policy titled, Nurse Staffing Post Information, showed the nurse staffing sheet would be posted daily, with the total number and the actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Aides. The policy further showed that the information posted would be in a prominent place readily accessible to residents and visitors. Observations on 04/30/2024 at 7:51 AM, showed the facility's Daily Nurse Staffing Form that day did not include the total number of staff and the total hours worked for evening and night shift. Joint observation and interview on 04/30/2024 at 9:07 AM with Staff Y, Staffing Coordinator, showed the Daily Nurse Staffing Form dated 04/30/2024 did not include the total number of staff and the total hours worked for evening and night shift. Staff Y stated that the nurse staffing post was to be posted in the entrance daily and that the receptionist was responsible for filling it out once they received the daily schedule. Staff Y further stated that it should be posted first thing in the morning and expected it to be filled out per shift. On 04/30/2024 at 1:55 PM, Staff B, Director of Nursing Services, stated they expected the nurse staffing form to be completed for the whole day and that it should be current. Staff B further stated they would expect to see the nurse staffing form posted on both floors of the facility. No associated WAC .

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 57 Resident 57 admitted to the facility on [DATE]. Review of Resident 57's November 2023 MAR showed Resident 57 was taking Depakote (a medication to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain] and bipolar disorder [a disorder associated with mood swings) two times a day. Review of the November 2023 MRR showed that the pharmacist documented, Please consider documenting risks/benefits for Depakote therapy or consider tapering to remove. Review of Resident 57's clinical record showed no documentation that there was follow up on the pharmacy recommendation. Review of Resident 57's February 2024 MAR showed Resident 57 was taking Seroquel (medication used to treat certain mental/mood disorders) two times a day. It also showed that Resident 57 was taking Venlafaxine (a medication to treat depression) once a day. Review of the February 2024 MRR showed that the pharmacist documented, The patient is currently taking Seroquel 25 mg [milligram-a unit of measurement] BID [twice a day] for MDD [Major Depression Disorder] agitation and Venlafaxine 250 mg QAM [every morning] for MDD. Current PHQ-9 [a tool used to assess depression] is 15, indicating moderate to severe depression. Recommend increasing Venlafaxine dose or adding adjunctive [additional treatment] therapy. Documented goal of therapy is PHQ-9 < [less than] 3, please consider optimizing patient's [resident's] therapy or clarify current goal of therapy. Review of Resident 57's March 2024 MAR showed Resident 57 was taking guaifenesin (a medication to relieve chest congestion) as needed. Review of the March 2024 MRR showed that the pharmacist documented, Patient has an order for guaifenesin 100mg/5mL [milliliter-a unit of measurement] 20mL Q6H [every 6 hours] as needed for cough. He has not been using guaifenesin and does not have a cough. Please consider discontinuation if no longer indicated. Further review of Resident 57's clinical record did not address the pharmacy recommendations for November 2023, February 2024, or March 2024. On 04/30/2024 at 1:22 PM, Staff YY, RCM, stated that the process for the monthly medication review was that the RCMs get the recommendations from the pharmacy, tell the physician, and sometimes they [physicians] agree or disagree. During a joint record review and interview on 04/30/2024 at 1:40 PM with Staff X, Pharmacist, stated that looking at the pharmacy recommendations for Resident 57 for the months of November 2023, February 2024, and March 2024, we didn't get a follow up from the doctor. In an interview and joint record review on 04/30/2024 at 2:28 PM, Staff B stated that the process for the monthly pharmacy review was that the pharmacy reviews resident's medications, the physician reviews the recommendations, and then staff implement the orders. Staff B stated they expected a follow up from the physician. Joint record review of Resident 57's clinical record showed Resident 57's clinical record did not address the pharmacy recommendations for November 2023, February 2024, or March 2024. Resident 57's clinical record did not address the pharmacy recommendations for November 2023, February 2024, or March 2024. Staff B stated the last one [physician response to pharmacy recommendation] is a follow up from August [2023] and I don't see any additional follow up from the doctor. Reference: (WAC) 388-98-1300 (4)(c) Based on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on for 2 of 5 residents (Resident 90 & 57), reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life. Findings included . RESIDENT 90 Resident 90 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 04/09/2024, showed Resident 90 was cognitively intact. Review of the physician's order summary report printed on 04/24/2024, showed Resident 90 was receiving insulin Glargine (a drug that lowers the level of glucose (a type of sugar) in the blood) 46 units two times a day with an order date of 04/03/2024. Review of the pharmacist Medication Regiment Review (MRR), dated 04/08/2024, showed there was a recommendation from the pharmacist to consider increasing insulin glargine to 50 units twice daily for better control of blood glucose/sugar. Further review the MRR showed Resident 90's physician agreed with the pharmacist's recommendation and signed it on 04/11/2024. Review of the April 2024 Medication Administration Record (MAR) showed that the pharmacist recommendation was not followed, and Resident 90 continued receiving Glargine 46 units two times a day. Joint record review and interview on 04/30/2024 at 9:07 AM with Staff PP, Resident Care Manager (RCM), showed the MRR dated 04/08/2024 had a recommendation from the pharmacist to increase the insulin glargine 50 units twice daily, signed by Resident 90's physician. Staff PP stated that Resident 90 at time refuses changed on their medications. When asked if they had documentation to show regarding the refusal. Staff PP stated they would check it but did not provide the documentation for resident refusal. On 04/30/2024 at 9:39 AM, Staff B, Director of Nursing, stated they would expect the pharmacy recommendations implemented timely.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to discard expired medication for 1 of 4 medication carts (Unit 200 Medication Cart), reviewed for medication storage. This failure placed the resident at risk to receiving expired or compromised medication. Findings included . Review of the facility's policy titled, Medication Storage in the Facility, reviewed on 12/24/2019, showed medication and biologicals are stored safely, secure, and properly, following manufacturer's recommendations or those of the supplier. It further showed that outdated or expired medications are immediately removed from stocks, disposed of according to procedure for medication disposal and reordered from the pharmacy if current order exists. During a joint observation and interview on 04/25/2024 at 3:56 PM with Staff W, Licensed Practical Nurse, showed the Unit 200 Medication Cart had one Lispro insulin pen (medication given to lower blood sugar) for Resident 120 that was opened on 03/22/2024 during resident's admission and had been used for 35 days. Staff W stated that the Insulin pen was good for 28 days after opening, the medication was expired, and it should have been properly disposed. On 04/26/2024 at 1:01 PM, Staff X, Pharmacist, stated Lispro pen were good for 28 days after opening and that the Lispro pen was expired. On 04/30/2024 at 11:28 AM, Staff B, Director of Nursing Services, stated the Lispro pen was good for 28 days after it was first opened and that it was expired. Reference: (WAC) 388-97-1300(2) .

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to offer/serve food substitutes and/or serve food that accommodated preferences for 1 of 2 residents (Resident 35), reviewed for food preferences. This failure placed the resident at risk for dissatisfaction with food, weight loss, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Serving a Meal, showed the facility should serve meals that meet the nutritional needs of the residents. The policy further stated that staff should, check to be sure everything is served that is required by the menu ticket, and the resident's preference. Review of the facility's policy titled, Resident Rights: Accommodation of Needs and Preferences and Homelike Environment Policy, dated January 2019, showed that it was the facility policy to identify and provide reasonable accommodation of the resident's needs and preferences. Review of Resident 35's nutrition care plan printed on 04/22/2024, showed an undated intervention that stated, Meal Ticket selections will be monitored with Food items known that Resident enjoys added if no Entrée is selected. The care plan further showed an undated intervention that Resident 35 disliked melon-like berries, grapes, and tangerines. Observation and interview on 04/24/2024 at 11:49 AM with Resident 35, showed they were served a glass of water, a glass of apple juice, a slice of garlic bread, a slice of iced lemon loaf cake, and a fruit cup. Resident 35 let Staff UU, Certified Nursing Assistant, know that they did not want the garlic bread and it was taken away. Resident 35 then requested a banana. Resident 35 stated they were not going to eat the lemon loaf cake as they had several pieces on their bedside table. Resident 35 further stated that the fruit cup had melons, cantaloupe, honey dew, grapes, and watermelon, and that they disliked melons. Resident 35 stated, So I guess I will have a banana and apple juice for lunch. Resident 35 stated that the staff, made a big deal of writing down their food preferences but was all talk and no answers. Another observation and interview on 04/25/2024 at 11:48 AM with Resident 35, showed they were served a glass of water, a glass of apple juice, a dessert, and an iced lemon loaf cake. Resident 35 stated that they had crossed everything off their menu and when this happened, they would get an iced lemon loaf cake or sometimes a dessert. During an interview and joint record review on 04/29/2024 at 1:54 PM with Staff UU, stated they would normally ask the resident if there was something else that they would prefer to eat and offer an alternative. Staff UU stated that Resident 35 had received grapes for lunch that day and that they offered them two bananas. Joint record review of Resident 35's undated [NAME] (care plan for CNAs), showed the resident disliked grapes. Staff UU stated that the server had served grapes because there was nothing else for fresh fruit. Staff UU stated that they would not expect to see a food item the resident dislikes on their meal tray. On 04/30/2024 at 8:22 AM, Staff D, Culinary Director, stated that when a resident crossed everything off their menu or left it blank, the server or aide would talk with the resident and work with their requests or preferences. Staff D stated that they were unaware that Resident 35 disliked melons or grapes. Staff D further stated that the cook had a list of items Resident 35 preferred to eat in these cases. During an interview and joint record review on 04/30/2024 at 11:58 AM with Staff VV, Registered Dietician, stated that when a resident did not pick something on their menu, or crossed items off, they or the dietary manager would talk with the resident and inform them that they could order off menu. Joint record review of Resident 35's nutritional care plan revised on 09/19/2022, showed the resident's food dislikes. Staff VV stated that they would have expected the resident to have been offered an alternative. Staff VV further stated that there seemed to be a disconnect in communication in getting the resident the right thing. On 04/30/2024 at 12:46 PM, Staff B, Director of Nursing Services, stated that they expected staff to go over the menu with the residents and that they expected their food preferences to be documented on the meal ticket and in their care plan. Staff B stated that they expected staff to serve a full meal based on the resident's preferences and diet. Staff B further stated that they expected staff to follow the care plan and take the food the resident disliked and replace it with an alternative. Reference: (WAC) 388-97-1140 (6) .

CONCERN (D)

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

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure bed rails and/or halos (type of bed rail shaped like a ring) were safe for 3 of 5 residents (Residents 35, 95 & 74), reviewed for bed rails safety. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's undated policy titled, Halo Ring Installation and Maintenance Policy, showed, Maintenance shall inspect all Halo Rings monthly to ensure proper installation and usage. This check shall be logged into the work order system. The policy further showed if any deficiency was found with the Halo Ring, maintenance staff would remove the affected hardware and replace it. RESIDENT 35 Resident 35 admitted to the facility on [DATE]. Review of Resident 35's transfers care plan showed an intervention, revised on 09/20/2022, showed, Assistive devices; Right and left Halo to assist in bed mobility [movement in bed]/ transfer; Staff to report to LN [Licensed Nurse] immediately if problem noted with Halo use or there is a problem with the equipment. Observations on 04/22/2024 at 9:59 AM and at 2:38 PM, and on 04/24/2024 at 9:06 AM, showed Resident 35's bed had two bed rails, a halo on the right side of the resident and a different type of bed rail on the left side of the resident. Observation and interview with Resident 35 on 04/24/2024 at 9:06 AM, showed both bed rails were wobbly. Resident 35 stated that they used them every day for turning and support. Resident 35 further stated that no one had assessed them. Joint observation and interview on 04/24/2024 at 1:19 PM with Staff UU, Certified Nursing Assistant (CNA), showed the bed rails were wobbly. Staff UU stated that the bed rails should not be wobbly, they should be firm, and tight at the bottom, maybe they have gotten loose. On 04/24/2024 at 3:11 PM, Staff C, Facility Director, stated that there was no documentation showing the maintenance of the facility's bed rails. Joint observation and interview on 04/24/2024 at 3:37 PM with Staff C, showed the left bed rail was wobblier than the right one. Staff C stated they did not know where the left bed rail came from as it did not belong to the facility, and they had not seen a bed rail like that. Staff C stated that the left bed rail appeared to have more play [movement] than it should. Staff C further stated that the right halo had more movement than they felt comfortable with. Staff C stated that they would expect the facility to be using their bed rails and have them have a tighter feeling, not have the whole extension moving with the rail. Staff C further stated that there was no way to know when the last routine maintenance occurred as there was no documentation. RESIDENT 95 Resident 95 admitted to the facility on [DATE]. Review of Resident 95's physician's order showed an order initiated on 02/23/2024 for Halos/Bed Enabler [rail]- Bilateral [both sides] for bed mobility. Observations on 04/22/2024 at 12:44 PM and on 04/24/2024 at 9:15 AM, showed Resident 95's bed rails were loose, the left was looser than the right rail. Joint observation and interview on 04/24/2024 at 3:11 PM with Staff C, showed Resident 95's left bed rail was flared out. Staff C stated that the halo ring, did not appear to be parallel, and that they would recommend replacing the bracket. On 04/30/2024 at 12:32 PM, Staff B, Director of Nursing Services, stated that the bed rails for Resident 35 and 95 should not have been wobbly. Staff B stated that Resident 35 should not have had a bed rail that did not belong to the facility. Staff B further stated that they expected maintenance staff to be checking the bed rails for function and tightness and expected there to be documentation. RESIDENT 74 Resident 74 admitted to the facility on [DATE]. Review of Resident 74's activities of daily living care plan revised on 04/19/2024, showed Resident 74 used bilateral bed enablers for bed mobility (moving in bed) and transfers. Observation on 04/23/2024 at 9:18 AM, showed bilateral bed rails in the raised position on Resident 74's bed, and the left bed rail was loose. On 04/23/2024 at 9:32 AM, Resident 74 stated they used their bed rails for turning in bed. On 04/24/2024 at 2:53 PM, Resident 74 stated there had been no routine checks done for their bed rails. On 04/24/2024 at 12:51 PM, Staff AAA, CNA, stated Resident 74 used their bed rails for pulling up in bed and when getting out of bed. Staff AAA stated they tell maintenance if they noticed a problem with resident's bed rails. On 04/24/2024 at 3:09 PM, Staff C stated, currently there was no documentation that showed bed rails/halos were being checked routinely. Staff C further stated there should be documentation of routine maintenance for the bed rails/halos. During a joint observation and interview on 04/24/2024 at 3:31 PM with Staff C, showed Resident 74's left rail was wobbly, Staff C stated that the left side [rail] is too loose. On 04/30/2024 at 2:40 PM, Staff A, Administrator, stated that they would expect regular, preventative maintenance for the Halos. Staff A stated they expect documentation for routine maintenance of the bed rails/halos from here on out. Reference: (WAC) 388-97-2100 (1) .

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 46 Resident 46 admitted to the facility on [DATE]. Review of the activities of daily living self-care needs care plan revised on 09/09/2020 showed that Resident 46 required set up assistance by one staff to eat and may need cueing or one person extensive assistance to start eating. Observation on 04/30/2024 at 8:50 AM, showed Staff P, CNA, was standing while assisting Resident 46 with their breakfast in their room. Staff P stood the entire time they assisted Resident 46 with their breakfast. On 04/30/2024 at 8:58 AM, Staff P stated that the facility trained them to be eye level with the residents but were not trained to sit down when assisting resident with meals. Staff P stated that it was their choice if they wanted to sit or stand. Staff P further stated that they usually sit down and that they decided to stand up while assisting Resident 46 with their breakfast. On 04/30/2024 at 9:04 AM, Staff H stated that staff should be sitting when they were assisting residents with their meal and that Staff P should have been sitting when assisting Resident 46 with their meal. On 04/30/2024 at 9:10 AM, Staff B stated that they expected staff to be sitting at eye level when assisting residents with their meal. RESIDENT 16 Resident 16 admitted to the facility on [DATE] with diagnoses that included blindness on both eyes. Review of the annual MDS dated [DATE], showed Resident 16 had moderately impaired cognition and required substantial/maximal (the helper does more than half the effort) assistance with eating. Observation on 04/26/2024 at 8:21 AM, showed Resident 16 was eating breakfast and Staff V, CNA, was standing while assisting Resident 16 with their breakfast meal. On 04/26/2024 at 8:33 AM, Staff V stated that they only need to be seated when assisting residents in the dining room. Staff V stated that when they were in the resident's room, I prefer to raise the bed and assist them [with eating] standing. Staff V further stated, personally, that is what I like, I do not use chair because I chose standing. On 04/29/2024 at 11:43 AM, Staff B stated when staff assist residents with their meals in the dining and resident rooms, they should be seated next to them. Staff B further stated that they would not expect staff to assist residents with their meals while standing. On 04/30/2024 at 8:23 AM, Staff A, Administrator, stated staff should be seated with residents when they assist residents with eating. Reference: (WAC) 388-97-0180(1)(2)(3) Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while entering a resident's room for 1 of 6 residents (Resident 34), use of urinary catheter (a flexible tube inserted into the bladder to drain urine) drainage bag for 2 of 3 residents (Residents 110 & 17), use of a mechanical lift sling for 1 of 1 resident (Resident 99), and meal assistance for 3 of 5 residents (Residents 99, 46 & 16) reviewed for dignity. These failures placed the residents at risk for a diminished self-worth and over-all well-being. Findings included . Review of the facility's undated policy titled, Promoting/Maintaining Resident Dignity, showed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, which maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy further showed that they will maintain resident privacy. Review of the facility's undated policy titled, Catheter Care/Bags, showed, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. It further showed that all catheter bags will be covered with a catheter bag cover to maintain resident privacy. KNOCKING ON RESIDENT DOOR PRIOR TO ENTERING RESIDENT 34 Resident 34 admitted to the facility on [DATE]. Observations on 04/25/2024 at 8:02 AM and at 8:04 AM, showed Staff O, Certified Nursing Assistant (CNA), entered Resident 34's room without knocking or identifying themselves to the resident prior to entering. On 04/25/2024 at 8:15 AM, Staff O stated before they entered a resident's room, they would knock, ask permission to enter and identify themselves. Staff O stated that they should have knocked, identified themself, and asked for permission prior to going inside Resident 34's room. On 04/25/2024 at 2:05 PM, Staff H, Registered Nurse (RN), stated prior to entering resident rooms, staff should knock, introduce themselves and let the resident know why they were there for. Staff H stated that Staff O should have knocked and introduced themselves prior to entering Resident 34's room. On 04/29/2024 at 1:10 PM, Staff B, Director of Nursing Services, stated they expected staff to knock on the resident's door, observe for any precautions, introduce themselves, let the residents know why they were there for and perform hand hygiene. Staff B further stated that Staff O should have knocked and introduced themselves prior to entering Resident 34's room. USE OF URINARY DRAINAGE BAG RESIDENT 110 Resident 110 admitted to the facility on [DATE] with diagnoses that included obstructive and reflex uropathy (a condition in which the flow of urine is blocked and causes the urine to flow backwards). Review of the admission Minimum Data Set (MDS-an assessment tool) dated 02/13/2024, showed Resident 110 had an indwelling foley catheter. Observations on 04/22/2024 at 2:25 PM, on 04/23/2024 at 9:11 AM, on 04/24/2024 at 8:20 AM, and on 04/25/2024 at 8:01 AM, showed Resident 110's catheter bag was covered with a blue covering with the bottom of the catheter bag exposed and visible from the hallway. During a joint observation and interview on 04/25/2024 at 9:03 AM with Staff J, CNA, showed Resident 110's catheter bag was exposed and was touching the ground. Staff J stated that the blue covering was what they had, and that the bottom of the catheter bag was not covered. Staff J further stated that they were aware that the catheter bag was not completely covered for privacy. On 04/25/2024 at 9:13 AM, Staff H stated that they were aware that the bottom of the catheter privacy bag was opened and that it did not provide the best privacy. Staff H stated that the catheter bag covers are not the best and that the catheter privacy bag should have been completely covered for privacy. On 04/29/2024 at 1:18 PM, Staff B stated that Resident 110's catheter bag should have been covered for privacy. MECHANICAL LIFT SLING RESIDENT 99 Resident 99 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed that Resident 99 had severely impaired cognition, dependent on the staff with meal intake and with transfer to/from a bed to a wheelchair. Observation on 04/25/2024 at 12:49 PM and on 04/26/2024 at 11:14 AM, showed Resident 99 was sitting up in their wheelchair at the second-floor nursing station located by their room. Further observation showed Resident 99 was sitting on purple colored mechanical lift sling left underneath the resident. On 04/26/2024 at 1:26 PM, Staff O, CNA, and Staff EEE, CNA, stated that they never removed Resident 99's mechanical lift sling after the resident was transferred to their wheelchair because it was hard to put it back on when they transferred the resident from their wheelchair to their bed. On 04/29/2024 at 1:09 PM, Staff GGG, RN, stated that Resident 99's mechanical lift sling should be removed after the resident transferred to their wheelchair. On 04/30/2024 at 9:44 AM, Staff B stated that mechanical lift sling should be removed after Resident 99 was transferred to their wheelchair and the staff should have not left the mechanical lift sling underneath the resident. MEAL ASSISTANCE RESIDENT 99 Observation on 04/26/2024 at 7:50 AM, showed Staff JJJ, CNA, was assisting Resident 99 with their breakfast while standing over the resident in the 700-unit dining room. On 04/26/2024 at 7:54 AM, Staff JJJ stated they were assisting while standing over Resident 99 because the resident was tall. On 04/30/2024 at 9:00 AM, Staff PP, Resident Care Manager, stated that staff should have been seated while assisting residents with meals. On 04/30/2024 at 9:32 AM, Staff B stated that they expected staff to sit down while assisting resident with meals. RESIDENT 17 Resident 17 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder (lack of bladder control due to a nerve problem in the brain or spinal cord) and had an indwelling urinary catheter. Observation on 04/24/2024 at 8:27 AM, showed Resident 17's urinary catheter drainage bag with amber colored urine, and it was visible to Resident 17's roommate and from the hallway. Joint observation and interview on 04/24/2024 at 8:35 AM with Staff Q, RN, showed Resident 17's urinary catheter bag was not covered with a privacy bag and was visible to Resident 17's roommate and from the hallway. Staff Q stated the urinary catheter bag should have been covered with a privacy bag. On 04/30/2024 at 10:21 AM, Staff B stated they expected Resident 17's urinary catheter bag to have been covered with a privacy bag.

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to inform residents and/or their representatives of risks and benefits before placement of bed against the wall for 2 of 2 residents (Residents 73 & 74), use of tilt in space (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) wheelchair for 1 of 1 resident (Resident 74), installation of a transfer pole for 1 of 2 residents (Resident 5), and prior to starting psychotropic (mind-altering) medications for 1 of 5 residents (Resident 99), reviewed for resident rights. These failures placed the residents at risk for not being fully informed before making decisions regarding their health care, alternative treatment options, and the right to refuse care. Findings included . Review of the undated facility's policy titled, Safety Devices/Restraints, showed bed against the wall, tilt in space wheelchair, and transfer poles were safety devices. The policy showed the facility shall explain to the resident/resident's representative, the potential risks, and benefits of using the device, not using a device, and alternatives to use. The policy further showed a consent should be obtained from the resident/resident's representative prior to initiating a device, and that potential negative outcomes should also be explained. BED AGAINST THE WALL RESIDENT 73 Resident 73 admitted to the facility on [DATE]. Multiple observations on 04/22/2024 at 10:01AM, on 04/23/2024 at 8:06 AM and at 12:58PM, on 04/24/2024 at 8:39 AM, and on 04/26/2024 at 8:37 AM, showed Resident 73 had their bed against the wall. On 04/24/2024 at 8:39 AM, Resident 73 stated they liked their bed against the wall. Review of Resident 73's electronic clinical records did not show a consent and/or risks and benefits document for their bed against the wall. On 04/26/2024 at 12:34 PM, Staff XX, Certified Nursing Assistant (CNA), stated that Resident 73 liked their bed by the wall. During an interview and joint record review on 04/26/2024 at 12:38 PM with Staff Q, Registered Nurse (RN), stated that Resident 73's bed had always been against the wall. Staff Q further stated that prior to placing a bed against the wall an assessment and consent were required from the residents and/or residents' representative. Joint record review of Resident 73's electronic clinical records with Staff Q did not show an assessment and/or consent for their bed against the wall. Staff Q stated they did not see a consent for Resident 73's bed against the wall. During an interview and joint record review on 04/29/2024 at 3:37 PM with Staff B, Director of Nursing Services, stated they expected residents to have an assessment and a consent with explanation of risk and benefits be completed prior to placing a resident's bed against the wall. Joint record review of Resident 73's electronic clinical records did not show a consent for bed against the wall. Staff B stated there should have been a consent done prior to placing Resident 73's bed against the wall. RESIDENT 74 Resident 74 admitted to the facility on [DATE]. Observations on 04/22/2024 at 10:44 AM and on 04/23/2024 at 9:32 AM, showed Resident 74's bed was placed against the wall. On 04/25/2024 at 2:33 PM, Resident 74 stated, no one asked if I care if my bed is against the wall and that no one asked them to sign anything. On 04/29/2024 at 1:42 PM, Staff W, Licensed Practical Nurse, stated they expected that prior to having a bed against the wall there should be an assessment done and risks and benefits provided to residents. During an interview and joint record review on 04/29/2024 at 2:07 PM, Staff B stated that before a resident had a bed against the wall there should be an assessment done by nursing, a physician order, and a consent that provided risks and benefits. Joint record review of Resident 74's electronic clinical record with Staff B showed no consent signed by Resident 74 and/or their representative. Staff B stated there was no consent signed by Resident 74 and/or their representative. USE OF TILT-IN-SPACE WHEELCHAIR RESIDENT 120 Resident 120 admitted to the facility on [DATE]. Observations on 04/22/2024 at 11:13 AM and on 04/26/2024 at 1:27 PM, showed Resident 120 was sitting in their tilt-in-space wheelchair. On 04/29/2024 at 1:42 PM, Staff W stated that before a resident used a tilt-in-space wheelchair, there needed to be consent from the resident and/or their representative. During an interview and joint record review on 04/29/2024 at 2:07 PM, Staff B stated that before a resident had a tilt-in-space wheelchair there should be an assessment done by nursing, a physician order, and a consent that provided risks and benefits. Joint record review of Resident 120's electronic clinical record had no documentation that Resident 120 was given the risks and benefits of using a tilt-in-space wheelchair. Staff B stated there was no documentation to show Resident 120 was given risks and benefits of using a tilt-in-space wheelchair.USE PSYCHOACTIVE MEDICATION RESIDENT 99 Review of the facility's policy titled, Informed Consent for psychoactive [a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior] Drugs revised in April 2017, showed that when the physician has ordered the use of Anti-Depressant drug (a type of medicine used to treat depression), the center per Federal and State Regulations and Center policy obtain informed consent from the resident or responsible party (when resident is not competent). An informed consent is obtained before drug prescribed is administered. The center's staff will place the signed Psychoactive Drugs Disclosure and Consent in the medical record under the Consent tab. Resident 99 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed that Resident 99 had severely impaired cognition. Review of the February 2024, March 2024, and April 2024 Medication Administration Record showed Resident 99 was taking sertraline (an antidepressant drug) 25 milligram once a day with an order start date of 09/21/2023. Review of Resident 99's informed consent for psychoactive medication showed that verbal consent was received for sertraline from Resident 99's representative on 09/21/2023. Further record review of Resident 99's medical record did not show a signed consent for sertraline use. On 04/29/2024 at 1:43 PM, during an interview and joint record review with Staff PP, Resident Care Manager, stated that after a verbal consent for a psychoactive drug was received, a signed consent should be obtained as soon as possible. Joint record review of Resident 99's consent document showed no signed consent for sertraline. Staff PP stated signed consent should have been obtained for sertraline. On 04/30/2024 at 11:21 AM, Staff B stated they would expect a signed consent should be obtained prior to psychoactive drug administration. Reference: (WAC) 388-97-0260 (2)(a-d) USE OF TRANSFER POLE RESIDENT 5 Review of the facility updated policy titled, Mobility Devices, revised in March 2021, showed, To allow residents to maintain or improve bed mobility or transfer ability using a halo device (a type of bed rail shaped like a ring) or transfer pole as an enabler, Nursing must assure that all devices used for mobility are care planned and consent obtained. Resident 5 was admitted to the facility on [DATE] with multiple diagnoses including a stroke (restriction of blood flow or sudden burst of blood vessel in the brain) with left-sided hemiparesis (weakness or inability to move the left side of the body). Review of the annual Minimum Data Set Assessment (MDS-an assessment tool), dated 02/12/2024, showed Resident 5 was moderately impaired and required staff assistance with transfer to/from their bed to wheelchair. Observation and interview on 04/22/2024 at 10:14 AM, showed Resident 5 had a transfer pole next to the left side of their bed. The pole ran from the floor and was secured to the ceiling wall. Resident 5 stated they used the transfer pole every day to transfer in and out of bed from his wheelchair. Observation on 04/22/2024 at 10:22 AM, showed Resident 5 was transferring themself from wheelchair to the bed using the transfer pole. Observation on 04/26/2024 at 12:04 PM, showed Resident 5 was transferring from their wheelchair to bed using the transfer pole with the assistance of Staff AA, CNA. During an interview and joint record review on 04/26/2024 at 10:56 AM with Staff Q, stated Resident 5 used their transfer pole every day to get in and out of bed. Joint record review of Resident 5's electronic clinical records did not show a consent for the use of a transfer pole. Staff Q stated there should have been a signed consent for Resident 5 for the use of a transfer pole device. On 04/30/2024 at 10:21 AM, Staff B stated they expected residents using a transfer pole to have a signed consent.

CONCERN (E)

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

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 16 of 16 residents (Residents 91, 6, 7, 10, 16, 20, 39, 42, 61, 63, 64, 78, 80, 100, 122 & 379) reviewed for resident rights. This failure placed the residents at risk of not understanding their rights and a reduced ability to self-advocate. Findings included . Review of the February 2023 to April 2024 Resident Council minutes did not show that the resident rights were being reviewed during Resident Council meetings. During an interview on 04/26/2024 at 10:15 AM with Residents 91, stated the facility staff did not review resident rights with them. Residents 6, 7, 10, 16, 20, 39, 42, 61, 63, 64, 78, 80, 100, 122 and 379 stated they agree with Resident 91. On 04/29/2024 at 10:16 AM, Staff DD, Social Worker, stated they did not review resident rights during resident council meetings. Staff DD stated they used to review it in the past but could not recall the last time they reviewed residents' rights during resident council meeting. On 04/30/2024 at 8:23 AM, Staff A, Administrator, stated, I think they should review them yearly. Staff A stated that residents rights used to be one of the agenda in the residents' council meetings in the past. Staff A further stated they should have reviewed it periodically. Reference: (WAC) 388-97-0300 (1)(a) .

CONCERN (E)

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

Deficiency F0574 (Tag F0574)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide the website address of the Washington State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) on the posted contact information in 7 of 7 facility areas (notice boards in units 100, 300, 400, 500, 600, 700, and inside of one elevator), reviewed for residents' rights. This failure placed the residents at risk for not being able to report their concerns online to the State Long-Term Care Ombudsman. Findings included . Observations on 04/26/2024 at 9:54 AM, at 11:59 AM, at 12:04 PM, at 12:10 PM, at 12:25 PM, and at 12:29 PM, showed that the posted State Long-Term Care Ombudsman information did not include the website address. During a joint observation and interview on 04/29/2024 at 9:03 AM with Staff A, Administrator, showed the posted State Long-Term Care Ombudsman information in the seven facility areas did not have a website address on it. Staff A stated they did not recall the last time they updated the contact information. Staff A further stated that the contact information should have been updated at least annually. Reference: (WAC) 388-97-0300 (7)(c) .

CONCERN (E)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 16 Resident 16 admitted to the facility on [DATE] with diagnoses that included blindness on both eyes. Review of the annual Minimum Data Set (an assessment tool) dated 03/19/2024, showed Resident 16 had moderately impaired cognition. Observation and interview on 04/22/2024 at 1:58 PM with Resident 16 showed there were five names with phone numbers posted on the wall by their bed and by the sink. Resident 16 stated the names and phone numbers posted on their walls were of their family members. The names and phone numbers were visible from the hallway. Further observations on 04/23/2024 at 7:50 AM, and on 04/24/2024 at 11:01 AM, showed Resident 16's room continued to have the five names with phone numbers posted on the wall by their bed and by the sink. The names and phone numbers posted by the sink were visible from the hallway. Observation on 04/24/2024 at 1:17 PM, showed the names and phone numbers were removed and placed on Resident 16's bedside nightstand. On 04/24/2024 at 1:39 PM, Staff CC, CNA, stated when Resident 16 needs assistance with calling on to family, they report it to the nurse and/or front desk staff. Staff CC stated, for me I do not call myself, I have never done it before. On 04/24/2024 at 1:43 PM, Staff BB, RN, stated that they did not encourage posting personal information in residents' room. Staff BB stated that Resident 16's representative had posted those names with phone numbers, and they knew the information was visible from the hallway. Staff BB further stated that there was no discussion with Resident 16's representative regarding whether this could be a concern for privacy. On 04/24/2024 at 1:53 PM, Staff AA, Resident Care Manager, stated posting personal information in Resident 16's room was concerning. Staff AA stated they removed the information from the wall and placed it on bedside nightstand. Staff AA further stated, I guess everybody has access to it, but if it is on the nightstand, I do not think people can see it unless they search for it. On 04/29/2024 at 11:43 AM, Staff B stated they saw the list of names with phone numbers in Resident 16's room and told the staff to remove it. Staff B further stated they did not expect Resident 16's and/or family members' personal information be displayed on their wall. Based on observation, interview, and record review, the facility failed to ensure privacy and confidential information were maintained regarding residents' weights for 9 of 9 rooms (Rooms 306B, 308A, 312B, 305B, 203, 205, 302B, 303A & 307B), and failed to ensure residents' medical records and representatives' information were maintained for 4 of 5 residents (Residents 67, 17, 16 & 100), reviewed for privacy. These failures placed the residents at risk for having their medical and personal information not kept confidential and a diminished quality of life. Findings included . Review of the facility's undated policy, Promoting/Maintaining Resident Dignity, showed that it was their policy to Maintain resident privacy. RESIDENT WEIGHTS Observation on 04/29/2024 at 8:21 AM, showed a piece of paper posted outside the shower room on the 300 unit dated 4/29 [04/29/2024]. The paper showed the following list of room numbers with residents' weights: - room [ROOM NUMBER]B 125 lbs. (pounds-a measurement of weight) - room [ROOM NUMBER]A 204 lbs. - room [ROOM NUMBER]B 123 lbs. with wheelchair and footrest - room [ROOM NUMBER]B 138 lbs. Observation on 04/30/2024 at 8:50 AM, showed a piece of paper posted outside the shower room on the 300 unit dated, 4/30/24 [04/30/2024]. The paper showed the following list of room numbers with residents' weights: - room [ROOM NUMBER] 148 lbs. - room [ROOM NUMBER] 166 lbs. - room [ROOM NUMBER]B 162 lbs. - room [ROOM NUMBER]A 175-50 =125 lbs. wheelchair with footrest and armrest - room [ROOM NUMBER]B 240 lbs. On 04/30/2024 at 9:05 AM, Staff ZZ, Certified Nursing Assistant (CNA)/Shower Aide, stated that resident weights were private information and shouldn't be on there [on the paper outside the shower room] and maybe put inside the shower room. On 04/30/2024 at 9:11 AM, Staff YY, Resident Care Manager, stated that resident weights were considered private information and should not have been posted in the hallway. On 04/30/2024 at 2:26 PM, Staff B, Director of Nursing Services, stated that resident weights were private information and that they would not expect that information to be posted in the hallway. MEDICATION ADMINISTRATION IN THE DINING ROOM RESIDENT 100 Resident 100 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 100 was cognitively intact. Review of the April 2024 Medication Administration Record showed Resident 100 had an order to apply a patch of Aspercreme Lidocaine (a product used to help reduce itching and pain) to lower back/neck topically (applied on the skin) in the morning for pain. Observation on 04/29/2024 at 11:44 AM, showed Resident 100 was sitting in the 700 Hall dining room for lunch. Staff GGG, RN, came to the dining room and applied the Aspercreme Lidocaine patch to Resident 100's lower back while the resident was standing, lifted their shirt up, and exposing their back. During the application of the patch to Resident 100's lower back, there were three staff and three residents in the dining room. On 04/29/2024 at 11:50 AM, Resident 100 stated that they would prefer the patch was applied while they were in their room. On 04/29/2024 at 2:56 PM, Staff GGG stated residents should have privacy during care and treatments. Staff GGG stated they asked Resident 100 to go to their room for the patch application, but the resident asked them to apply the patch in the dining room. On 04/30/2024 at 9:29 AM, Staff B stated that they would expect staff to provide privacy during any treatment or care. Reference: (WAC) 388-97-0360 (1) UNATTENDED COMPUTER SCREEN Resident 67 Observation of the Unit 400 Central Medication Cart on 04/24/2024 at 9:01 AM, showed a computer screen was left open showing Resident 67's Medical Administration Record (MAR) with no staff around. During a joint observation and interview on 04/24/2024 at 9:04 AM with Staff Z, Registered Nurse (RN), showed the computer screen was left open with no staff around and Resident 67's MAR was visible to anyone in the hallway. Staff Z stated they forgot to lock the computer screen and it should have been locked when staff was not using it. On 04/30/2024 at 10:21 AM, Staff B stated they expected that the computer screen containing residents' information be locked when staff were not around RESIDENT'S REPRESENTATIVES INFORMATION POSTED ON THE WALL RESIDENT 17 Resident 17 was admitted to the facility on [DATE]. Observation on 04/24/2024 at 8:27 AM, showed Resident 17's representatives' names and phone numbers were written on a white board and posted on the wall above the sink. The contact information was visible with Resident 17's roommate and in the hallway. During a joint observation and interview on 04/24/2024 at 8:30 AM with Staff Q, RN, showed Resident 17's representatives names and contact information were visible to Resident 17's roommate and from the hallway. Staff Q stated Resident 17's personal information should have been posted somewhere else in the room to provide privacy. On 04/30/2024 at 10:21 AM, Staff B stated they expected that Resident 17's representatives' contact information should have been posted somewhere in the room that could not be seen by other people to ensure privacy.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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500 UNIT DINING ROOM-LUNCH Observation of the 500 Unit Dining Room on 04/22/2024 at 12:02 PM, showed Resident 73, Resident 77, Resident 84, Resident 98, and Resident 41 were eating their food on their lunch tray. In another observation of the 500 Unit Dining Room on 04/23/24 at 12:16 PM, showed Resident 73, Resident 77, Resident 84, Resident 98, Resident 41, Resident 49, and Resident 17 were eating their food on their lunch tray. On 04/23/2024 at 12:27 PM, Staff EE, Culinary Services Aide, stated, I think we get used to using trays in room due to COVID-19 (an infectious disease-causing respiratory illness) and we kept doing it in the dining rooms too, and I think that is not right. On 04/23/2024 at 12:58 PM, Staff FF, CNA, stated that the trays were only intended for transporting meals to the residents. Staff FF stated, I do not think we should leave the tray with residents. On 04/29/2024 at 10:04 AM, Staff D stated that residents should not eat their meals on meal trays. Staff D further stated they would not expect the staff to leave trays with residents after they delivered the meals. On 04/29/2024 at 11:43 AM, Staff B stated they expected staff to remove the tray after they delivered their meal and that they should not leave it on the table. Reference: (WAC) 388-97-0880 (1) Based on observation, interview, and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 2 of 6 dining rooms (100 Unit Dining Room & 500 Unit Dining Room), reviewed for dining observations. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Serving a Meal, showed to place served meal items on dining table or the full tray on the overbed table if the resident eats in their room. 100 UNIT DINING ROOM-BREAKFAST Observation on 04/23/2024 at 8:20 AM in the 100 Unit Dining Room, showed Resident 14, Resident 53, Resident 26 and Resident 38 were eating their breakfast on the tray. 100 UNIT DINING ROOM-LUNCH Observation on 04/23/2024 at 11:56 AM in the 100 Unit Dining Room showed Staff J, Certified Nursing Assistant (CNA), delivered Resident 14's lunch tray. Staff J placed the tray on the table, removed the cups from the tray and placed it on the table. Resident 14's plate remained on the tray and Resident 14 was eating their lunch on the tray. In another observation on 04/23/2024 at 11:58 AM in the 100 Unit Dining Room showed, Staff I, CNA, delivered a lunch tray to Resident 53. Staff I did not remove the plates off the tray and Resident 53 was eating their lunch on the tray. Further observation at 12:01 PM, showed Resident 93 and Resident 68 were eating their lunch on the tray. Joint observation and interview on 04/23/2024 at 12:35 PM with Staff I, showed Resident 53's lunch was on the tray. Staff I stated that they did not remove the tray when residents were served in the dining room. Staff I further stated that they were not trained to remove the tray. On 04/23/2024 at 12:42 PM, Staff K, Culinary Service Aide, stated that the plates and cups should come off the tray when they deliver the tray to the residents. Staff K further stated that the CNAs preferred to leave the trays on and that it was easier for them to deliver the trays. On 04/29/2024 at 10:35 AM, Staff D, Culinary Director, stated that staff should remove the trays when serving residents in the dining room. Staff D further stated that they could use the tray to serve residents, but they had to remove it after their meals were served. On 04/29/2024 at 1:05 PM, Staff B, Director of Nursing, stated that they expected staff to remove the trays when serving residents in the dining room.

CONCERN (E)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- an assessment tool) was completed timely for 4 of 23 residents (Residents 86, 14, 90 & 99), reviewed for significant change in condition. This failure placed the residents at risk for delayed care planning, further Activities of Daily Living (ADL) decline, unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed that a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting,' 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary [involving two or more different subjects or areas of knowledge] review and/or revision of the care plan. The RAI showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar days). The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). RESIDENT 86 Resident 86 admitted to the facility on [DATE]. Review of the nursing progress note dated 10/31/2023 showed Resident 86 was admitted to hospice for comfort care. Review of Resident 86's SCSA MDS with an ARD of 11/14/2023 showed a completion date of 11/28/2023, which was 14 days late. RESIDENT 14 Resident 14 admitted to the facility on [DATE]. Review of the nursing progress note dated 03/10/2024, showed Resident 14 admitted to hospice care. Review of Resident 14's SCSA MDS with an ARD of 03/18/2024, showed a completion date of 04/01/2024, which was eight days late. In an interview and joint record review on 04/25/2024 at 11:32 AM with Staff G, MDS/Registered Nurse, stated that they followed the RAI manual for MDS completion. Staff G stated they would complete a SCSA MDS when residents were admitted on or discharged off hospice and if there was a weight loss, change in their ADLs, skin issue and/or if the whole care plan needed to be revised. Staff G stated that once a significant change was identified, they would set the ARD within 14 days and would have 14 days to complete the SCSA MDS. Joint record review of Resident 14's SCSA MDS with an ARD of 03/18/2024 showed a completion date of 04/01/2024. Staff G stated that they signed/completed Resident 14's SCSA MDS within 2 weeks of the ARD and that they did not think the SCSA MDS was completed late. Joint record review of Resident 86's SCSA MDS with an ARD of 11/14/2023 showed a completion date of 11/28/2023. Staff G stated that Resident 86's SCSA MDS was set right and that this was their process. On 04/25/2024 at 11:49 AM, Staff F, MDS Coordinator, stated that their process would be to set the SCSA MDS ARD within 14 days from hospice admission and complete the assessment within 14 days from the ARD. Staff F stated that they have been an MDS nurse for a long time, and this was the first time they have heard that the SCSA MDS had to be completed within 14 days from hospice admission. When asked if hospice admission was when it was determined that a resident had a significant change, Staff F stated, yes, it would certainly seem so. On 04/25/2024 at 12:12 PM, Staff B, Director of Nursing, stated that Resident 86 and Resident 14's SCSA MDS should have been completed within 14 days of hospice admission. RESIDENT 90 Resident 90 admitted to the facility on [DATE]. Review of the electronic health record under the Census Page, showed Resident 90 was admitted to hospice care on 01/05/2024. Review of Resident 90's SCSA MDS with an ARD of 01/16/2024, showed it was signed and completed on 01/26/2024, which was seven days late. During a joint record review and interview on 04/29/2024 at 2:50 PM with Staff G, showed Resident 90 was admitted to hospice care on 01/05/2023 and their SCSA MDS was completed on 01/26/2024. Staff G stated that Resident 90's SCSA MDS was completed late per the RAI manual. On 04/30/2024 at 9:48 AM, Staff B stated that staff should have followed the RAI manual and completed Resident 90's SCSA MDS timely. RESIDENT 99 Resident 99 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 99 had a weight loss and a stage 3 pressure ulcer (a full thickness tissue loss to an area of the skin caused by constant pressure on the area for a long time). Review of the MDS assessment look up showed there was no SCSA MDS completed for Resident 99. Joint record review and interview on 04/29/2024 at 2:34 PM with Staff G, showed Resident 99's quarterly MDS assessment dated [DATE] had two areas of decline. Staff G stated that when there were two areas of decline, a SCSA would be completed but no SCSA MDS was completed for Resident 99. On 04/30/2024 at 9:41 AM, Staff B stated they expected staff to complete a SCSA MDS for Resident 99 because the resident had two areas of decline. Reference: (WAC) 388-97-1000 (3)(b) .

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** BED RAILS/HALOS Resident 95 admitted to the facility on [DATE]. Review of Resident 95's physician's order showed an order, initiated on 02/23/2024 for Halos/Bed Enabler- Bilateral [both sides] for bed mobility. Review of Resident 95's care plan printed on 04/22/2024, showed no care plan for halos/bed enablers. Observations on 04/22/2024 at 12:44 PM and on 04/24/2024 at 9:15 AM, showed Resident 95 had halo bed rails. Interview and joint record review on 04/24/2024 at 1:31 PM with Staff II, RN, stated that halo bed rails should be included in the care plan. Joint record review showed Resident 95 had no halo bed rails care plan. Staff II stated that they could not find a care plan for Resident 95's halo bed rails. Interview and joint record review on 04/24/2024 at 2:16 PM with Staff PP, RCM, stated that bed rails/halos should be included in the care plan. Joint record review showed Resident 95 had no halo bed rails care plan. Staff PP stated they could not find a care plan for Resident 95's bed rails/halos and that there should have been one. Interview and joint record review on 04/30/2024 at 12:32 PM with Staff B, stated that there should be a care plan for bed rails/halos. Joint record review of Resident 95's care plan showed a new intervention for bed rails/halos was initiated on 04/24/2024. Staff B stated that there should have been a care plan for Resident 95's bed rails/halos prior to 04/24/2024. VISION Resident 39 admitted to the facility on [DATE]. Review of Resident 39's quarterly Minimum Data Set (an assessment tool), dated 12/05/2023, showed Resident 39's vision was moderately impaired and wore corrective lenses (glasses). Review of Resident 39's impaired vision care plan printed on 04/23/2024, stated Resident 39 wore glasses while awake. The care plan further showed interventions that read, Ensure that eyeglasses are in place and being worn by resident, Arrange consultation with eye care practitioner as required, and Staff to make sure resident's glasses are labeled. Observations on 04/24/2024 at 8:38 AM, on 04/26/2024 at 11:47 AM, and on 04/29/2024 at 8:29 AM, showed Resident 39 was awake and not wearing their glasses. On 04/24/2024 at 8:39 AM, Resident 39 stated that they had not worn their glasses for two months because they needed new glasses. Joint observation of Resident 39's glasses on 04/26/2024 at 1:00 PM with Staff QQ, CNA, showed the frame of the glasses were without lenses. Staff QQ stated that the last time they saw Resident 39 wear their glasses was almost more than a month ago. On 04/26/2024 at 2:44 PM, Staff II stated that if a resident wore glasses, it should be included in the care plan and [NAME] (care plan for CNAs) and expected staff to follow it. On 04/30/2024 at 12:53 PM, Staff B stated they expected staff to follow and review residents' care plans daily. Staff B stated staff could not follow the care plan if Resident 39's glasses were broken, and the lenses were missing. Staff B further stated that staff should have reported that Resident 39 was not wearing their glasses or that they were broken. Reference: (WAC) 388-97-1020 (1)(2)(a) Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 5 of 23 residents (Residents 73, 74, 120, 95 & 39), reviewed for care plans. The failure to develop care plans for bed against the wall, tilt-in space (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) wheelchair, bed enablers (bed rails)/halos (type of bed rail shaped like a ring), and vision placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Safety Devices/Restraints, showed that bed against the wall, tilt in space wheelchair, and bed enablers/halos were safety devices. The policy further showed that care plans should be updated accordingly to include the development and implementation of interventions to address any risks related to the use of the device. Review of the facility's undated document titled, Process for Halos, Bed Rails, showed to update the care plan where most appropriate. The policy further showed that if the Halos were for transfers or mobility, to care plan under the Activities of Daily Living (ADL) focus care plan. BED AGAINST THE WALL RESIDENT 73 Resident 73 admitted to the facility on [DATE]. Multiple observations on 04/22/2024 at 10:01AM, on 04/23/2024 at 8:06 AM and at 12:58PM, on 04/24/2024 at 8:39 AM, and on 04/26/2024 at 8:37 AM, showed Resident 73 had their bed against the wall. On 04/24/2024 at 8:39 AM, Resident 73 stated they liked their bed against the wall. On 04/26/2024 at 12:34 PM, Staff XX, Certified Nursing Assistant (CNA), stated Resident 73 liked their bed by the wall. Review of Resident 73's comprehensive care plan printed on 04/23/2024 did not show a care plan for bed against the wall. On 04/26/2024 at 12:38 PM, Staff Q, Registered Nurse (RN), stated Resident 73's bed had always been against the wall. Staff Q further stated that residents with bed against the wall should have a care plan. During an interview and joint record review on 04/29/2024 at 3:27 PM with Staff B, Director of Nursing Services, stated they expected residents with bed against the wall to have a care plan. Joint record review of Resident 73's care plan did not show a care plan for bed against the wall, Staff B stated there should have been one. RESIDENT 74 Resident 74 admitted to the facility on [DATE]. Observations on 04/22/2024 at 10:44 AM and on 04/23/2024 at 9:32 AM, showed Resident 74 had their bed against the wall. Review of Resident 74's comprehensive care plan printed on 04/23/2024, showed no care plan initiated for having their bed against the wall. On 04/29/2024 at 1:42 PM, Staff W, Licensed Practical Nurse, stated that before a resident had their bed against the wall, they would assess for safety and provide risks and benefits. Staff W stated, I'm assuming there should be a care plan for having a bed against the wall. On 04/29/2024 at 1:51 PM, Staff YY, Resident Care Manager (RCM), stated that they, along with the admission nurse were responsible for initiating care plans for residents. Staff YY stated that they were unsure if there should be a care plan for having a bed against the wall. During an interview and joint record review on 04/29/2024 at 2:07 PM with Staff B, stated that there should be a care plan for residents who had their bed against the wall. Joint record review of Resident 74's comprehensive care plan showed no care plan for bed against the wall. Staff B stated, I don't see one [care plan] for bed against the wall and that they expected there to be one. TILT-IN-SPACE WHEELCHAIR Resident 120 admitted to the facility on [DATE]. Observations on 04/22/2024 at 11:13 AM and on 04/26/2024 at 1:27 PM, showed Resident 120 was sitting in their tilt-in-space wheelchair. Review of Resident 120's comprehensive care plan printed on 04/23/2024, showed no care plan initiated for a tilt-in-space wheelchair. Joint observation and interview on 04/29/2024 at 1:42 PM with Staff W, showed Resident 120 was sitting in their tilt-in-space wheelchair. Staff W stated there should be care plan for tilt-in-space wheelchair. An interview and joint record review on 04/29/2024 at 1:51 PM with Staff YY, stated there should be a care plan for use of a tilt-in-space wheelchair. Joint record review of Resident 120's comprehensive care plan, showed no care plan for the tilt-n-space wheelchair. Staff YY stated there was no care plan for Resident 120's tilt-in-space wheelchair. An interview and joint record review on 04/29/2024 at 2:07 PM with Staff B, stated that they expected there to be a care plan for tilt-in-space wheelchair. Joint record review of Resident 120's comprehensive care plan showed no care plan for their tilt-in-space wheelchair, Staff B stated there should have been one.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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UNDATED FOOD ITEMS IN THE 600 UNIT RESIDENT 35 Observation on 04/25/2024 at 11:57 AM, showed seven iced lemon loaf cakes in Resident 35's room, including one iced lemon loaf cake with mold (often fuzzy surface growth of fungus especially on damp or rotting matter). Joint observation and interview on 04/25/2024 at 12:06 PM with Staff S, CNA, showed seven iced lemon loaf cakes had no expiration or use by date and one of them had mold on it. Staff S stated the cake was spoiled. Joint observation and interview on 04/25/2024 at 12:22 PM with Staff D showed seven iced lemon loaf cakes had no expiration or use by date and one of them had mold on it. Staff D stated that once the cake was thawed (defrosted) from the freezer it was good for five days according to manufacturer's instructions. Staff D stated that there was no process in place for the nursing staff to know this and that there should have been. Staff D further stated that the moldy iced lemon loaf cake should not have been in Resident 35's room. On 04/26/2024 at 9:21 AM, Staff D stated that eating moldy food could put the resident at risk of getting sick. Staff D further stated that the cakes should have been labeled with a use by date. On 04/30/2024 at 12:45 PM, Staff B stated that they would not expect to have moldy food in a resident's room. Staff B stated that the food should be labeled and discarded within three days, or if unlabeled, discarded. Staff B further stated that the iced lemon loaf cakes should have been labeled. Reference (WAC) 388-97-1100 (3) Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 2 of 3 walk-in kitchen refrigerators (Produce Walk-in Refrigerator & Dessert Walk-in Refrigerator), for 1 of 1 dry storage room, for 1 of 3 resident refrigerators (100 Unit Resident Refrigerator), for 1 of 1 kitchen, for 2 of 2 dining rooms (400 Unit Dining Room and 100 Unit Dining Room), and for 1 of 7 units (600 Unit) reviewed for food service. The failure to label, date, and discard food items, sanitize thermometers between use, and perform hand hygiene placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Food Safety and Storage Requirements, showed that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. The policy showed that labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen, (where applicable) discarded; and keeping foods covered or in tight containers. The policy further showed that foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone (temperatures where bacteria can grow rapidly). Strategies include but are not limited to washing hands properly before distributing trays, washing hands between contact with residents and after collecting soiled plates and food waste, and use of gloves when touching and assisting with ready-to-eat foods. Review of the facility's undated policy titled, Record of Food Temperatures, showed, Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy. Review of the facility's policy titled, Food Brought in from an Outside Source, dated February 2024, showed, Foods or beverages brought in from the outside will be labeled with the resident's name, room number and dated by staff with the current date the item(s) are brought into the facility for storage. FOOD ITEMS IN THE PRODUCE WALK-IN REFRIGERATOR Joint observation and interview on 04/22/2024 at 8:34 AM with Staff D, Culinary Director, showed the Produce Walk-in Refrigerator had one plastic container of romaine lettuce dated 3/30 [03/30/2024] with no use by date, one clear plastic container labeled salad with preparation date of 4/14 [04/14/2024] with no use by date, and one plastic container of chopped carrots with no label or use by date. Staff D stated the romaine lettuce and salad mix should have been used within three days and discarded after the third day. Staff D further stated that the container of carrots should have been labeled and dated with use by date. FOOD ITEMS IN THE DESSERT WALK-IN REFRIGERATOR Joint observation of the Dessert Walk-in Refrigerator on 04/22/2024 at 8:44 AM with Staff D, showed 12 trays that contained slices of chocolate cream pie, which were uncovered. Staff D stated that the staff was not done preparing desserts and that they would cover the slices of chocolate cream pie when they were done. Staff D further stated that they expected the staff to cover it as the dish was done. FOOD ITEMS IN THE DRY STORAGE ROOM Joint observation and interview on 04/26/2024 at 9:35 AM with Staff D, showed the Dry Storage Room had the following food items: -One opened bag of rainbow sprinkles with best before date of 07/19/2023 -Two unopened bags of peanuts with best by date of 02/09/2024 -Six unopened boxes of Quaker (brand name) Grits with best by date of 10/01/2023 -Three unopened boxes of Quaker Grits with best by date of 07/11/2023 Staff D stated that their process was to discard food items that were past the use by date. Staff D further stated that the rainbow sprinkles, peanuts, and grits should have been discarded. FOOD ITEMS IN THE 100 UNIT RESIDENT REFRIGERATOR Observation of the 100 Unit Resident Refrigerator on 04/26/2024 at 1:36 PM, showed a signage outside the refrigerator door that read, opened/saved items need a date written on them. No date, they get thrown out. Further observation of the third refrigerator shelf contained one plastic container of pasta, one plastic container of salad mix, and one fast food paper bag labeled with Resident 46's name. Additional observation of the bottom closed compartment of the refrigerator showed one over ripe banana, two containers of cooked rice, one package of bread, and one plastic storage bag of injera (sour fermented pancake) that were unlabeled and undated. During an interview and joint observation on 04/26/2024 at 1:48 PM, Staff H, Registered Nurse, stated that the 100 Unit refrigerator were for residents and that food brought in from home should be labeled with resident's name and dated. Joint observation of the 100 Unit Refrigerator showed two undated containers and one undated paper bag labeled with Resident 46's name. Staff H stated that they were the residents' personal containers and that they didn't date them. Staff H stated that the food in the bottom closed compartment refrigerator belonged to staff. Joint observation showed two containers of rice, one package of bread, and one brown banana that were unlabeled and undated. At 1:54 PM, Staff H spoke to Staff B, Director of Nursing Services, and stated that staff should have a separate refrigerator to place their personal food items. On 04/29/2024 at 10:32 AM, Staff D stated that the CNAs [Certified Nursing Assistant] should label and date resident's food that was brought in from home. Staff D further stated that staff should not store their food in resident refrigerators and that they have staff refrigerators in the break room where staff should be storing their food. On 04/29/2024 at 1:10 PM, Staff B stated that they expected staff to label resident's food brought from home with the resident's name and date. Staff B further stated that staff should not be storing their food in the residents' refrigerators. HAND HYGIENE WITH FOOD PREPARATION IN THE KITCHEN Observation and interview on 04/26/2024 at 9:20 AM showed Staff N, Culinary Service Prep, removed their used gloves, placed a bag of salad greens in a container, covered it with plastic wrap and labeled it. Staff N did this three times and when they were done, they went inside the two walk-in refrigerators [Produce Walk-in and the Dairy Refrigerators]. Staff N did not perform hand hygiene after removing their used gloves. Staff N stated that they perform hand hygiene when they come into the kitchen. When asked if they performed hand hygiene before and after glove use, Staff N stated, Not often. Staff N further stated that they should have performed hand hygiene after they removed their used gloves. On 04/26/2024 at 1:05 PM, Staff D stated that Staff N should have performed hand hygiene after they removed their used gloves. HAND HYGIENE DURING MEAL TRAY AND THERMOMETER SANITIZATION IN THE 400 UNIT DINING ROOM Observation in the 400 Unit Dining Room on 04/26/2024 at 11:31 AM, showed Staff M, Culinary Service Aide, applied gloves, took the temperature of the Salisbury steak using a thermometer. Staff M did not sanitize the thermometer prior and/or after use. Staff M then took the temperature of the pork chop and wiped the thermometer with a paper towel. Staff M continued to use the thermometer to take the temperatures of the potatoes, puree potatoes, zucchini, tomato soup and gravy, and wiped the thermometer using the same used paper towel between food items. Staff M did not sanitize the thermometer between food items. Observation on 04/26/2024 at 12:06 PM, showed Staff M returned to the 400 Unit Dining Room, applied gloves, returned to the tray line, and prepared a resident's tray. Staff M did not perform hand hygiene prior to applying gloves or returning to the tray line. On 04/26/2024 at 12:09 PM, Staff M stated that they performed hand hygiene when they come to work, before serving, and before/after glove use. Staff M stated they should have washed their hands before glove use. Staff M further stated that the facility taught them how to use/clean the thermometer but that they did not teach them what to clean the thermometer with. Staff M stated they used paper towels and that they did not want to use alcohol wipes because they did not want the alcohol to get in the food. On 04/26/2024 at 1:05 PM, Staff D stated staff should perform hand hygiene before and after glove use and as soon as they entered the dining room. Staff D stated that Staff M should have performed hand hygiene before glove use and when they entered the dining room. Staff D stated that their process was to sanitize the thermometer with alcohol prep pads (wipes) before and after taking food temperatures. Staff D further stated that Staff M should have sanitized the thermometer before and between food items with alcohol wipes. On 04/30/2024 at 9:48 AM, Staff A, Administrator, stated they expected food items to be labeled/dated, covered/sealed, and expired/past use by date to be discarded. Staff A stated that they expected staff to perform hand hygiene before and after glove use, sanitize the thermometer between use and staff to store their food in the staff refrigerators. Staff A further stated residents' food brought from home should have been labeled/dated and anything that was not labeled/dated in the refrigerator should have been discarded. HAND HYGIENE IN THE 100 UNIT DINING ROOM Observation in the 100 Unit Dining Room on 04/22/2024 at 11:55 AM, showed Staff I, CNA, delivered Resident 47's tray and provided set up assistance. Staff I then moved Resident 47's walker, got milk from the drink cart, and gave it Resident 47. Without performing hand hygiene, Staff I went to the tray line and placed utensils on multiple trays. Staff I took a lunch tray and gave it to Resident 53. Staff I touched Resident 53's bread with bare hands and put butter on it. Staff I then took the bread with their bare hands and placed it on Resident 53's hands. On 04/22/2024 at 12:40 PM, Staff I stated that they performed hand hygiene before/after care, after touching anything dirty and that they must wear gloves or use utensils when preparing residents food. Staff I stated they held Resident 53's bread with bare hands and stated that they performed hand hygiene prior to touching the bread with their bare hands. Staff I further stated that they should have performed hand hygiene after touching Resident 47's walker. On 04/29/2024 at 11:20 AM, Staff E, Infection Preventionist, stated that staff should perform hand hygiene before/after care and before/after glove use. Staff E stated that Staff I should have performed hand hygiene after touching the walker and should not have been touching food with bare hands. Staff E further stated if Staff I were to touch food, they expected them to wear gloves. On 04/29/2024 at 1:05 PM, Staff B stated they expected Staff I to perform hand hygiene after they touched Resident 47's walker and before they went to the tray line. Staff B further stated that staff should not be touching residents' food with bare hands.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** STAFF S On 04/25/2024 at 9:13 AM, Staff S, wore gloves to assist Resident 39 with peri-care (cleaning of private parts) in the resident's bathroom. Staff S with the same used gloves, pulled the resident's pants up and transferred Resident 39 into their wheelchair while touching multiple surfaces of the wheelchair. Staff S touched Resident 39's bedside table, their hand, the TV remote control, bedside drawer, wheelchair brakes, and walker. Staff S assisted Resident 39 to transfer from their wheelchair into their bed. Staff S then assisted Staff II, Registered Nurse (RN), with applying a condom catheter on Resident 39. Staff S stretched the condom catheter and applied it to Resident 39. Staff S did not do hand hygiene and/or changed their used gloves in between task, after assisting Resident 39 in the bathroom or after assisting the resident back into their bed. On 04/25/2024 at 10:24 AM, Staff S stated they should have removed their used gloves and washed their hands after assisting Resident 39 in the bathroom. Staff S stated they should have applied new gloves to assist the resident with transfers, and then completed hand hygiene and changed their gloves prior to assisting with the condom catheter. On 04/25/2024 at 10:51 AM, Staff II stated that hand hygiene should be completed before and after assisting a resident with peri-care. Staff II stated that Staff S should have done hand hygiene and put on a new pair of gloves as it put the resident at risk for, contamination and infection. On 04/29/2024 at 4:54 PM, Staff WW stated that Staff S should have removed their used gloves after care, performed hand hygiene, assisted with resident transfer, performed hand hygiene again, and put on a new pair of gloves prior to assisting with applying a condom catheter. Staff WW stated that contamination happened in multiple areas. On 04/30/2024 at 12:28 PM, Staff B stated that Staff S should have performed hand hygiene after assisting the resident with peri-care, remove their used gloves, and performed hand hygiene again prior to the next task. RESIDENT 110 Review of Resident 110's physician's order with a start date of 04/15/2024 showed an order for enhanced barrier precaution for foley catheter (a flexible tube inserted into the bladder to drain urine). Staff to wear gown and gloves with high-contact resident care activities (dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or toileting) every shift. Observations on 04/24/2024 at 11:03 AM, on 04/25/2024 at 1:43 PM, and on 04/26/2024 at 1:32 PM, did not show an enhanced barrier precaution signage on Resident 110's door and/or a PPE cart in the hallway. Observations on 04/29/2024 at 8:15 AM, did not show an enhanced barrier precaution signage on Resident 110's door. Staff I, CNA, attempted to reposition Resident 110 in bed. Staff I removed Resident 110's pillow and attempted to reposition the resident again. When Staff I was unable to reposition Resident 110, Staff I removed their used gloves, threw it in the thrash and left Resident 110's room to call for help without performing hand hygiene. Shortly after, Staff I and Staff MM, CNA, went inside Resident 110's room and closed the door to assist the resident without applying a gown or gloves prior to entering the room. On 04/29/2024 at 8:23 AM, Staff I stated that they assisted Resident 110 with repositioning, washed their face and provided oral care. Staff I stated Resident 110 was not on barrier precautions and that they were not instructed to wear a gown and gloves when providing care to Resident 110. Staff I stated that they would look in the [NAME] (care guide for CNAs) to know if residents were on barrier precautions. Staff I further stated that they should have performed hand hygiene after removing their used gloves. On 04/29/2024 at 9:05 AM, Staff H, RN, stated that their process for residents on barrier precautions would be to place a signage on the resident's door and a PPE cart by the resident's room. Staff I stated that barrier precautions were communicated to everyone and that it should be in the resident's care plan. Staff H further stated Resident 110 was on enhanced barrier precaution and that staff should be wearing gowns and gloves during care. Joint observation with Staff H showed that Resident 110 did not have an enhanced barrier precaution signage on their door and the PPE cart that was in front of the soiled utility room and did not have gowns available for use. Staff H stated that there should have been an enhanced barrier precaution signage on Resident 110's door and gowns available in the PPE cart. On 04/29/2024 at 11:20 AM, Staff E stated that residents on precautions should have a signage on their door, an orange sticker by their name and a PPE cart in the hallway. Staff E stated that Staff I should have worn a gown and gloves during high contact care and performed hand hygiene after removing their used gloves. Staff E further stated that Resident 110's should have had an enhanced barrier precaution signage on their door and a PPE cart in the hallway. On 04/29/2024 at 1:13 PM, Staff B stated that they expected there to be an enhanced barrier precaution signage on Resident 110's door, staff to use appropriate PPE and staff to perform hand hygiene after removing their used gloves. Reference: (WAC) 388-97-1320 (1)(c) STAFF TT Observation on 04/22/2024 at 8:37 AM, showed Staff TT, CNA, was coming out of room [ROOM NUMBER] holding a soiled hospital gown with their bare hand. The soiled hospital gown was not in a bag. Staff TT went to room [ROOM NUMBER] and brought with them the soiled gown from room [ROOM NUMBER]. Staff TT went to room [ROOM NUMBER] holding the soiled gown with their bare hand and placed it in a clear plastic bag with a soiled gown from room [ROOM NUMBER]. Staff TT went to room [ROOM NUMBER] with soiled gowns in a plastic bag, then went to room [ROOM NUMBER]. Staff TT then placed the bag of soiled gowns on Resident 114's (room [ROOM NUMBER]) bedside table and put more soiled gowns in it. Staff TT then took the bag of soiled gowns to the soiled utility room. Staff TT did not do hand hygiene before entering or after leaving these rooms. HAND HYGIENE/MEAL TRAYS STAFF TT On 04/23/2024 at 8:17 AM, Staff TT brought a breakfast meal tray to room [ROOM NUMBER]-A and placed it on Resident 279's side table. Staff TT then donned gloves without doing hand hygiene and assisted Resident 279 to the bathroom, removed their soiled gloves, and did not do hand hygiene. Staff TT then assisted Resident 279 with their breakfast tray, removed a lid from an oatmeal bowl, opened a package of sugar and poured it into Resident 279's oatmeal bowl. Staff TT did not do hand hygiene in between these tasks. Another observation on 04/23/2024 at 8:45 AM, showed Staff TT took one used pink pitcher from the 300 Dining Room, washed it with hand soap and water, then filled it with ice and water, and took it to Resident 281 (room [ROOM NUMBER]-B). On 04/23/2024 at 8:57AM, Staff TT stated they should have not taken soiled gown from room [ROOM NUMBER] to Rooms 302, 301 & 303 and that they should have performed hand hygiene before entering and after leaving those rooms. Staff TT further stated that they should have not washed the used water pitcher in the sink with hand soap and water. On 04/26/2024 at 11:55 AM, Staff YY, Resident Care Manager (RCM), stated that staff should perform hand hygiene in between tasks, after glove use, and before entering/after leaving residents' rooms. Staff YY further stated that staff [Staff TT] should have not taken residents personal used items into other residents' rooms, soiled items should have been bagged before coming out of residents' rooms, and that water pitchers should be washed in the kitchen and not with hand soap and water. On 04/29/2024 at 11:50 AM, Staff D, Culinary Director, stated that used water pitchers should be washed in the kitchen's dishwasher with hot temperature water and not in the dining room sinks. On 04/29/2024 at 3:16 PM, Staff B stated that used residents' personal items should not be taken into other residents' rooms and that residents' used items should have been contained in a bag prior to leaving residents' room. Staff B stated that staff [Staff TT] should perform hand hygiene before entering/after leaving residents' rooms, in between tasks, after providing toileting care, and before putting/after glove use. Staff B further stated that residents' water pitchers should have been washed in the kitchen. Based on observation, interview, and record review, the facility failed to store clean linens appropriately for 1 of 7 units (200 Unit) and failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and with meals trays for 6 of 7 staff (Staff CCC, LLL, ZZ, S, TT & V), reviewed for infection control. In addition, the facility failed to ensure Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) and/or Enhanced Barrier Precautions (EBP- precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 3 of 6 residents (Residents 27, 99 & 110), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Infection Prevention and Control Program, dated 03/21/2024, showed, Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. Review of the facility's undated policy titled, Hand Hygiene, showed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy showed that use of gloves does not replace hand hygiene, to perform hand hygiene prior to donning [putting on] gloves, and immediately after removing gloves. The policy further showed that hand hygiene should be performed between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment (PPE), including gloves, after handling items potentially contaminated with blood/body fluids/secretions/or excretions, during resident care, moving from a contaminated body site to a clean body site, and after assistance with personal body functions such as elimination and hair grooming. LINEN STORAGE Observations on 04/25/2024 at 1:42 PM, on 04/26/2024 at 8:49 AM, on 04/26/2024 at 10:49 AM, and on 04/26/2024 at 12:40 PM, showed folded clean towels that were uncovered and stored on a table in the 200 Unit hallway. Additional observation on 04/29/2024 at 11:08 AM, showed a housekeeping cart with a garbage container parked next to the clean uncovered towels. During an interview and joint observation on 04/29/2024 at 8:45 AM with Staff III, Certified Nursing Assistant (CNA), stated that the towels were used as clothing protectors for residents when eating. Joint observation of the clean towels showed they were uncovered. Staff III stated that the towels were uncovered. On 04/29/2024 at 3:30 PM, Staff WW, Infection Preventionist (IP), stated that clean linens should be stored in a covered area and not uncovered in the hallway. On 04/30/2024 at 2:14 PM, Staff B, Director of Nursing Services, stated clean linens should be stored in covered areas like the clean utility rooms. HAND HYGIENE/GLOVE USE STAFF CCC Observation on 04/24/2024 at 10:31 AM, showed Staff CCC, Occupational Therapist, was helping Resident 71 get set up for brushing their teeth. Staff CCC left the room to get a cup from the medication cart in the hall and did not perform hand hygiene when they left and/or re-entered Resident 71's room. Additional observation on 04/24/2024 at 10:39 AM, showed Staff CCC left Resident 71's room and took a container of sanitizing wipes located at the nurse's station and re-entered the room without performing hand hygiene. On 04/24/2024 at 2:32 PM, Staff CCC stated they should perform hand hygiene before entering and when leaving a resident's room. Staff CCC stated they should have performed hand hygiene before and after providing care in Resident 71's room. STAFF LLL Observation on 04/29/2024 at 9:30 AM, showed Staff LLL, Laundry Lead, removed their used gloves and did not perform hand hygiene before touching surfaces in the laundry room and outside the laundry room. On 04/29/2024 at 9:30 AM, Staff LLL stated their process was to do hand hygiene after taking off their gloves and no, I didn't wash my hands. On 04/29/2024 at 3:30 PM, Staff WW stated they expected staff to wash their hands every time they enter and exit a resident's room. Staff WW stated that hand hygiene should be done as soon as staff removed their gloves. On 04/30/2024 at 2:14 PM, Staff B stated they expected hand hygiene to be done before and after touching a contaminated surface, in addition to entering and leaving the [residents] room. Staff B further stated that hand hygiene should be done immediately after removing gloves. STAFF ZZ Observation on 04/25/2024 at 10:05 AM, showed Staff W, Licensed Practical Nurse, was cleaning Resident 71's pressure ulcer (bed sore). Staff ZZ, CNA, assisted Staff W by helping Resident 71 turn to their side and continued holding them during the wound care process. Staff W put on new gloves to apply the Hydrofera Blue [a type of moist wound dressing] to the wound, which would not stay in place. Staff ZZ was wearing the same gloves and assisted Staff W to hold Resident 71's wound dressing. On 04/25/2024 at 10:40 AM, Staff ZZ stated that when they helped with the dressing change for Resident 71, they weren't touching anything dirty and that they were assuming that the resident's gown was clean prior to touching the clean Hydrofera Blue dressing. On 04/25/2024 at 10:47 AM, Staff W stated that Staff ZZ should have changed their gloves and wash their hands before helping to hold the Hydrofera Blue dressing on the cleaned area. On 04/29/2024 at 3:30 PM, Staff WW stated that either Staff W should have been the one touching the Hydrofera Blue dressing or Staff ZZ should have changed their gloves before touching the cleaned area. On 04/30/2024 at 2:14 PM, Staff B stated that Staff ZZ should have changed their gloves and performed hand hygiene prior to touching the Hydrofera Blue dressing.ENHANCED BARRIER PRECAUTIONS According to Centers for Disease Control and Prevention (CDC) website, last reviewed on 08/01/2024, high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use such as wound care, and any skin opening requiring a dressing. RESIDENT 99 Review of a wound consult note dated 04/18/2024, showed Resident 99 had a wound on their sacrum (an area above tailbone) and left second toe that required a dressing. Review of the April 2024 treatment administration record showed Resident 99 had an order for wound care for their sacrum and left second toe wounds. Observations on 04/24/2024 at 3:30 PM, on 04/25/2024 at 1:36 PM, and on 04/29/2024 at 11:24 AM, showed no EBP sign on Resident 99's room door or Personal Protective Equipment (PPE) cart was placed by the resident's room. Observation on 04/26/2024 at 1:03 PM, showed Staff O, CNA, and Staff EEE, CNA, were transferring Resident 99 from their wheelchair to their bed without wearing a gown. On 04/26/2024 at 1:26 PM, Staff O and Staff EEE stated they used gloves only during Resident 99's transfer and did not know if other PPE was required other than gloves. Observation on 04/29/2024 at 12:42 PM, showed Staff GG, RN, was providing wound care for Resident 99's sacrum wound and was not wearing a gown during wound care. Observation on 04/29/2024 at 1:04 PM, showed Staff MMM, CNA, was applying incontinence brief for Resident 99 without wearing a gown during the incontinence care. On 04/29/2024 at 1:06 PM, Staff MMM stated they did not know that Resident 99 was on precaution. On 04/29/2024 at 1:09 PM, Staff GG stated that Resident 99 was not on precaution. On 04/29/2024 at 1:37 PM, Staff PP, RCM, stated that Resident 99 was on EBP, and staff should wear gown and gloves during high contact resident care activities. Joint observation with Staff PP showed there was no signage posted on the resident's room door that showed Resident 99 was on EBP. Staff PP stated there should be an EBP signage on Resident 99's room door. On 04/29/2024 at 1:56 PM, Staff E, IP, stated that for residents on EBP, wearing gloves and gown were required during high contact resident care activities. Staff E further stated that Resident 99 should have been placed on EBP. On 04/30/2024 at 9:45 AM, Staff B stated Resident 99 should have been placed on EBP. Observation on 04/22/2024 at 12:39 PM, showed Staff V, CNA, delivered five food trays to different residents in the 400 Dining Room while touching a resident's wheelchair, table surfaces and picked something off the floor using a paper towel without performing hand hygiene. On 04/22/2024 at 12:39 PM, Staff V stated that they had performed hand hygiene outside the dining room but not while inside. Staff V stated that the policy encouraged them to perform frequent hand hygiene when serving food between residents. CONTACT PRECAUTIONS Resident 27 Review of the progress note dated 04/28/2024, showed Resident 27 was placed on contact precaution (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) for a lesion to their right armpit due to history of methicillin-resistant staphylococcus aureus (bacteria that is resistant to several antibiotics) to the back area. Observation on 04/29/2024 at 12:04 PM, showed Staff KK, CNA, entered Resident 27's room with a meal tray without wearing a gown or gloves. Resident 27's door had a contact precaution signage posted. Staff KK came out of the room, performed hand hygiene, and continued to deliver meal trays to other residents. On 04/29/2024 at 12:10 PM, Staff KK stated they did not put on a gown or gloves since they were only delivering a meal tray to the resident and were not providing care. Observation and interview on 04/29/2024 at 12:05 PM, showed Staff U, Laundry Staff, entered Resident 27's room without wearing a gown or gloves. Staff U came out of the room and hand sanitized their hands and proceeded to deliver laundry to other rooms. Staff U stated they did not wear a gown or gloves because they were only delivering clean laundry to the resident and did not provide care. Observation on 04/29/2024 at 1:29 PM, showed, Staff T, Housekeeper, enter Resident 27's room without putting on a gown or gloves. On 04/29/2024 at 1:35 PM, Staff T stated they did not wear a gown or gloves because they went in to clean Resident 27's room and did not have contact with the resident. On 04/30/2024 at 10:21 AM, Staff B stated staff were required to perform hand hygiene before they start passing meal trays and in between serving meals. Staff B further stated they expected staff to wear a gown and gloves before they entered a contact precaution resident room.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for 1 of 3 residents (Resident 1), reviewed for quality of care. The failure to monitor hypoglycemia (low blood glucose [a measurement of the amount of glucose (sugar) in the blood] and hyperglycemia (high blood glucose level) placed the resident at risk for unmet care needs and negative health outcomes. Findings included . Review of the facility's undated protocol titled, Diabetic [a person who has diabetes (a group of diseases that affect how the body uses blood sugar/glucose)] Hypo[hypoglycemia]/Hyperglycemia Protocol, showed that nursing will follow the direction of the provider's parameter and orders based on the individual who may respond to diabetes differently. The protocol further showed that nursing will monitor for signs and symptoms of hypoglycemia/hyperglycemia. Resident 1 admitted to the facility on [DATE] with diagnoses that included type 2 (adult onset) diabetes mellitus without complications. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 02/28/2024, showed Resident 1 had severe impairment in cognition. Review of Resident 1's Hemoglobin A1c laboratory result (a test that reflects the average blood sugar level for the past two to three months) with report date of 01/10/2024, showed it was 5.9% (percent) and was flagged for high result (a normal hemoglobin A1c is below 5.7%). Review of Resident 1's provider [physician's] notes dated 01/11/2024, showed Resident 1 had type 2 diabetes with long-term insulin (medication to lower the blood sugar). The provider note showed after they discussed Resident 1's age and stable diabetes with the resident's representative, and ordered to stop the blood sugar checks and insulin injections. The provider notes further showed staff were directed to continue to monitor for hypoglycemia/hyperglycemia protocol for Resident 1. Review of Resident 1's care plan revised on 12/11/2023, showed a care plan for diabetes and an intervention that directed staff to monitor, document, and report to physician as needed for signs or symptoms of hypoglycemia and hyperglycemia. Review of Resident 1's January 2024, February 2024, and March 2024 Medication and Treatment Administration Record (MAR and TAR) showed no record of monitoring of hypoglycemia and/or hyperglycemia. Review of the provider notes dated 03/19/2024, showed Resident 1 was noted with agitation and high [did not specify how high Resident 1's blood sugar level] glucose reading. Review of the provider notes dated 03/20/2024, showed they discussed Resident 1's change of condition with Resident 1's representative, and the resident representative decided to send Resident 1 to the hospital for further evaluation. Review of the hospital emergency department notes dated on 03/20/2023, showed Resident 1 was admitted to the hospital with diagnoses that included altered mental status and high blood sugar. On 04/16/2023 at 9:51 AM, Staff E, Registered Nurse, stated that if a resident had diagnosis of diabetes, hypoglycemia/hyperglycemia would be monitored and documented. During a joint record review and interview on 04/16/2024 at 10:17 AM with Staff C, Resident Care Manager, showed Resident 1's January 2024, February 2024, and March 2024 MAR and TAR, had no documentation to show hypoglycemia/hyperglycemia were monitored. Staff E stated there was a care plan for it and that there should have been documentation and monitoring for signs and symptoms of hypoglycemia/hyperglycemia for Resident 1. On 04/16/2024 at 12:32 PM, Staff D, Doctor of Nursing Practice, Advanced Registered Nurse Practitioner, stated that their expectation was that nursing staff would monitor Resident 1 for signs and symptoms of hypoglycemia/hyperglycemia and notify them for changes. On 04/16/2024 at 12:45 PM, Staff B, Director of Nursing, stated that Resident 1 was placed on alert charting after discontinuation of blood sugar checks and insulin injections. Staff B further stated there was a care plan for resident 1 to be monitored for hypoglycemia/hyperglycemia and that they were unable to provide documentation to show Resident 1 was consistently monitored for sign and symptoms of hypoglycemia/hyperglycemia per their providers' recommendation and the facility's protocol. Reference: WAC 388-97-1060(1) .

Oct 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure suction machines (a medical device to remove secretions [mucus/saliva/blood] obstructing a person's airway) were functioning properly, and medical crash cart (easily accessible supplies/equipment for life saving procedures) were stocked for 6 of 6 nursing units (Transitional Care, 100 Unit, 400 Unit, 500 Unit, 600 Unit & 700 Unit), reviewed for essential equipment. This failure placed Resident 1 and other residents at risk for choking, unmet care needs, and other medical complications. Findings included . NURSING 100 AND TRANSITIONAL CARE UNIT Review of the Daily Crash Cart [emergency cart] Supplies Checklist, dated October 2023, found at the Transitional Care and 100 nursing unit, showed a form on a clipboard that was blank. Further review of the form showed it included the suction machine and suction kits, and there was no place to check if the suction machine was functional and/or if the supplies were stocked. NURSING 400 UNIT AND NURSING 500 UNIT Review of the Daily Crash Cart Supplies Checklist, dated October 2023, found at the 400 and 500 nursing unit, showed the forms had check marks on 10/09/2023, the rest of the form was blank from 10/01/2023 to 10/08/2023, and from 10/10/2023 to 10/18/2023. The form included the suction machine and suction kits, and there was no place to check if the suction machine was functional and/or if the supplies were stocked. NURSING UNIT 600 AND NURSING UNIT 700 Review of the Daily Crash Cart Supplies Checklist, dated October 2023, found at the 600 and 700 nursing unit, showed the forms had check marks on 10/01/2023, the rest of the form was blank from 10/02/2023 to 10/18/2023. The form included the suction machine and suction kits, and there was no place to check if the suction machine was functional and/or if the supplies were stocked. Review of the admission record showed Resident 1 admitted to the facility on [DATE] with a diagnosis that included dysphagia (difficulty swallowing food or liquid). An interview on 10/17/2023 at 9:34 AM with Collateral Contact 1 (CC1), stated that they noticed Resident 1 had trouble swallowing secretions that was in the resident's mouth, CC1 stated they left the room to get a nurse to help. Then an unnamed nurse came with a suction machine and tried to use it to suction the extra secretions from Resident 1's mouth. CC1 stated that when the suction machine was turned on, it did not work, and it could not suction the extra secretions from Resident 1's mouth. CC1 stated, I got a paper towel, placed it on my finger and used it to sweep Resident 1's mouth of the extra secretions. That helped to clear the extra secretions from Resident 1's mouth when the suction machine did not work. On 10/18/2023 at 1:25 PM, Staff D, Licensed Practical Nurse, stated that the crash carts were checked daily using the form [Daily Crash Cart Supplies Checklist], which was on the clip board that was attached to the cart. On 10/27/2023 at 1:09 PM, Staff C, Resident Care Manager, stated that the crash carts were checked every night by the night shift nurse, and when it was checked, it was written down on the form. Staff C also stated they did not know where the August 2023 or the September 2023 forms were located. On 10/27/2023 at 3:30 PM, Staff B, Director of Nursing Services, stated that the crash carts and the suction machines should be checked every night by the night shift nurse. Staff B also stated that they started to check to ensure the suction machines were stocked with the necessary supplies and were functional on 10/18/2023, after they gave an in-service about it. Staff B further stated that they were not able to provide documentation to support that the crash carts and the suction machines were checked before October 2023. Reference: (WAC) 388-97-2100(2) .

Feb 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment by monitoring the exit doors off of the memory care unit (MCU) when the locks on the fire doors were disabled and residents who wandered could potentially leave without staff knowledge for 6 the 21 residents (Residents 1, 8, 10, 14, 17 and 21) reviewed for safe, functional, and comfortable environment. This failure placed the residents at risk for elopement, harm, and a diminished quality of life. On 02/14/2023 at 10:00 AM, the State Fire Marshall's office identified a situation where the egress doors on the MCU did not open during the facility's Life Safety re-certification survey. On 02/14/2023 at 4:04 PM, an Immediate Jeopardy was called due to the egress doors not opening. At around 5:30 PM that night, the immediacy was removed. The egress doors opened, and the facility was working with the keypad installation. Findings included . Review of an undated facility fire watch report documented, fire watch personnel: shall have no other duties. Review of the MCU assignment sheet dated 02/10/2023 showed 21 residents where in the MCU. Interview on 02/15/2023 at 4:21 PM, Staff E, Nursing Assistant Certified, said they routinely worked on the MCU and were familiar with each residents' care and mobility needs. Staff E said Residents 1, 8, 10, 14, 17 and 21 could walk without assist of staff or without the use of assistive devices. A phone interview on 02/15/2023 at 4:37 PM, Staff C, Facilities Director, said when the North and South fire doors were tested on [DATE] they did not open when the codes were pushed into the keypads and that should have opened the doors. Staff C also said the locks on the fire doors had been disabled so the doors could open, and an alarm was in place to alert the staff on the unit if the fire doors were opened. Staff C said new keypads were ordered and expected to arrive to the facility and would be installed when they arrived at the facility. Staff C then said the fire watch was started because the North and South fire doors did not lock. Observations on 02/15/2023 at 5:37 PM and at 5:43 PM, showed the North and South fire doors opened to the outside of the facility. When the bar on the door was pushed by the investigator, no staff members responded or were observed near the doors. Interview on 02/15/2023 at 5:47 PM with Staff B, Director of Nursing Services, said they found out something was wrong with the keypads on the fire doors on the MCU and they had staff assigned to watch the doors. Staff B stated there should have been a staff member there to watch the doors, but that staff member was reassigned to another unit and there was nobody to watch the doors until night shift that day. Staff B stated that their expectation was on each shift a designated staff member would be assigned to visually watch the doors until the doors get repaired and that should be their only assignment. Staff B stated the staff member should document every 15 minutes when it was done. Interview on 02/15/2023 at 7:19 PM, Staff D stated, There is not a staff dedicated to watch the doors, I just started using this form and checking off every 15-minute checks of the door, Staff A, Administrator, just gave it to me to start. We still don't have a designated staff member. Interview on 02/16/2023 at 2:13 PM, Staff A said that there was not an assigned/designated staff member when the doors did not work from 02/14/2023 to 02/15/2023 at 7:40 PM. Reference: (WAC) 388-97-3220 (1) .

Feb 2023 9 deficiencies

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 2 of 2 residents (Residents 33 & 45) had been assessed for the self-administration of medication. The facility's failure to assess the residents for self-administration of medications placed the residents at risk for the improper administration of the medications. Findings included . Review of the facility's policy titled Self-Administration of Medications with an effective date of 11/2017, revealed Policy: If a . resident requests to self-administer medications(s) the interdisciplinary team will assess the resident for determine if it clinically appropriate to home the resident's choice . The Procedure 3. Determination of the residents' ability self-administer medications by the IDT (Interdisciplinary Team) will be documented in the resident's medical record The procedure further directed 4. Education will be provided to the resident on identification of the medication, name. indication (reason for use), dose, route, times (s) of administration, side-effects, adverse consequences . 5. A periodic assessment of the resident's ability to self-administer medication will be performed . 6. A physician's order will be obtained and recorded in the chart and 9. Nurse to check with the resident each shift for appropriate medication administration. RESIDENT 33 Review of Resident 33's Electronic Medical Record (EMR) Minimum Data Set (MDS) found under the MDS tab with an Assessment Reference Date of 11/23/2022 revealed Resident 33's Brief Interview for Mental Status (BIMS) score was 15 of 15 which indicated Resident 33 was cognitively intact. The EMR lacked evidence Resident 33 was assessed for the ability to self-administer medications by the IDT, lacked a physician's order to self-administer the medication and lacked documentation of Resident 33's education to properly administer the medication. Review of Resident 33's Physician's orders found in the EMR under the Orders tab revealed an order for Chlorhexidine Gluconate Solution to Place and dissolve 15 ml [milliliter] buccally [between the gums and the inner lining of the mouth cheek] every day and evening shift for Gingivitis [a form of gum disease]. Use 15 ml to swish for 20 seconds and spit [not swallow]. Observation of Staff N, Registered Nurse, during a medication pass on 02/08/2023 at 9:50 AM, revealed Staff N prepared a medication cup of 15 ml of Chlorhexidine Gluconate Solution and Resident 33's other medications. Staff N administered the other medications to Resident 33, then place the medication cup with the Chlorhexidine Gluconate Solution on the resident's overbed table and exited the room. Interview with Staff N on 02/08/2023 at 10:00 AM, revealed when asked why they left the Chlorhexidine Gluconate Solution at Resident 33's bedside, Staff N stated, the aide will help her with oral care and administer the Chlorhexidine Gluconate Solution. Interview on 02/10/2023 at 9:30 AM, Staff B, Director of Nursing, confirmed that no residents in the facility had been assessed by the IDT to self-administer medications. RESIDENT 45 Review of Resident 45's admission Record dated 02/09/2023 found in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including acute pain related to left knee hemarthrosis (bleeding into the knee joint). Review of Resident 45's admission MDS assessment with an ARD Date of 11/27/2022 and found in the EMR under the MDS tab, indicated a BIMS score of 14 out of 15, which indicated Resident 45 was cognitively intact. Review of Resident 45's Order Summary Report, dated 02/09/2023 and found in the EMR under the Orders tab, indicated an order for Lidocaine External Cream 4% (Lidocaine). Apply to R [right] knee topically four times a day for Pain. There was no order on the summary report to indicate Resident 45 was to self-administer the Lidocaine cream. Review of Resident 45's undated comprehensive Care plan found in the EMR under the Care Plan tab revealed no documentation to indicate the resident was self-administering medication. A thorough review of Resident 45's EMR indicated no documentation to show the resident had been assessed to ensure they were able to safely administer their own medication. During an interview on 02/05/2023 at 9:50 AM, Resident 45 stated the cream was their own Lidocaine cream and that the nurses was providing a cup of it [in a medicine cup] about four times per day and then Resident 45 was the one applying the cream on their knee when needed. Observations on 02/05/2023 at 10:11 AM, on 02/07/2023 at 9:48 AM, 12:20 PM and 2:05 PM, and on 02/08/2023 at 9:50 AM and 1:38 PM, Resident 45 had a medication cup on their overbed table that was ½ full of a white cream during each of these observations. A follow-up interview on 02/08/2023 at 9:50 AM, Resident 45 stated, That's my Lidocaine cream for my feet [for their knee per the physician's order and pointing at the medication cup with white cream in it on the overbed table]. I had a bad night last night with pain in my feet. Resident 45 stated the cream had been applied on their feet due to pain. Resident 45 was not able to say how many times the cream was applied to their feet. An interview on 02/10/2023 at 9:15 AM, Staff S, Licensed Practical Nurse, confirmed the cream the resident was using was Lidocaine cream and the order indicated the cream to be used on the resident's knee. Staff S stated Resident 45 did not have an order for medication self-administration and that that the cream should not have been left at the bedside. During an interview on 02/10/2023 at 9:18 AM, with Staff C, the Resident Care Manager, stated residents were only allowed to self-administer medication (including Lidocaine cream) if a physician had written an order to self-administer the medication and only after an assessment had been done by the facility to determine the resident could safely administer the medication. Staff C also indicated their expectation was a care plan was to be in place for the self-administration of medication. Reference: (WAC) 388-97-0440 .

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure timely reporting of potential abuse to appropriate entities as required for 1 of 2 residents (Resident 32) reviewed for abuse. This failure placed the resident at risk for abuse and neglect. Findings included . The facility's Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition Policy dated 04/2021 read, in pertinent part, Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Each resident also has the right to be free from mistreatment, neglect, and misappropriation of property. (The facility) implements policies and procedures so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents, and Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met: 1.The source of the injury was not observed by a person or the source of the injury could not be explained by the resident: and 2.The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of the injuries observed at one particular point in time or the incidence of injuries over time, and Procedure: 4. Identification: (Facility) staff will identify events such as suspicious bruising, injuries of unknown origin or changes in resident behavior that may be a result of abuse and/or neglect and investigate these occurrences thoroughly, and Reporting/Response: a. (Facility) staff reports any occurrences of injuries of unknown source immediately to the Director of Nursing and or Administrator. b. (Facility) reports allegations and substantiated occurrences of abuse, neglect, exploitation, misappropriation of property, or injuries of unknown source to the state (sic) appropriate state agency and law enforcement officials in accordance with NH Guidelines: AKA [also known as] The Purple Book. Review of Resident 32's admission Record dated 02/09/2023, found in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including encounter for palliative care and dementia (memory loss). Review of Resident 32's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 01/17/2023, found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident was severely cognitively impaired. Review of Resident 32's Physician Encounter Notes, dated 02/05/2023 and found in the EMR under the Notes tab read, in pertinent part, Assessment: Bruising, Unknown cause of injury. Plan: I was called today by nursing staff in relation to this patient. Nursing staff called to report a new bruise to patient's forehead, patient denies any injury however she does have a history of confusion. Review of Resident 32's Progress Notes, dated 02/05/2023 and found in the EMR under the Notes tab, read, in pertinent part, NAC [Certified Nursing Assistant] reported to this LN [Licensed Nurse] that resident has bruise on forehead, went to check on resident, noted bruise on forehead, measured 4.0 cm [centimeter] x 4.5 cm, purplish color, no c/o [complaints of] headache, no dizziness, neuro [neurological] checks WNL [within normal limits], ROM [range of motion] WNL. When asked resident said, I might bump to something, I don't know. Resident alert and verbalizes needs, no c/o pain related to [r/t] bruise. Notified on call ARNP [Advanced Registered Nurse Practitioner] and order to check neuro. also notified Resident's [representative] and [Hospice]. Review of Resident 32's Progress Notes, dated 02/05/2023 and found in the EMR under the Notes tab, indicated the Resident is alert per her baseline and bruise is very visible on forehead. Denied pain or discomfort r/t bruise, no break in skin no swelling. Bruise is purple in color. Review of Resident 32's Progress Notes, dated 02/06/2023 and found in the EMR under the Notes tab read, Resident continues to be on AC [Alert Charting] for extensive bruising on forehead. Continues to be on neuro [assesses the resident's motor, sensory response, and level of consciousness] checks with stable vital signs. Alert and oriented, able to make needs known. was up most of the night, restless, given PRN [as needed] oxycodone [a potent pain medication]) X1 [times one] for c/o headache with good effect. Resident 32 was observed on 02/07/2023 at 11:48 AM with a very large bruise across their entire forehead and along the bridge of their nose spreading between their eyes on both sides. The bruising was dark purple/black in color. The resident was interviewed at this time and was asked if they were able to tell the surveyor how they received the bruising and Resident 32 stated they did not know .but thought they might have fallen. During an interview on 02/07/2023 at 11:50 AM, with Staff N, Registered Nurse, stated they were very familiar with the resident but did not know what had caused the resident's bruising. During an interview on 02/07/2023 at 11:52 AM, Staff V, NAC, stated they were aware of the resident's bruising but did not know how it happened. Staff V stated that the nurse asked them, and they thought Resident 42 bumped it somewhere. During an interview on 02/07/2023 at 2:12 PM with Staff B, Director of Nursing, stated they were aware of the resident's bruising but had not seen the resident in person to assess it. Staff B confirmed the injury was of unknown source and stated they were working on an investigation to determine the cause and rule in/rule out abuse. Staff B stated the occurrence had not been reported to appropriate entity since Resident 32's bruising was not significant. Staff B stated their expectation was that reporting of potential abuse, including injuries of unknown source, were to be reported to the appropriate entities based on The Purple Book. Staff B was not able to define reporting directive in the Purple Book with any detail. Resident 32 was observed with Staff B on 02/07/2023 at 2:28 PM, (two days after Resident 32's bruising was initially identified). Staff B confirmed the significance of the resident's injury/bruising and stated, It looks like an injury of unknown origin. I guess we are going to call it in (to the appropriate agencies) now, and We follow the Purple Book. Reference: (WAC) 388-97-0640 (5)(a) .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were consistently receiving showers/grooming services for 2 of 3 residents (Residents 432 and 50) reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk for poor hygiene, medical complications, and a diminished quality of life. Findings included . The facility's Basic Care Standards Policy dated 10/2019 read, in pertinent part, Nursing services provided to residents will be implemented by licensed and certified personnel according to guidelines identified in the policy; and Bathing-Each resident will be bathed at least once a week. This may be a shower, or bed bath, as directed by the [NAME] and resident preferences; and Dressing and grooming- .female residents will be assisted with trimming of facial hair and makeup as desired. RESIDENT 432 Review of Resident 432's admission Record in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including epilepsy (a neurological disorder in which the brain activity become abnormal causing seizures) and need for assistance with personal care. Resident 432's comprehensive Minimum Data Set (MDS) assessment was not available in the system at the time of the survey due to the resident's recent admission. Review of Resident 432's undated Activities of Daily Living/Self Care Needs Care Plan, found in the EMR under the Care Plan tab, indicated the resident required assistance from staff to complete their bathing and grooming activities. Interventions included set up assist for personal hygiene and two staff assist to provide bath/shower. The care plan did not indicate what the resident's bathing preferences were (the number of times per week or time of day the resident preferred to bathe). There was no documentation in the resident's EMR to indicate an assessment had been done to determine the Resident 432's bathing preferences (including the number of times per week or the time of day the resident preferred to be bathed). The unit shower schedule was requested and a Shower Schedule for TCU [Transitional Care Unit] October 2022 was provided to the surveyor. The schedule indicated showers by room number rather than by resident and revealed Resident 432 was to be showered once per week on Thursdays. Review of Resident 432's shower records dated 01/27/2023 through 02/09/2023, found under the Tasks tab in the EMR, indicated the resident received showers on 02/01/2023 and 02/05/2023 with extensive assistance from staff. The resident's grooming records of the same date range indicated the resident received grooming services daily between 01/27/2023 and 02/09/2023. No refusal of showers was documented on the record. Resident 432 was observed on 02/05/2023 at 10:47 AM, on 02/07/2023 at 9:58 AM, 12:22 PM and 2:06 PM, on 02/08/2023 at 10:01 AM and 1:42 PM, and on 02/09/2023 at 9:45 AM. The resident was in their room and had a disheveled appearance with ½ to ¾ inch long facial hairs over their entire chin as well as the left side of their top lip during all the observations. During an interview on 02/05/2023 at 9:45 AM, Resident 432 was asked about grooming preferences for facial hair, Resident 432 stated, I want it trimmed. I can feel it there (pointing at the hair on her chin), but they (staff) haven't helped me, and I can't do it myself. I am not okay with the (facial) hair. Resident 432 was observed with Staff W, Certified Nursing Assistant, on 02/09/2023 at 9:53 AM. Staff W confirmed the resident's chin and mustache area hair was long and stated that female residents were to have their facial hair removed with showers and additionally per their preference. An interview on 02/09/2023 at 1:38 PM with Staff B, the Director of Nursing stated their expectation was staff were to ask female residents if they wanted facial grooming with each shower and additionally if there was a concern with facial hair. Staff B stated, I would expect them to address it [facial hair]. RESIDENT 50 Review of Resident 50's admission Record dated 02/09/2023, found in the EMR under the Admissions Tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including depression and dementia (memory loss). Review of Resident 50's admission MDS dated [DATE], found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating mild cognitively impairment. The MDS assessment also showed the resident required total assistance of two or more staff members for bathing/showering. Review of Resident 50's undated Activities of Daily Living/Self Care Needs Care Plan, found in the EMR under the Care Plan tab, indicated the resident required assistance from staff to complete their bathing activities. Interventions included staff to provide total assistance with bathing/shower. The care plan indicated the resident preferred to shower but did not indicate the resident's preferences related to the number of times per week or time of day the resident preferred to bathe. There was no documentation in the EMR to indicate an assessment had been done to determine the Resident 50's bathing preferences (including the number of times per week or the time of day the resident preferred to be bathed). The unit shower schedule was requested from the facility, but it was not provided prior to the survey exit on 02/10/2023. Review of Resident 50's shower records dated 01/11/2023 through 02/09/2023, found under the Tasks tab in the EMR, indicated the resident did not receive a shower between 01/16/2023 and 01/24/2023 (a period of eight days) and/or between 01/29/2023 and 02/06/2023 (a period of eight days). No shower refusals were documented on the record. Observation on 02/06/2023 at 9:27 AM, Resident 50 appeared disheveled, and their hair was oily. An interview on 02/08/2023 at 1:08 PM, Staff N, Registered Nurse, confirmed residents on the unit were only bathed once per week and stated the shower aide on the Memory Care Unit was only available on Mondays and Tuesdays and so all resident baths were given on those days. Staff N stated that showers were given based on facility schedule and not on each residents' preferred schedule. An interview on 02/08/2023 at 1:25 PM, with Staff Z, Resident Care Manager, stated showers were given once per week on an assigned day for each resident in the facility. Staff Z stated they knew some residents preferred more than one shower per week and shower/bathing preferences were supposed to be indicated on each residents' care plan. Staff Z stated each resident should be assessed for their bathing preferences, including how many showers per week they wanted and the time of day they wished to be bathed, but was not able to locate anything in either Resident 50 or Resident 432's record to show this type of assessment had been done. Staff Z stated the facility's admission Nurse was responsible for assessing bathing preferences for each resident. During a follow-up interview on 02/09/2023 at 11:30 AM, Staff Z stated the unit where Resident 432 was residing normally provided showers to residents based on their room number and the unit where Resident 50 was residing gave residents their showers on Mondays and Tuesdays because these were the days the shower aide was available to give showers on their unit. Staff Z stated grooming (including the removal of facial hair) was to be done on shower days or more often if staff noticed a concern. Staff Z stated if a resident refused bathing or grooming, this was to be documented in the grooming/shower portion of the resident's record and the bathing/grooming was expected to be offered again on a different day. During an interview with the Staff Y, admission Nurse, on 02/10/2023 at 1:04 PM, Staff Y confirmed there was nothing in the admission assessment conducted upon resident entry or re-entry to the facility to address bathing preferences including the number of times per week or the time-of-day residents preferred to be bathed. Staff Y stated that unless a resident verbalized these preferences on their own, they were bathed once per week. Reference: (WAC) 388-97-1060 (2)(c) .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to consistently monitor nutrition and/or provide interventions as needed to prevent weight loss for 1 of 3 residents (Residents 54) reviewed for nutrition and weight loss. Resident 54 experienced a significant weight loss of 5.1 percent (%) in 1 month and 14.68% in 6 months. This failure placed the resident at risk for continued weight loss, worsened nutritional status and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Nutrition and Hydration Maintenance Policy date 01/2019 read, in pertinent part, (Facility) evaluates individual resident to assist with maintaining their nutrition and hydration, and Resident weights are reviewed weekly by the Resident Care Managers to identify any weight trend changes, and Residents with identified changes in weight will be referred to the Nutrition/Hydration Committee to evaluate and document cause of weight change, identify nutritional interventions, additional staff support for eating activity, need for diagnostic testing and physician review for unavoidable weight loss and or no concern to change (sic), and Interventions that can assist in maintaining residents nutritional (sic) include but not limited to . a. protein supplement shakes b. Med Pass supplement c. snacks. Review of Resident 54's admission Record dated 02/09/2023 and found in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (memory loss), mood disturbance, and anxiety. Review of Resident 54's Quarterly Minimum Data Set (MDS) assessment dated [DATE], found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Review of Resident 54's Nutritional Care Plan, dated 11/14/2022, found in the EMR under the Care Plan tab, indicated the resident had a nutritional problem related to their medical diagnoses, history of failure to thrive, and cognitive decline. The care plan goal indicated the resident was to maintain weight within five pound plus or minus 217 pounds. Interventions included provide and serve diet as ordered, provide, and serve supplements as ordered, RD (Registered Dietician) to follow as needed, weekly weights, and the resident representative to bring in food and beverage periodically. Review of Resident 54's Order Summary Report, dated 02/09/2023 and found in the EMR under the Orders tab, indicated orders for the resident to be served a regular diet with regular texture and consistency and for a health shake 120 cc (cubic centimeters) three times daily with meals. Review of Resident 54's Medication Administration Record (MAR)s and Treatment Administration Record dated 11/01/2022 through 02/09/2023 revealed no documentation to indicate the resident was receiving bedtime snacks. The documents indicated the resident was not regularly consuming the ordered health shakes. Review of Resident 54's Weights and Vitals Summary dated 02/09/2023 and found in the EMR under the Vital Signs tab, indicated the following weights: 08/06/2022 was 218.0 pounds. 09/26/2022 was 212.0 pounds. 10/31/2022 was199.0 pounds. 11/28/2022 was 196.0 pounds. 12/27/2022 was 196.0 pounds. 01/30/20233 was 186.0 pounds. Further review of the weights indicated a 14.68% weight loss between 08/06/2022 and 01/30/2023 (six months) and a 5.1% weight loss between 12/27/2022 and 01/30/2023 (one month). Review of Resident 54's Quarterly Dietary Assessment, dated 11/14/2022 and found in the EMR under the Assessment tab, read in pertinent part, Resident most recently assessed for weight change on 10/20, and . with diet unchanged since last review. Weights show 20 pound (9.2%) loss in 90 days, 8 pound (3.9%) in less than 30 days. Intake variable, ave [average] 50-75% at meals, occasionally less than 25%. Health Shakes increased at last review, variable acceptance per MAR, a little better over past couple days. Discussed with nursing, unlikely that . [the resident] would accept an increase in Health Shakes. They were increased to TID [three times daily] at last review. Staff encourages . [the resident] to eat with variable results. The . [resident representative] visits frequently and encourages . [the resident] as well. Has been sleeping late, so sometimes misses breakfast. BMI [Body Mass Index] of 24.6 is in healthy range, decreased from 27.2 in August [2022]. Resident is at nutritional risk d/t [due to] weight loss and cognitive impairment. The assessment indicated the plan was to continue the resident's diet as ordered and nursing was to encourage intake. The goal indicated was no further weight loss. The assessment indicated the RD would monitor closely and would consider further interventions if weight loss continued. Review of Resident 54's EMR revealed no further review of the resident's nutritional status or weight loss. Resident 54 was observed sitting in an easy chair in the common room on 02/07/2023 between 11:55 AM and 12:25 PM. The resident was served their lunch on a tray in front of their easy chair at 12:14 PM and an unnamed Hall Tray Staff assisted the resident with set up of their meal. Resident 54 was served a banana, cranberry juice, noodles with veal sauce, and baked zucchini. The resident was not observed to be served their ordered health shake during the meal. The resident was observed to consume approximately 30% of their meal. The unnamed Hall Tray Staff was not observed to assist the resident eat or encourage them to eat the meal before it was removed from Resident 54. Resident 54 was observed on 02/08/2023 between 12:35 PM and 1:13 PM, while eating their lunch and sitting in their easy chair in the common area of the unit. The resident was served a small can of Shasta cola, rice, grapes, a dinner roll, and pork with gravy and green beans. Resident 54's health shake was served and sitting on their tray, but the health shake was not observed to be consumed prior to Resident 54's meal being taken away. The unnamed Hall Tray Staff was not observed to assist the resident with their meal and/or encouraged to eat. The resident was observed to consume approximately 25% of their meal. An alternate meal was not observed to be offered to Resident 54. During an interview on 02/08/2023 at 1:18 PM, Staff D, Infection Preventionist/Resident Care Manager, indicated the facility conducted a weekly weight meeting. Staff D indicated the facility's Dietician had been out of the building for a couple of weeks. During a follow-up interview with Staff D on 02/09/2023 at 11:41 AM, Staff D stated the weekly nutritional status meeting notes should be documented in the resident's record under the progress notes tab but stated Resident 54 had not been reviewed by the weekly IDT since November 2022. Staff D also confirmed the resident had not been reviewed by the Dietician or the Dietary Manager since 11/14/2022. During an interview on 02/09/2023 at 1:25 PM, Staff B, the Director of Nursing stated anyone who was experiencing a weight loss was expected to be reviewed by the IDT team in the weekly nutrition/weight meetings. Staff B also stated they had not been able to find anything to indicate Resident 54 had been reviewed in the weekly meetings for several months and that they were unsure of what percentage of weight loss was considered a significant weight loss and indicated Resident 54 should have been on the list of residents who were being reviewed each week based on Resident 54's documented weight loss. During an interview on 02/10/2023 at 9:31 AM, Staff X, RD, stated they had not seen the resident in person yet and had just done a review of the resident's record that morning and indicated Resident 54 was receiving health shakes but had only consumed four of the 27 shakes offered so far in February of 2023. Staff X confirmed the weekly nutrition/weight meeting notes for each resident were supposed to be documented in each resident's clinical record, but they had not been documenting anything. Staff X stated there were several things that they thought could be implemented for Resident 54 to try to halt weight loss including fortifying meals, adding a supplement, increase their protein intake, and recommending a physician's order for scheduled bedtime snacks and that Resident 54's weight loss could not be considered unavoidable until all these potential options were exhausted. Reference: (WAC) 388-97-1060 (3)(h) .

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident received adequate assessment and monitoring for the use of CPAP (Constant Positive Airway Pressure) machine for 1 of 1 resident (Resident 432) reviewed for respiratory care and services. In addition, there was no order for the use of the CPAP machine, and no monitoring and/or maintenance of the CPAP machine to ensure proper usage. These failures placed the resident at risk for respiratory infection, unmet care needs, and potential negative outcomes. Findings included . Review of the facility's undated Noninvasive Ventilation [CPAP, BiPAP (Bilevel Positive Airway Pressure), AVAPS [Average Volume Assure Pressure Support]) Policy read, in pertinent part, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice, and 2. The facility will obtain an order for the use of CPAP, BiPAP or AVAPS device and settings from the practitioner, and 3. A personal CPAP/BiPAP/AVAPS device may be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use, and 5. Nursing will assess the skin integrity around the mask site daily to ensure there is (sic) no impairments to the skin, and 6. Document the use of the machine, resident's tolerance, any skin, respiratory or other changes and responses. Review of Resident 432's admission Record. dated 02/09/2023, found in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including epilepsy (a neurological disorder in which the brain activity become abnormal causing seizures) and obstructive sleep apnea (sleep related breathing disorder). Review of Resident 432's comprehensive Care Plan found in the EMR under the Care Plan tab indicated nothing regarding resident's use of a CPAP machine. Review of Resident 432's Order Summary Report, dated 02/09/2023, found in the EMR under the Orders tab, indicated no orders for the resident's use of or the care and maintenance of their CPAP machine. Review of Resident 432's Medication Administration Records (MARs) and Treatment Administration Records (TARS) dated 01/27/2023 through 02/09/2023 revealed nothing to indicate facility staff had been monitoring the resident's use of her CPAP machine. Review of Resident 432's EMR revealed no assessment related to the use of the CPAP machine and no information how the facility manages the resident's CPAP machine since admission to the facility on [DATE]. Resident 432 was observed in their room on 02/05/2023 at 10:45 AM, on 02/07/2023 at 09:58 AM, 12:22 PM and 2:06 PM, on 02/08/2023 at 10:06 AM and 1:42 PM, and on 02/09/2023 at 9:44 AM. The resident was awake during all the observations and was not using their CPAP machine. The CPAP mask was observed laying halfway in and halfway out of the resident's bedside table drawer and was not labeled/dated and was not placed in a clean plastic bag to ensure proper storage when not in use, and the CPAP machine's water chamber had no water in it. An interview on 02/05/2023 at 10:45 AM, Resident 432 stated they had been using the CPAP machine every night since admission and thought the settings on the machine were messed up and no one had been in to help fix this issue. Resident 432 stated they were not aware the mask was to be labeled and placed in a plastic bag for cleanliness and staff had not been assisting to ensure this was done. An interview on 02/09/2023 at 12:49 PM, Staff S, Licensed Practical Nurse, confirmed they were aware Resident 432 was using a CPAP machine and stated that they observed the resident wearing the CPAP and the caregivers [Certified Nursing Assistants] tell them the resident was using it. Staff S then checked the resident's physician's orders and confirmed there were no orders in place for the resident's CPAP usage and stated, There should be an order for that [the use of the CPAP]. An interview on 02/09/2023 at 12:56 PM, Staff C, the Resident Care Manager stated they did not know Resident 432 had been admitted to the facility with a CPAP machine. Staff C stated, There should be an order set in there [for the use of the CPAP]. There should also be an order for cleaning it [the CPAP]. I guess we didn't catch it. Staff C stated the CPAP mask was to be bagged when not in use and settings for the machine were supposed to be verified before it was used. An interview on 02/09/2023 at 1:32 PM, the Staff B, Director of Nursing stated they expected orders and a care plan to be in place for the use of a CPAP machine and CPAP masks were expected to be bagged when not in use. Reference: (WAC) 388-97-1060 (3)(j)(vi) .

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide risks and benefits of taking a psychotropic (psychoactive - mind altering) medication when there was a change in dosage for 1 of 1 resident (Resident 111) reviewed for unnecessary medications. This failure placed the resident at risk for unnecessary psychotropic medication, adverse side effects, and a diminished quality of life. Findings included . Review of Resident 11's Electronic Medical Record (EMR) under the Census tab revealed an admission date of 11/29/2022 with diagnoses that included insomnia (trouble falling asleep and/or staying asleep). Review of the admission Minimum Data Set (MDS) dated 02/05/2022 found in the EMR under the MDS tab revealed Resident 111's Brief Interview for Mental Status (BIMS) score was 13 out of 15, which revealed Resident 111 was cognitively intact. Review of Resident 111's Physician Orders in the EMR under the Orders tab, revealed an order dated 11/29/2022 for Ambien (a hypnotic psychoactive medication) ER (Extended Release) 6.5 mg (milligrams) orally each night. Review of the EMR revealed a Physician Order dated 01/20/2023 under the Orders tab that the physician discontinued Resident 111's Ambien ER 6.5 mg and ordered Ambien 10 mg one tablet orally each night to promote sleep. Review of Resident 111's EMR revealed the lack of documentation that Resident 111 had been educated on the Ambien's change of dosage and the risk and benefits of taking this medication. Interview on 02/09/2023 at 1:27 PM, Staff B, Director of Nursing, stated that the facility failed to educate Resident 111 on the change of dosage and the risk and benefits of the medication. Staff B also confirmed the facility lacked a policy that directed staff to educate residents on the risk and benefits of psychoactive medications. Reference: (WAC) 388-97-1060 (3)(k)(i) .

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure a medication error rate was less than 5% for the 27 medication administrations for 4 of 9 residents (Residents 111, 72, 95 & 33) reviewed for medication administration. The facility's medication error rate was 14.18%. This failure placed the residents at risk of experiencing adverse side effects, ineffective medication, and potential negative outcomes. Finding included . RESIDENT 111 Observation on 02/07/2023 at 11:30 AM, Staff L, Licensed Practical Nurse (LPN), was preparing Resident 111's Insulin pen (medication to regulate the resident's blood sugar). Staff L attached the new needle set, then dialed the correct dosage of insulin and administered the insulin, without priming the needle set. An interview on 02/07/2023 at 11:32 AM, Staff L stated they knew to prime the insulin pen prior to Insulin administration but forgot. Review of the physician's orders in the EMR under the Orders tab revealed Resident 111 was to receive 17 units of Lispro Insulin. Review of the undated Lilly manufacturer instruction for the Lispro Insulin pen package instructions revealed that after attaching the needle set, the dose dial was to be set to 2 units and push the dose knob to expel the air from the needle set and prime the needle set. The manufacturer's instructions indicate that If you do not prime before each injection, you may get too much or too little insulin. RESIDENT 72 Observation on 02/07/2023 at 9:40 AM, Staff N, Registered Nurse, placed Resident 72's K-[NAME] (a potassium supplement) 20 mEq (milli-equivalents) in a small bag and crushed the medication. The crushed K-[NAME] was mixed with a small amount of food and administered to Resident 72. Review of the physician's orders in the EMR under the Orders tab revealed Resident 72 was to receive K-[NAME] 20 mEq orally each morning. Review of the undated K-[NAME] manufacturer's instruction revealed the medication should not be crushed and may cause gastrointestinal (stomach) pain and bleeding. Interview on 02/07/2023 at 9:40 AM, Staff N confirmed the K-[NAME] was crushed. Interview on 02/10/2023 at 11:30 AM, Staff O, Consulting Pharmacist (CP), confirmed that K-[NAME] should not be crushed. RESIDENT 95 Observation on 02/10/2023 at 10:13 AM, Staff U, LPN, placed four Aspirin 81 mg EC (Enteric Coated) tablets in a small plastic bag and crushed the medications, then transferred the crushed medication to a medication cup. Staff U then moved toward Resident 95 to administer the medication. Interview with Staff U at the time of the observation, confirmed enteric coated Aspirin should not be crushed because it could cause gastrointestinal upset and injury. Interview with Staff O on 02/10/2023 at 11:30 AM, revealed the pharmacy must have picked the wrong Aspirin when they filled Resident 95's medications and placed Aspirin 81 mg EC instead of Aspirin 81 mg. Similar Findings: RESIDENT 33 Observation on 02/08/2023 at 9:50 AM, revealed Staff L prepared a medication cup of 15 milliliters (ml) of Chlorhexidine Gluconate solution. Staff L placed the medication cup with the Chlorhexidine Gluconate solution on Resident 33's overbed table, exited the room and did not ensure the medication was administered as ordered. Review of Resident 33's EMR, the physician's orders under the Order tab included an order for Chlorhexidine Gluconate solution to Place and dissolve 15 ml buccally [between the gums and the inner lining of the mouth cheek] every day and evening shift for gingivitis [a form of gum disease]. Use 15 ml to swish for 20 seconds and spit (not swallow). Reference: (WAC) 388-97 1060 (3)(k)(ii) .

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure expired liquid supplements, medical ointments, and wound treatment supplies were disposed of timely in accordance with current accepted professional standards of practice for 3 of 3 medication storage rooms (Medication Storage Rooms in Unit 700, 400 & Memory Care) reviewed for medication storage and labeling. In addition, the facility failed to ensure no food items was stored in the medication storage refrigerator in the Memory Care Medication Storage. These failures placed the residents at risk of receiving compromised medical supplements, treatment supplies, food snacks, and possibly experience adverse side effects. Findings included . Review of the facility provided policies and procedures titled, Medication: Labeling, Storage, Retention and Disposal, revised in July 2022 showed, multi-dose bottles, over the counter medications, and bulk supplies are labeled with the date of opening by the Licensed Nurse (LN) opening the bottle. It also showed, Expired medications are removed from medication cart and medication room and returned to the pharmacy and disposed of, as appropriate. 700 MEDICATION STORAGE ROOM A joint observation with Staff D, Infection Preventionist/Resident Care Manager, on 02/09/2023 at 12:56 PM, showed that the 700 Medication Storage Room had the following expired liquid feeding supplement and wound dressings: -One container of Twocal HN (brand name - nutritional supplement) that expired on 03/01/2021. -14 pieces of Allevyn Life (brand name) foam dressing (made of highly absorbent material) that expired on 02/01/2022. -Two pieces of Allevyn Life heel dressing that expired in March 2020. -Five boxes of HydraFoam (brand name) Hydrophilic (highly absorbent dressing that maintains a moist wound environment) foam dressing that expired on 06/13/2022. -Seven pieces of Allevyn Gentle Border (waterproof adhesive dressing) foam dressing that expired on 08/01/2022. 400 MEDICATION STORAGE ROOM A joint observation with Staff D on 02/09/2023 at 1:11 PM, showed that the 400 Medication Storage Room had two containers of Twocal HN that expired on 11/01/2022. MEMORY CARE UNIT MEDICATION STORAGE ROOM A joint observation with Staff D on 02/09/2023 at 1:28 PM, showed that the Memory Care Unit Medication Storage Room had the following expired medical supplies: -15 single packets of Povidone-Iodine (used on the skin to decrease risk of infection) swab sticks that expired in January 2022. -54 single packets of Lubricating Jelly (to allow smooth movement) that expired on 07/01/2022. - One box of single packets of Skin Protectant Ointment that was ¾ full that expired in July 2022. MEMORY CARE UNIT MEDICATION STORAGE ROOM REFRIGERATOR A joint observation with Staff D on 02/09/2023 at 1:21 PM, showed that the Memory Care Unit Medication Storage Room Refrigerator had food items that included one opened bottle of Favoritos (brand name) soft drink, one container of Noosa (brand name) key lime yogurt, two cups of unopened apple sauce, and multiple cups of unopened yogurt. On 02/09/2023 at 1:31 PM, Staff D acknowledged that the above liquid supplements, medical ointments, and wound treatment supplies found in the medication storage rooms were expired. Staff D also stated that the process was to discard any expired items and acknowledged that there should be no food items in the Memory Care Unit medication refrigerator. On 02/09/2023 at 1:59 PM, Staff B, Director of Nursing Services, stated that expired medications, liquid feeding supplements, and medical supplies were to be discarded or returned to the pharmacy. Staff B also stated that food items should have been in a separate refrigerator and not in the medication refrigerator. Reference: (WAC) 388-97-1300 (2) .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to remove outdated food from the residents' refrigerator on the 700 Unit and failed to ensure food stored in the dietary's walk-in coolers were labeled, dated when first opened and/or discarded after the expiration date. In addition, the facility failed to ensure food items were covered when non-food items were stored in the walk-in cooler. These failures placed the residents at risk for food borne illness (caused by ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the undated facility policy titled, Thawing directed Thaw food in a cooler .items should be covered, labeled and dated. An undated facility policy titled Storage Procedures indicated, Food should always be in a closed container . and Stock rotation is a good management practice. The facility lacked a policy for the placing of non-food items in the cooler with residents' food. 700 HALL/UNIT Observation of the 700-hall residents' foods refrigerator on 02/05/2023 at 8:30 AM revealed the following: -A full half gallon container of egg nogg, with a manufacturer's expiration date of 02/03/2023. - Two-thirds of a quart of half-and-half, with a manufacturer's expiration date of 02/03/2023. - A quart of half-and-half, which was opened but lacked the date opened - Half quart of apple juice, which lacked the opened date. - Two containers of nectar thickened apple juice, which lacked the date opened. - Three-fourths of a loaf of wheat bread in the door of the refrigerator lacked the date opened and was hard to the touch. WALK-IN REFRIGERATORS & COOLERS Joint observations of the walk-in refrigerators/cooler in the dietary/kitchen on 02/10/2023 at 11:15 AM with Staff I, Culinary Director, revealed the following: - Cut flowers in water and vases were on a rolling cart in the food storage walk-in refrigerator with uncovered beverages also in the walk-in refrigerator. Staff I stated the flowers were placed there on 02/09/2023. - The walk-in refrigerator also contained a manufacturer's container of yogurt with an expiration date of 12/25/2022. Observation of another walk-in cooler revealed the following: - A food storage container of a product resembling egg salad lacked a label with contents and preparation date. - A box that contained seven Danish Rolls had been opened, left uncovered and lacked the date opened. - Two pans of cut and uncut chocolate cake were uncovered and undated. Observation of the food preparation area in the dietary area, under the table revealed two rolling bins of an unknown dry items resembling oatmeal were stored without a label as to the contents and date. In the smaller walk-in refrigerators, located outside the kitchen revealed the following: - Two open boxes of uncovered and undated bacon. - Two unlabeled, undated steam table pans of what resembled salmon were in the walk-in cooler in dietary and were not covered or labeled. - A metal rolling cart with trays of fish and pork chops, which Staff I stated were thawing before cooking, were uncovered. A fan in the walk-in refrigerator had a build-up of debris and was blowing air directly on the uncovered food. In a tub on the bottom shelf was an unlabeled, undated blue food storage bag of what appeared to be chicken, appeared dry and freezer burnt. On a lower shelf on a tub, there was a food storage bag of what appeared to be tamales, which lacked a label and date. The tub also contained two packages of unlabeled and undated, described as veggie burgers. Interview with Staff I on 02/10/2023 at 11:45 AM was asked if the food items in the unlabeled containers or which lacked a date should be served to residents. Staff I responded No. Staff I also confirmed food should be covered and discarded when expired. Reference: (WAC) 388-97-1100 (3) .

Jan 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or their representatives received information on the current recommendations from the Center for Disease and Control (CDC) Prevention for 3 of 5 (Residents 18, 49 & 1) related to influenza (flu - an infectious disease caused by a flu virus) and/or pneumococcal (pneumonia - lung infection) vaccinations. This failure placed the residents at risk for not being informed, contracting influenza and/or pneumonia, medical complications, and a diminished quality of life. Findings included . Review of the facility Influenza and Pneumococcal Vaccine Administration policy with a revision date of August 2022 revealed that Influenza and pneumococcal vaccines are administered after validating no contraindications exist. The facility Infection Control Preventionist and or designee is responsible for the vaccine administration program to: 1. Educate the resident and responsible parties regarding the importance of the annual influenza vaccine and to obtain informed consent, the facility will provide the current CDC Influenza Vaccine Information Statement and the Resident Influenza Vaccine Informed Consent. 2. Educate the resident and responsible parties regarding the importance of the pneumococcal vaccines and to obtain informed consent, the facility will provide the current CDC Pneumococcal Vaccine Information Statement and the Pneumococcal Vaccine Informed Consent. RESIDENT 18 Resident 18 admitted to the facility on [DATE] with a medical diagnosis list that included lung disease. Review of the electronic vaccination record dated 07/20/2020 showed the resident refused the influenza and pneumococcal vaccine. Further review of the electronic medical record did not show the resident received education regarding the influenza or the pneumococcal vaccine. RESIDENT 49 Resident 49 admitted to the facility on [DATE] with a diagnosis list that included a respiratory illness. Review of an undated electronic vaccination record showed the resident refused the influenza and pneumococcal vaccine. Further review of the electronic medical record did not show the resident received education regarding the influenza or the pneumococcal vaccine. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] with a diagnosis list that included Parkinson's disease (brain disorder that caused unintended or uncontrollable movements). Review of an undated electronic vaccination record showed the resident refused the influenza and pneumococcal vaccine. Further review of the electronic medical record did not show the resident received education regarding the influenza or the pneumococcal vaccine. Interview on 01/24/2023 at 4:06 PM, Staff C, Infection Preventionist, said if the residents refuse the vaccinations, the refusals should be documented, and the residents/resident representatives would be provided education on the vaccine that was refused. Reference: (WAC) 388-97-1340 (2) .

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely initiate an infection control program which included an ongoing surveillance and analysis of the surveillance data to prevent/and or reduce the spread of COVID 19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) for 5 of 7 nursing units (Nursing Units 200, 300, 400, 500 and 700). The facility had 45 residents and 15 staff members (staff were unidentified to protect their health information) that tested positive for COVID-19 within 18 days and two residents were hospitalized . The facility was unable to identify dates, shifts or locations of staff resident room assignments from 01/01/2023 to 01/18/2023, which decreased the potential for successful tracking and analysis of the infection due to the inability to identify the staff members that worked with the residents. Additionally, staff (Staff E) failed to wear and remove the appropriate Personal Protective Equipment (PPE - N95 respirator/mask, eye protection/face shield/googles & gloves) after exiting a COVID positive resident room on aerosol precautions (Transmission Based Precautions [TBP]). These failures placed the residents, staff, and visitors at risk of facility acquired or healthcare-associated infections, and related complications. Findings included . UNIT 200 Review of a nursing progress note dated 01/01/2023 showed, Resident 3 tested positive for COVID-19 on 01/01/2023, the resident complained of shortness of breath and not feeling well. The resident showed signs and symptoms of difficulty breathing and was placed on supplemental oxygen and was transferred to the hospital on [DATE] by an emergency medical response unit and admitted to the hospital. The resident was readmitted back to the facility on [DATE]. Review of a nursing progress note dated 01/03/2023 showed Resident 4 tested positive for COVID-19 on 01/03/2023. UNIT 300 Review of nursing progress notes dated 01/01/2023 to 01/06/2023 showed Residents 1, 5 and 7 tested positive for COVID-19. UNIT 400 Review of the nursing progress notes dated 01/06/2023 to 01/16/2023 showed Residents 8, 9, 10, 11, 12, 13, 15 16, 17, 18, 19 22, 23, 24, 33 and 38 tested positive for COVID-19. UNIT 500 Review of the nursing the progress notes dated 01/05/2023 to 01/17/2023 showed Residents 6, 20, 21, 26, 27, 28, 29, 30, 32, 34, 35, 36, 37, 43 and 44 tested positive for COVID-19. UNIT 700 Review of a nursing progress note dated 01/15/2023 showed Resident 31 tested positive for COVID-19 on 01/15/2023, was transferred and admitted to the hospital on [DATE] for shortness of breath and was readmitted back to the facility on [DATE]. Review of the nursing progress notes dated 01/16/2023 showed Residents 40, 41, 42 and 45 tested positive for COVID-19 on 01/16/2023. COVID-19 POSITIVE STAFF Review of the staff listing dated 01/19/2023 showed 15 staff members tested positive for COVID-19 from 01/01/2023 to 01/18/2023. Staff were removed from the facility and/or work schedule until permitted to return to facility for work. The facility was unable to provide documented tracking, trending, or analysis of the COVID-19 infection in the 200, 300, 400, 500 or 700 nursing units or for the 15 positive staff members from 01/01/2023 to 01/18/2023. Interview on 01/23/2023 at 2:40 PM, Staff C, Licensed Practical Nurse/Infection Preventionist, stated, I would track anybody that had an infection at the end of each month. I will compile my reports from that tracking, I don't have this month, January done yet. Interview on 01/23/2023 at 2:28 PM Staff B, Director of Nursing Services, stated that they did not keep track of which staff worked with which resident. They only assign the staff by resident units, not by resident room numbers and that it would be helpful to track staff by the resident room numbers they were assigned to work on, not just by the resident units they were assigned to work on. Interview on 01/24/2023at 4:31 PM, Staff A, Administrator, said they just completed a timeline of events in relation to the residents and staff that tested positive for COVID-19 from 01/01/2023 to 01/24/2023. PROPER USE OF PPE AND DISINFECTION OF EQUIPMENT Observation on 01/23/2023 at 11:43 AM, Staff E, Medical Assistant, came out of room [ROOM NUMBER] wearing a surgical mask, the resident room door had a sign posted on the door that read Aerosol Contact Precautions: everyone must, including visitors, doctors and staff wear a respirator [N95 face mask]. The sign also read clean and disinfect shared equipment. There was an isolation cart on the outside of the resident room, close to the door with gowns, gloves, N95 masks and face shields visible in the cart. Staff E removed the equipment (computer monitor) on wheels from the room that was used for residents' tele visits with medical staff outside of the facility. Staff E did not sanitize the equipment on wheels after leaving room [ROOM NUMBER], was not wearing an N95 and did not sanitize and/or changed their face shield. Interview and joint observation on 01/23/2023 at 11:44 AM, with Staff D, Registered Nurse, said the residents in room [ROOM NUMBER] were on aerosol precautions and Staff E was observed to leave room [ROOM NUMBER] wearing a surgical mask [should be wearing an N95 respirator], did not sanitize and/or change their face shield, and did not sanitize their equipment on wheels. Staff D stated that Staff E should have worn an N95 mask in the resident room, threw the face shield away when Staff E left the room, put on a new face shield, and disinfected the equipment before wheeling it down the hallway. Observation on 01/23/2023 at 11:46 AM showed Staff E, after leaving room [ROOM NUMBER], a room with COVID positive residents, entered Resident 48's room [the resident was up to date with their COVID vaccinations] that was not on aerosol precautions. Staff E, coming from room [ROOM NUMBER] was wearing the same surgical mask and face shield and the potentially contaminated equipment on wheels. On 01/23/2023 at 11:52 AM, Staff E left Resident 48's room, then entered Resident 7's room [the residents were up to date with their COVID vaccinations] that was not on aerosol precautions wearing the same surgical mask, face shield and the potentially contaminated equipment on wheels. Interview on 01/23/2023 at 11:58 AM, Staff E stated, I was in room [ROOM NUMBER] that was on precautions for COVID [positive residents] before I went to Resident 48 or Resident 7's room. I did not wear an N95 mask in the resident's room that was on precautions. I wore a surgical mask in that room. I did not change the surgical mask or the face shield after I left the residents room that was on precautions for COVID, or before I entered Resident 48 or Resident 7's room. I didn't disinfect the equipment in between the rooms. I usually wipe down the screen with disinfectant. I don't disinfect the stand, the wheels or anything else because I was told I did not need to. I did not disinfect the screen or anything today because it has been a very busy day. Interview on 01/24/2023 at 4:35 PM, Staff C said that Staff E should have worn an N95 face mask in the resident room that was on aerosol precautions, removed the face mask and face shield, replaced with a new face mask and face shield, and sanitized the equipment outside of the resident's room on aerosol precautions before Staff E left to go to Resident 48 and Resident 7's rooms. On 01/24/2023, the facility provided an untitled, undated document that was identified by the facility management (Staff A, Staff B and Staff C) as a timeline of events that documented the date of the resident room moves, the date the Department of Health was called and when staff was removed from the work schedule. Reference: (WAC) 388-97-1320 (2)(a)(b)(c) .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to inform residents and/or their representatives of suspected or confirmed cases of COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) in the facility and of actions taken to decrease the risk of spread for 9 of 9 residents (Residents 18, 26, 31, 49, 15, 7, 48, 3, and 2) reviewed for notification of suspected or confirmed COVID-19 cases in the facility. This failure placed the residents/resident representatives at risk of not being aware of positive COVID-19 residents and staff. Findings included . Review of the facility COVID-19 policy dated October 2022 documented, the facility will provide weekly updates to residents, resident representatives, and families through email. Additional/intermittent updates will be communicated if new cases, or system clusters occur within the weekly update time frame. RESIDENTS Review of the nursing progress notes dated 01/01/2023 to 01/18/2023 for Residents 18, 26, 31, 49, 15, 7, 48, 3 and 2 did not show documented notification or updated information on residents or staff that tested positive for COVID-19. RESIDENT REPRESENTATIVES Review of the documents dated 01/02/2023, 01/03/2023, 01/05/2023, 01/06/2023, 01/09/2023, 01/12/2023, 01/16/2023 and 01/18/2023 was addressed to: Families and Friends of the Facility. The document did not include residents, the document was addressed to Families and Friends of the Facility. The document did not indicate which family and/or friend the document was sent to or if the document was received. There were not any email addresses listed on the document, or dates the document was sent, or dates the document was received. Interview on O1/19/2023 at 12:17 PM with Staff A, Administrator, stated I notify all the resident's families and family representatives about COVID by electronic mail (e-mail). It would be in the resident's progress notes when the resident was notified and updated when another resident or staff member tested positive for COVID-19. No associated WAC

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• 45% turnover. Below Washington's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
• 85 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $13,543 in fines. Above average for Washington. Some compliance problems on record.
• Grade F (36/100). Below average facility with significant concerns.

Bottom line: Trust Score of 36/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is The Broadview Center's CMS Rating?

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

How is The Broadview Center Staffed?

CMS rates THE BROADVIEW CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at The Broadview Center?

State health inspectors documented 85 deficiencies at THE BROADVIEW CENTER during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 83 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates The Broadview Center?

THE BROADVIEW CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 211 certified beds and approximately 122 residents (about 58% occupancy), it is a large facility located in SEATTLE, Washington.

How Does The Broadview Center Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, THE BROADVIEW CENTER's overall rating (2 stars) is below the state average of 3.2, staff turnover (45%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting The Broadview Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is The Broadview Center Safe?

Based on CMS inspection data, THE BROADVIEW CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at The Broadview Center Stick Around?

THE BROADVIEW CENTER has a staff turnover rate of 45%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was The Broadview Center Ever Fined?

THE BROADVIEW CENTER has been fined $13,543 across 1 penalty action. This is below the Washington average of $33,214. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is The Broadview Center on Any Federal Watch List?

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

Facility Details

Beds: 211
Avg. Residents: 122
Occupancy: 58.2%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
1 Immediate Jeopardy citation: -12
85 Deficiencies: -10
Fines ($13,543): -2
Final Score: 36/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505416