How many inspection deficiencies does ALDERWOOD MANOR have?

ALDERWOOD MANOR has 86 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at ALDERWOOD MANOR?

ALDERWOOD MANOR has a three-star staffing rating from CMS with 0.96 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 ALDERWOOD MANOR located?

ALDERWOOD MANOR is located in SPOKANE, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ALDERWOOD MANOR have?

ALDERWOOD MANOR has 85 certified beds.

Who owns ALDERWOOD MANOR?

ALDERWOOD MANOR is a for profit - partnership facility and is part of the LIFE CARE CENTERS OF AMERICA chain.

What questions should families ask when visiting ALDERWOOD MANOR?

Families visiting ALDERWOOD MANOR should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ALDERWOOD MANOR compare to other nursing homes?

ALDERWOOD MANOR has a 3-star overall rating, which is average compared to other nursing homes in WA. Consider visiting multiple facilities before making a decision.

ALDERWOOD MANOR

Name: ALDERWOOD MANOR
Address: 3600 EAST HARTSON AVENUE, SPOKANE, WA, 99202, US
Telephone: (509) 535-2071
Rating: 3.0

3600 EAST HARTSON AVENUE, SPOKANE, WA 99202 · (509) 535-2071

For profit - Partnership 85 Beds LIFE CARE CENTERS OF AMERICA Data: November 2025

Trust Grade

35/100

#90 of 190 in WA

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ALDERWOOD MANOR nursing home in SPOKANE, WA - Photo 1 of 4

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Last Inspection: October 2024

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

Overview

Alderwood Manor has a Trust Grade of F, indicating significant concerns about its care quality, which is classified as poor. It ranks #90 out of 190 nursing homes in Washington, placing it in the top half, and #7 out of 17 in Spokane County, suggesting only six local facilities perform better. Fortunately, the facility is improving, with reported issues decreasing from 26 in 2024 to just 1 in 2025. Staffing is rated average, with a 3/5 star rating and a turnover rate of 57%, which is slightly above the state average. However, there have been serious incidents, such as a resident suffering a fractured arm due to improper transfer methods and another developing additional pressure ulcers because of inadequate skin assessments, highlighting critical areas needing attention despite some strengths in RN coverage, which exceeds that of 78% of state facilities.

Trust Score: F
In Washington: #90/190
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $32,214 in fines. Lower than most Washington facilities. Relatively clean record.
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: 86 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 26 issues

2025: 1 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

3-Star Overall Rating

Near Washington average (3.2)

Meets federal standards, typical of most facilities

Staff Turnover: 57%

11pts above Washington avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $32,214

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: LIFE CARE CENTERS OF AMERICA

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (57%)

9 points above Washington average of 48%

The Ugly 86 deficiencies on record

3 actual harm

Sept 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to monitor a surgical wound for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure wounds. This failure placed residents with surgical incisions at risk of potential worsening skin conditions and complications. Findings included .A facility document titled Documentation and Assessment of Wounds, revised 06/12/2025, showed the facility Policy was to guide nurses in the assessment of wounds to include pressure ulcer/injuries (damage to the skin and underlying tissue caused by unrelieved pressure that restricts blood flow), venous (open sore on the lower leg from impaired circulation), arterial (painful wounds caused by poor circulation), diabetic (sores, ulcers, or chronic conditions that develop in people with diabetes, often on the feet, due to poor circulation, nerve damage), and dehisced surgical wounds (surgical wound that split open or separate), and other wounds not otherwise specified. A wound observation was to be made with each dressing change. The provider would be notified of changes and updated with a treatment plan if applicable. The nurse that performed the treatment would do an as needed assessment and document if a change had occurred (if wound appeared to be infected or appeared to have declined).Review of a facility assessment, dated 06/10/2025, showed Resident 1 was admitted with diagnoses to include Peripheral Vascular Disease (PVD, a circulation disorder that affected the peripheral arteries and veins, most commonly in the legs and arms, due to a narrowing or blockage), below knee amputation on both legs, and Diabetes. The resident was able to make their needs known.Per record review, the resident had dry gangrene (caused by insufficient blood flow leading to tissue death) to their right fingertips and had them amputated on 06/19/2025. The resident arrived at the facility with a dressing on their right hand which was not to be removed until their follow up with the surgeon on 06/24/2025.Review of a surgical follow up visit on 06/24/2025 showed the resident had their dressing removed in the office and wound care was ordered to be done daily. Resident 1's next follow up was on 07/01/2025.Review of the resident's Treatment Administration Record (TAR) for June 2025 showed the resident's wound care included cleansing the wound, covering the wound with an ointment type gauze, and to secure it with self-adherent wrap. The wound care was marked as done daily from 06/24/2025 to 06/29/2025, on 06/30/2025 there was no signature. Nurse progress notes were reviewed from 06/24/2025 thru 06/30/2025 and no documentation was found about the resident's surgical wound on their right hand. Review of a surgical follow up on 07/01/2025, Resident 1 had their dressing removed and the surgeon noted the fingertips were healing but the resident had developed a large blister over the palm of their hand. The surgeon debrided (removal of dead skin) the blister. The surgeon documented there appeared to be a soft tissue infection. New wound care was ordered, the resident was to start on antibiotics, and the area was to be monitored for increased redness. The resident's next follow up appointment was 07/11/2025.The TAR for July 2025 showed the resident's new wound care orders were to wash the hand with water or normal saline, apply bacitracin (antibiotic ointment) to a non-adherent dressing, and cover with gauze. The dressings were marked as done from 07/02/2025 through 07/13/2025 daily. There was nothing on the TAR to show the resident's right hand was monitored for increased redness or signs of worsening infection. Review of nurses notes from 07/01/2025 to 07/11/2025 showed a note written by Staff D, Registered Nurse (RN), on 07/04/2025. It was documented the resident's right-hand wound infection had mild redness and odor which was resolving with antibiotics. Staff D had written a note on 07/05/2025 which showed the wound appeared less inflamed (red, swollen, hot) and redness appeared to have lessened. Review of a surgical follow up note on 07/11/2025 showed the resident rated their pain a 7 out of 10 (0 being no pain, 10 being the worst pain) and described the pain in the hand and into the wrist. It was noted the resident's hand was red and the resident had wound cellulitis (bacterial infection of the skin and underlying tissues, characterized by red, swollen, warm, and painful skin). The surgeon discussed going to the hospital for a CT scan (a scan that created a detailed image of the inside of the body to help in diagnoses such as an infection), but the resident wanted to wait and do the CT scan as outpatient. The resident was instructed to report to the hospital if symptoms worsened. The wound care remained the same. Review of nursing progress notes from 07/11/2025 to 07/13/2025 showed no documentation the resident's hand was monitored by staff which would include a description of the wound on the right hand or if the wound infection had worsened. A nurses note on 07/14/2025 showed the resident was sent to the hospital for a worsened infection of their right hand. There was no documentation to show the assessment of the wound and how the infection had worsened.Review of hospital notes on 07/14/2025 showed the resident arrived at the hospital with redness that had progressed on their hand and the resident had nausea/vomiting. The resident complained their hand and wrist were very painful and tender. The provider documented the resident's finger amputation wound was closed and there was a large purulent wound (drainage that is thick, cloudy, and typically white, yellow, or green which indicated an infection) and mass on the palm of their hand with tenderness and warmth on the palm and wrist. An emergent debridement was done. The resident remained in the hospital and had an additional surgery to amputate the right four fingers and palm. On 09/02/2025 at 1:30 PM, Resident 1 was up in their electric wheelchair in their room. The resident had both legs, below the knee, amputated. The resident's right hand was the thumb and base of the thumb. The surgical incision appeared to be healing. The resident stated they originally had their fingertips removed on the right hand. The resident said a large blister then developed on their palm, while at the facility, and the area became hotter and more painful. The resident was started on antibiotics for an infection. The resident went on to say they were right handed and had a difficult time feeding themselves. During an interview on 09/02/2025 at 11:10 AM, Staff A, Wound Nurse, stated residents with wounds would have a wound observation form filled out weekly. The form would include a description of the wound and measurements. If a resident had a surgical wound and an order for a dressing change, it would be documented on the TAR. If the surgical area opened, the staff would then do a wound observation form, and any abnormal findings would be charted in the progress notes. Staff A stated they were not familiar with Resident 1's wound due to being out of the facility at that time.On 09/02/2025 at 12:27 PM, Staff B, Resident Care Manager (RCM), stated if a resident had a surgical wound and there was a change with the surgical area, or signs and/or symptoms of an infection, the surgeon would be contacted. The TAR would be where staff monitored for redness or signs/symptoms of an infection. Staff B stated they knew Resident 1 was on antibiotics for an infection and the hand became more painful so was sent to the hospital. Staff B had not observed the wound prior to the last surgery since the resident was on a different unit.On 09/02/2025 at 1:07 PM, Staff F, RCM, stated Resident 1 was on their unit when they had dry gangrene on their right fingertips and then had them amputated. Staff F stated the floor nurses would do wound care if the wound nurse was not available. Staff F stated they had not observed the resident's wound but stated the resident had developed an infection. Staff F said if there was a concern with a surgical wound, staff contacted the surgeon.On 09/04/2025 at 1:50 PM, Staff C, Director of Nursing (DNS), stated when Resident 1 had their initial surgery and then amputation of their hand, they were being trained as the DNS. Staff C stated the facility did not do wound observation forms for surgical incisions; the surgeons would be the ones to monitor and follow up on the residents. Staff C stated the policy had since changed. On 09/12/2025 at 2:30 PM, Staff D, RN stated they had just started to work at the facility when Resident 1 had their hand surgery. Staff D remembered they were alerted to Resident 1's hand wound when they came to work but could not recall what the wound looked like. Staff D said they did do wound care on the resident's hand and if there was any abnormality, they would have documented it in the progress notes. On 09/12/2025 at 2:45 PM, Staff E, Licensed Nurse (LN), stated they would do wound care for Resident 1 if it had not been done on dayshift. Staff E recalled the resident was picky about the wound care if they had a follow up visit to the surgeon the following day. The resident would refuse the dressing to be changed because they preferred the surgeon do it. Staff E did not recall the resident had a blister on their hand and could not recall how the resident's wound appeared. Reference: WAC 388-97-1060(1)

Oct 2024 22 deficiencies

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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Based on interview and record review, the facility failed to accommodate preferences for bedtime routine for 1 of 2 sampled residents (Resident 44) reviewed for choices. This failure placed the resident at risk for a diminished quality of life. Findings included . Review of a 08/16/2022 facility policy titled Person Centered Planning, showed the facility would develop a person-centered care plan that addressed the goals, preferences, values, and practices of the resident. This policy showed it would include the resident's participation and reflect the resident's right to make informed choices. In an interview on 10/22/2024 at 8:36 AM, Resident 44 stated, I would prefer to be woken up at or before 6:00 AM to remove the bi pap [respiratory equipment] off as early as possible. Resident 44 stated their preferred bedtime hours was around 8:00 PM. Review of a 10/17/2024 quarterly assessment showed the staff identified it was very important for Resident 44 to choose their own bedtime. Review of a 04/15/2024 Activities Evaluation showed Resident 44's preferred wake up time in the morning was 8:00 AM to 8:30 AM and preferred time to retire was between 11:00 PM to 11:30 PM. Review of Resident 44's care plan showed no instruction to the staff of Resident 44's preferences for their waking or bedtime hours, or that it was very important for Resident 44 to choose their bedtime hours. In an interview on 10/29/2024 at 10:37 AM, Staff L, Activities Coordinator, confirmed they helped identify the residents' preferences for activities and preferred routines in daily life by completing Section F in the Minimum Data Set (an assessment tool) and the Activities Evaluation. Staff L stated that once they gathered information on the resident's preferences, it is then added to the care plan. Staff L acknowledged Resident 44's plan of care did not instruct the staff in the resident's preferences for bedtime or waking hours. Reference WAC 388-97-0900(1)-(4). .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a secure place for residents to store their valuables for 1 of 2 sampled residents (Resident 13) reviewed for personal property. This failure placed residents at risk for their property to be lost or stolen, and decreased quality of life. Findings included . The Life Care Centers of America Inventory of Personal Belongings policy revised 06/12/2024 documented on admission, a resident or their representative would bring in personal clothing and it was to be marked with the resident's name by the laundry department then returned to the resident after labeled or washed. This was done to ensure all of the resident's clothing was returned once it had been laundered. The policy did not describe how other belongings were to be secured or safeguarded. A review of the 08/20/2024 quarterly assessment documented Resident 13 had diagnoses including dementia and depression. Resident 13 was moderately impaired cognitively, and it was somewhat important to the resident to have a place to lock their belongings to keep them safe. During an interview on 10/22/2024 at 11:57 AM, Resident 13 stated they had a wedding ring and two diamond bracelets come up missing from their room. The resident stated they had removed their bracelets to clean them and then was unable to find them. They stated it was possible they had lost them at dialysis, but they did not know what had become of the jewelry. Resident 13 stated they would like a lock for their belongings but they had not been asked. Review of the personal belonging inventory sheets kept in a binder at the [NAME] Unit nursing station documented that when admitted on [DATE], Resident 13 had 1 nightgown, 1 suitcase for dialysis, 1 sweatshirt, and 1 tablet (type not listed). There was no jewelry documented on the inventory sheet. Grievance logs dated from May 2024 through October 2024 were reviewed. There were no entries on the logs related to missing jewelry belonging to Resident 13. During an interview on 10/29/2024 at 12:22 PM, Staff D, Registered Nurse, Resident Care Manager, stated when a resident was admitted , any clothing or durable items were added to a personal belonging sheet. Resident 13 had reported earlier that they were missing a ring and it had been located; the resident's spouse had taken the ring home. Staff D stated Resident 13 had not mentioned they were missing bracelets. At this time, Resident 13's room was observed. The nightstands and dressers were observed with the resident's permission. There was no lock box in any of the drawers, and none of the drawers had a locking mechanism on them for the resident to secure their belongings if desired. Resident 13 stated they would use a lock if they had one and Staff D notified the resident this would be arranged. During an interview on 10/29/2024 at 12:50 PM, Staff C, Assistant Director of Nursing, stated newer residents were asked on admission if they wanted a lock box for their belongings. Some of the rooms on the [NAME] Unit had locked drawers but not all. Staff C stated it was possible that residents that had lived at the facility longer had not known they could have a place to lock up their belongings and they would recheck with the residents. Reference: WAC 388-97-0880

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting allegations of abuse to the State Agency (SA) within the required timeframe and completing thorough investigations for 1 of 4 sampled residents (Resident 25) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse. Findings included . Review of an October 2022 facility policy titled Abuse - Prevention showed the facility prevented and prohibited all types of abuse, neglect, misappropriation of resident property, and exploitation. This policy showed the facility would identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, to include verbally or physically aggressive behavior. Review of a 06/27/2024 facility policy titled Abuse - Reporting and Response- Suspicion of a Crime showed it instructed the staff to report immediately to the SA, but no later than 2 hours after an allegation involving abuse or neglect was made, if the events that caused the allegation resulted in serious bodily injury, and no later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury. Review of Appendix D in the October 2015 Nursing Home Guidelines The Purple Book, showed it instructed the facility to log the incident in the SA Log within 5 days of event discovery and report it to SA Hotline if psychological or physical harm occurred. The guideline additionally instructed the facility to report events to the local law enforcement in cases of sexual abuse or misappropriation/exploitation. Where there was no harm associated with mental or physical abuse allegations, the guideline instructed the facility to log the incident in the SA log within 5 days of discovery. A 06/17/2024 facility policy titled Abuse - Conducting an Investigation showed that all allegations of abuse were promptly and thoroughly investigated by the facility. The policy showed the facility would prevent abuse while the investigation was in progress, and take appropriate corrective action based on the investigation findings. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, misappropriation or resident property was reported, the Administrator or designee would investigate the occurrence and provide protection to the alleged victim and other residents. Review of a 10/11/2024 assessment showed Resident 25 re-admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 25 as cognitively intact, used a wheelchair, and was independent with mobility throughout the facility. This assessment showed Resident 25 displayed verbal behavioral symptoms directed toward others, like threatening, screaming and/or cursing and other behavioral symptoms not directed toward others, like hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. In an interview on 10/30/2024 at 9:21 AM, Staff G, Nursing Assistant, described Resident 25's behavior. Staff G stated, Some days it's yelling out at residents non-specifically, then at staff. Sometimes goes into mania, like very high mania, thinking [they're] invincible. Staff G stated that Resident 25 vocalized loudly and made threats to the staff, yells and accuses the staff, hollers at other residents get out of my way. Review of the medical record showed a 05/13/2024 progress note. This progress note showed Resident 25, had a hard morning, shouting loudly, and angrily in the hall, playing the music and TV [television] loudly, upsetting the res [resident] across the hall. Res settled down after a while. Review of the medical record showed no information the facility investigated the extent of how Resident 25's behaviors upset the resident across the hall or other residents, to include ruling out psychological harm, and implementing protective measures to prevent recurrence. Review of a 05/29/2024 progress note showed Resident 25, had some verbal aggression toward another resident . Review of the SA Log showed no documentation the facility logged the incident in the log within 5 days of discovery. Review of a 05/31/2024 note showed the staff identified Resident 25 engaged in, 1 episode of verbal aggression noted today with another resident at approx. [approximately] 11pm today. Res stated to resident to 'shut your mouth! Review of the SA Log showed no documentation the facility logged the incident within 5 days of discovery, completed an investigation, and put measures in place to prevent recurrence of verbal aggression towards another resident. Review of a 06/02/2024 progress notes showed the staff witnessed Resident 25, was talking loudly to another male. Record review showed no documentation the facility ruled out a resident-to-resident event occurred, to include psychological harm, and measures to prevent recurrence. Review of a 10/06/2024 progress note showed Resident 25 was, agitated today. Was going down the hall saying, 'everyone better stay out of my way!' This note showed Resident 25 moved towards a female resident coming down the hall, but this nurse intercepted [Resident 25]. Record review showed no documentation the facility ruled out a resident-to-resident event occurred, to include psychological harm, and develop and implement measures to prevent recurrence. The above findings were shared with Staff A, Administrator, on 10/30/2024 at 8:41 AM. Staff A acknowledged the facility did not follow its abuse and neglect policies and procedures. No further information was provided. Reference WAC 388-97-0640(2).

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer, for 1 of 2 sampled residents (Resident 51), reviewed for hospitalization/discharge. This failure placed the resident at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman. Findings included . The 08/29/2024 discharge assessment documented Resident 51 was cognitively intact to make decisions regarding their care and had diagnoses which included anxiety and opioid dependence. Review of Resident 51's record showed a nursing progress note documented in the early morning hours of 08/29/2024, the resident was observed to be pulling their hair and experiencing severe jerking movements of their body. The resident was assessed, and per direction of the on-call provider, the resident was sent to the hospital for evaluation. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital. In an interview on 10/29/2024 at 12:05 PM, Staff E, Medical Records, stated the Notice of Transfer or Discharge form was filled out when a resident discharged from the facility or was transferred to the hospital, and Staff F, Receptionist, sent the form to the Ombudsman's office. Staff E reviewed Resident 51's record and confirmed the form was not present. In an interview on 10/29/2024 at 12:20 PM, Staff F, stated once they received the Notice of Transfer or Discharge form from the Resident Care Managers, the form was sent to the Ombudsman's Office. Staff F stated once the form had been sent, it was given to Medical Records to be placed in the resident's record. After review of Resident 51's record, Staff F confirmed the form was not present. Reference (WAC) 388-97-1020 (2)(a-d)

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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Based on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they are hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 1 of 2 sampled residents (Resident 51), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding the right to a bed-hold, while they were hospitalized . Findings included The 08/29/2024 discharge assessment documented Resident 51 was cognitively intact to make decisions regarding their care and had diagnoses which included anxiety and opioid dependence. Review of Resident 51's record showed a nursing progress note documented in the early morning hours of 08/29/2024, the resident was observed to be pulling their hair and experiencing severe jerking movements of their body. The resident was assessed, and per direction of the on-call provider, the resident was sent to the hospital for evaluation. Additional record review found no documentation that showed the resident had been provided a bed-hold notice as required. In an interview on 10/29/2024 at 11:31 AM, Staff B, Director of Nursing, stated bed hold notices were done upon admission and again when a resident was transferred to the hospital. Per Staff B, the bed hold was completed by Medical Records and should have been in the resident's record. In an interview on 10/29/2024 at 12:05 PM, Staff E, Medical Records, stated the bed hold notice was an electronic form and was part of the resident's record, if the form was not in the resident's record, then it was not done. After review of Resident 51's record, Staff E confirmed no bed hold notice was done. Reference (WAC) 388-97-1020 (4)

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and incorporate specific recommendations made by the PASARR Level 2 evaluator for 1 of 3 sampled residents (Resident 25) reviewed for pre admission screening. A PASARR (Preadmission Screening and Resident Review) Level 2 Evaluation is a person-centered evaluation that is completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition. This failure placed Resident 25 at risk for unmet mental health care needs. Findings included . Review of a 10/11/2024 assessment showed Resident 25 admitted to the facility on [DATE] with medically complex conditions and assessed as cognitively intact. The assessment showed the diagnoses of depression and bipolar disorder. Bipolar disorder is a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking, and behavior. These shifts can make it difficult to do daily tasks and maintain relationships. In an interview on 10/30/2024 at 9:21 AM, Staff G (Nursing Assistant) was asked about Resident 25's behavior. Staff G stated, I know there's been times [the resident] has heard a lot of noise early in the morning and it may irritate [them]. I'm unsure what really sets [the resident] off. Some days none [behavior], some days it's yelling out. Staff G described Resident 25 as impulsive and stated, sometimes goes into mania, like very high mania, thinking [they are] invincible. Review of Resident 25's medical record showed a 05/04/2024 PASARR Level 2 that recommended to the facility to keep Resident 25's room free of obstacles that could make it difficult for them to maneuver their wheelchair, encourage bedroom to be well-lit during the day and gradually decreasing amount of light in the room as bedtime approaches. Keep room quiet, dark and cool at night to encourage improved sleep. Encourage powering down all electronic devices at least 30 minutes prior to bedtime. Keep calendar, clock, and daily schedule in an easily visible location. The evaluation also recommended to the facility to be clear in communication with Resident 25, limiting direction to 1-2 steps at a time. Be consistent with information conveyed and refrain from making multiple changes to a plan if at all possible. Especially last-minute changes. Monitor for small changes in speech patterns, decreased need for sleep, or increased distractibility or disorganized thoughts and alert mental health prescriber as rapidly as possible - early intervention can assist in avoiding a full blown manic episode. Mania is the most intense and extreme phase of bipolar disorder and can interfere with daily functioning and impair judgment. It can also lead to psychosis (the person loses touch with reality). Review of Resident 25's care plan showed no documentation the facility incorporated the PASARR Level 2 recommendations to help support Resident 25's mental health care needs. An observation of Resident 25's room on 10/30/2024 at 9:19 AM showed no clock or daily schedule in an easily visible location as recommended by the PASARR Level 2. The above information was shared with Staff A, Administrator, on 10/30/2024 at 9:02 AM. Staff A acknowledged the PASRR Level 2 recommendations were not and should be in the care plan. You get the Level 2 and incorporate those recommendations. Reference WAC 388-97-1915 (4). .

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a PASARR Level 1 [preadmission screening for individuals with a mental disorder and/or intellectual disabilities] was completed as required for 2 of 5 residents (Residents 3 and 27) reviewed for pre admission screening. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Resident 3> Review of a 10/25/2024 comprehensive assessment showed Resident 3 re-admitted to the facility on [DATE] from the hospital with medically complex conditions, to include depression and anxiety disorder. Review of Resident 3's diagnoses list also included somatization disorder (when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning). Review of the medical record showed no presence of a PASARR Level 1. The above findings were shared with Staff A, Administrator, and Staff B, Director of Nursing, in a joint interview on 10/28/2024 at 1:23 PM. Staff A acknowledged the medical record showed no presence of a PASARR Level 1. Staff B presented a paper copy of a PASARR Level 1 dated 03/25/2020. Review of the PASARR Level 1 showed no recognition of anxiety, depression, or somatization disorder diagnoses. Staff A acknowledged the PASARR Level 1 was not accurate, should have been updated, and stated, Right now there is nothing marked. I see things [diagnoses] that should have been marked. <Resident 27> The 07/26/2024 admission assessment documented Resident 27 had diagnoses which included depression, anxiety, and dementia. Review of Resident 27's record documented a PASARR was completed on 07/18/2024 prior to the resident's admission to the facility, Section 1A documented the resident had anxiety and a mood disorder, but the box for a Level II evaluation as required was unchecked. Further record review found no documentation that the PASARR had been redone to attain a Level II evaluation. In an interview on 10/29/2024 at 9:36 AM, Staff A stated that the PASARR should have been redone and a Level II referral should have been made and this was important to meet the care needs of the resident. Reference: WAC 388-97-1915 (1)(2)(a-c)

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 ensure the provider was notified when a resident had possible seizure activity for 1 of 2 sampled residents (Resident 37) reviewed for quality of care. This failure placed residents at risk of not being assessed for possible decline by their provider, unintended health consequences, and decreased quality of life. Findings included . A review of the annual assessment dated [DATE] documented Resident 37 had diagnoses including dementia, and paralysis on one side of their body from a stroke. The resident was severely cognitively impaired and had not had a previous diagnosis of having seizures. A nursing progress note dated 10/19/2024 at 3:16 PM documented Resident 37 was in the dining room with their family when the resident had what looked like an absence seizure, (a short period of staring blankly in to space). The resident's hand and foot were having seizure like movements for about 10 minutes. The resident was aware and speaking during the time and held their affected hand. When asked, the resident stated they did not want to go anywhere. The provider was notified via binder. The note documented Resident 37's vital signs (measurements of the resident's blood pressure, heart rate, respirations, and oxygen saturations) were within normal limits. A review of the vitals section of the electronic medical record (EMR) had no vital signs documented for 10/19/2024. Further review of nursing progress notes from 10/20/2024 to 10/26/2024 documented the resident was on alert charting due to a seizure and had not had any further seizure activity. There were no provider progress notes in the EMR after 10/03/2024. On 10/29/2024 at 10:43 AM, the Provider communication binder (a binder kept at the nurse's station that notified providers on paper of non-emergent resident situations) was reviewed with Staff C, Assistant Director of Nursing. There was no entry for Resident 37 on 10/19/2024 regarding possible seizure activity. Staff C stated once the provider had reviewed the information in the binder, they initialed the document, possibly wrote new orders or instructed staff to continue to monitor a resident. Staff C stated recent notifications in the binder had been removed by Staff B, Director of Nursing, and a copy of the 10/19/2024 provider notification regarding Resident 37's possible seizure was requested. During an interview on 10/29/2024 at 12:39 PM, with Staff C and Staff D, Resident Care Manager, Staff D stated without the notification document, it was difficult to know if the provider had been aware of Resident 37's possible seizure. Staff D stated they had to assume Resident 37 had a seizure until there was something from the provider that documented it was something else. Staff D stated if the resident had a seizure, this was a change of condition and the provider needed to be notified. Staff C stated they expected staff to obtain a resident's vital signs and notify the provider, especially for a resident who had no previous diagnosis of seizures. Staff C stated staff would be educated on what needed to be reported to the provider. In an email correspondence dated 10/29/2024 at 2:37 PM, Staff B, Director of Nursing, documented the provider notification sheet regarding Resident 37's possible seizure was unable to be located. Staff B documented the provider was going to evaluate Resident 37 on that day, 10/29/2024, 10 days after the initial event. Reference: WAC 388-97-1060(1)

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to identify and monitor a pressure ulcer for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. This failure put the resident at risk for worsening breakdown of their skin, infection, and unintended health consequences. Findings included . A review of the 08/19/2024 admission assessment documented Resident 24 had diagnoses including paralysis of one upper extremity following a stroke and left fractured femur (thigh bone). Resident 24 was cognitively intact and was at risk for development of pressure ulcers but had none when admitted . On 09/16/2024, a significant change assessment was completed that documented Resident 24 rejected care and had one unstageable (the ulcer was covered by a layer of dead tissue that may have been green, brown, or black and made it unable to determine the extent of the wound underneath) pressure ulcer not present on admission. The 08/23/2024 care plan documented Resident 24 was at risk for break in skin integrity related to decreased mobility. Staff were to provide a pressure relieving mattress and wheelchair cushion, provide treatments as ordered, and conduct weekly skin checks and notify Social Services or the Director of Nursing if the resident refused. On 09/19/2024, the care plan was updated to show Resident 24 had an unstageable pressure ulcer to their left heel related to immobility and resistance to skin checks. Staff were to administer medications and treatments as ordered, assess wound healing, measure length, width and depth where possible, assess and document status of the wound perimeter, wound bed and healing progress, report improvement and decline to the provider. If the resident refused, staff were to confer with the resident and the interdisciplinary team to try alternate methods. The provider gave the following orders for the resident's care: -08/13/2024 check under brace to left lower extremity twice daily for skin breakdown. Resident has to be in bed with the brace open but not removed. -08/18/2024 weekly skin assessment on Sunday, document new and chronic skin impairments. -09/11/2024 Consult the wound care provider group. A review of hospital records documented on 08/06/2024 on the daily flow sheet, the resident had wounds on both heels. The wound on the right heel was not named and the wound on the left heel was called pressure. The left heel wound was described as redness. A registered dietician note dated 08/10/2024 documented the resident had a stage 1 pressure ulcer on their heel (redness that did not turn white when pressed, skin still intact.), but did not state which heel. A photograph of Resident 24's left heel was included in the hospital documentation. It showed the outer aspect of the resident's heel had a dark purple area similar in diameter to a golf ball. The skin surrounding the area was red. There were no measurements of the area on the heel. A review of the treatment administration records (TAR) for August, September 2024 showed the skin under Resident 24's brace was checked twice daily as ordered (with only one omission) beginning on 08/13/2024 until the order was discontinued on 09/19/2024. Weekly skin checks were completed as ordered beginning 08/18/2024. There were no omissions, and no refusals were documented. Weekly Skin Evaluations form documented in the assessment area of the electronic medical record (EMR) documented on 08/18/2024, the resident's skin was normal and there were no new findings. On 08/25/2024, the resident refused to have their skin evaluated and agreed to have their skin checked once they were in bed. On 09/01/2024, there were no new issues. On 09/08/2024, there was an abrasion to the left lower extremity, a skin tear to the right forearm, and no new skin issues were seen or reported. All skin evaluations were reviewed, and the only refusal documented was on 08/25/2024. A review of the Skin Integrity Update forms in the assessment area of the EMR documented on 09/11/2024, Resident 24 had an unstageable pressure ulcer on their left heel, the resident was resistant to skin checks, and often refused to allow staff to see full skin on assessment. The ulcer on the heel was unstable, and the Director of Nursing was notified immediately. All of the Skin Integrity Update forms that were part of the EMR were reviewed and there was no documentation the resident had refused skin assessments. A 09/12/2024 physician assistant (PA) progress note from the consulting wound care provider documented Resident 24 had a wound to their heel, the wound had been noted in the resident's hospitalization notes on 08/10/2024, but the resident had refused evaluations of their extremities multiple times. Last week, a nurse noticed the dark area on the heel. The wound was described as pressure, measured 3.5 centimeters (cm) by 4.4 cm by 0, unstageable, all eschar (dead tissue), and treatments were ordered. On 10/22/2024 at 10:19 AM, Resident 24 was observed in their room scooting in their wheelchair. The resident was wearing a pressure relieving boot on their left foot. Resident 24 stated they had a pressure ulcer on their left heel. They stated it had gotten worse after they got to the facility, but it was being treated, and the wound was improving. On 10/24/2024 at 9:49 AM, Resident 24 stated they had been seen by the wound care PA that morning, and some dead tissue had been removed from their wound. On 10/30/2024 at 10:52 AM, the treatment for Resident 24's heel was observed with Staff D, Resident Care Manager. After removal of the old dressings, the left heel was observed. The outer aspect of the heel had an area of injury similar in diameter to a fifty-cent piece. The area was covered with a dark scab-like tissue in the center of the wound. There was slough (dead moist yellowish tissue) around the perimeter from 9 o'clock to 12 o'clock. The skin surrounding the wound was red. There was minimal drainage present. The area was redressed according to the orders. There was no concern with the infection control practices during the observation. On 10/30/2024 at 12:01 PM, Staff H, Nursing Assistant, stated when Resident 24 was first admitted , they wore a firm brace on their left leg that kept their leg straight. Staff H stated when Resident 24 went to bed, they were unable to sleep because of the brace. They also had padded foam boots they were supposed to wear, but complained the boots also interrupted their sleep because they made their feet hot. Resident 24 refused to keep the boots on at night. Staff H stated the resident then developed a wound on their calf, so the brace was discontinued. After the wound care company began working with the resident's heel, Resident 24 then got better about keeping a boot on their left foot. Staff H stated the resident was angry when they were admitted and refused care, but that got better as time went on. During a follow-up interview with Resident 24 on 10/30/2024 at 12:25 PM, they stated they were told in the hospital that a pressure sore was building. They wore the leg brace but had no foot rests on their wheelchair at the hospital so they propped their left leg on top of their right so they could scoot around and this position caused the sore on the back of their calf. They stated they were provided foam boots for their heels right from when they got to the facility, but they did not wear them because they were unable to sleep with them on. Staff gave the resident a pillow instead to put under their legs to prop them up off the mattress. Resident 24 stated the hospital was not doing treatments on their heels; those started after they went to the facility. During an interview on 10/30/2024 at 1:24 PM, Staff M, Resident Care Manager, stated when Resident 24 first arrived at the facility, they refused to have their skin checked so it was several days before they were allowed to look. Staff M reviewed the hospital photographs and stated they had not seen the hospital pictures of Resident 24's heel before then and the wound in the picture looked like a suspected deep tissue injury. They were unable to say what the heel looked like when the resident was admitted . Staff M stated had they known of the heel wound, they would have done more monitoring, and would have had staff measure it to make sure it was improving. Staff M stated the resident was given the foam boots and all residents have pressure relieving mattresses, but there were still a few other interventions they could have tried to help keep the resident's heel from further breakdown. During an interview on 10/30/2024 at 3:56 PM, Staff B, Director of Nursing, stated Resident 24 had not allowed staff to look at their skin from the waist down initially, but agreed that those refusals had not been documented. Staff B stated once the wound was identified, they did a full skin assessment on all residents to ensure there were none that had been overlooked and so they could put interventions in place. Staff B stated they had nurses sign statements that the resident had refused skin observations, but those were not completed until 10/16/2024. Staff B agreed there had been no documentation of the wound until 09/11/2024. Reference: WAC 388-97-1060(3)(b)

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to demonstrate orthotic devices (devices to help support muscles, tendons and ligaments in the wrist and hands) were implemented and monitored to prevent contractures for 1 of 3 sampled residents (Resident 10) reviewed for Position/Mobility. This failure placed the resident at risk for deterioration in Range of Motion (ROM) abilities and development of contractures. Findings included . On 10/22/2024 at 12:03 PM, Resident 10 stated that they participated in a Restorative Nursing Program for, arms and legs, hands and feet. On 10/23/2024 at 9:31 AM, Resident 10 was observed sitting in their wheelchair, with their legs propped on a pillow, and a rolled washcloth to each hand grip. On 10/24/2024 at 2:21 PM, Resident 10 was observed with a rolled washcloth to each hand grip and they stated, They gave me a splint for both hands. But it hurt my hands so now I have washcloths. The observation showed the washcloth to the right hand grip was out of Resident 10's hand. Resident 10 stated that they had the rolled washcloths on yesterday and all the time. On 10/25/2024 at 9:39 AM, Resident 10 was again observed to have rolled washcloths to their hand grips, and stated, The right hand [washcloth] it falls out, but the left hand [grip] is good. In an interview on 10/25/2024 at 9:14 AM, Staff O, Restorative Nursing Assistant, stated, We use wash cloths to keep [the resident's] hands open. Staff O described Resident 10's hands as stiff. In an interview on 10/25/2024 at 3:18 PM, Staff P, Nursing Assistant, stated that the rolled washcloths were used because Resident 10 does not want their nails digging in the palm and will tell us to readjust it every so often. In an interview on 10/25/2024 at 8:16 AM, Staff Q, Nursing Assistant, stated Resident 10 used the rolled washcloths to the hands to, help cushion their arms and that the staff put them in place every morning. Review of an 08/06/2024 quarterly assessment showed Resident 10 was assessed to be cognitively intact, and with the diagnosis of a progressive neurological condition. The assessment showed Resident 10 had functional limitation (which interfered with daily functions or placed resident at risk of injury) to both arms and legs. This assessment showed the staff provided a Range of Motion program but no splint or brace assistance. Review of a care plan showed Resident 10 has limited physical mobility related to a progressive neurological condition, with risk for contractures. The care plan showed a 02/27/2024 instruction to the staff to apply orthotics to both hands, to be worn by the resident up to 6 hours a day and off at night, and to check the skin each shift. A 10/25/2024 addendum to the instruction showed, Often refuses orthotics. If refused, offer rolled up washcloths and place in resident's grip. Review of the medical record showed no documentation the staff applied the hand orthotics, monitored its application or tolerance, identified refusals, and how it managed the refusals. The above information was shared with Staff B, Director of Nursing, on 10/28/2024 at 2:17 PM. Staff B acknowledge the lack of monitoring of the orthotics and stated, I do not see an order for this [orthotics] to be in the [treatment administration record] to ensure it is in place for six hours during the daytime. I do not see it is being complied with, how often [the resident] is refusing, why [the resident] is refusing, and the use of the washcloth and tolerance to it. Reference WAC 388-97-1060 (3)(d), (j)(ix).

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 1 of 2 residents (Resident 18)reviewed for incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the resident at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment. Findings included . Review of a 10/15/2024 quarterly assessment showed Resident 18 re-admitted to the facility on [DATE]. This assessment showed the resident admitted to the facility with a stroke and assessed to have moderate cognitive impairment. The assessment showed the resident required substantial/maximal assistance to transfer to the toilet, was frequently incontinent of bowel and bladder, and no toileting program in place to manage the resident's incontinence. An observation on 10/22/2024 at 9:40 AM showed Resident 18 in bed. When asked if they required assistance to use the bathroom for bowel and bladder elimination, Resident 18 stated, I go right in my britches. I unfortunately have a problem, so I end up going in my pants. Resident 18 stated that they mainly experienced bladder incontinence. Resident 18 was unaware if they were on a bowel and bladder toileting program. On 10/28/2024 at 2:41 PM, Resident 18 was observed again in bed and stated, I prefer using the bathroom, but I can't make it. My walker is behind the door. I call but if the staff is not on time I do it on my own. They don't come in out of the blue and ask if I need to use the bathroom. Review of a 01/11/2024 Urinary Incontinence Tool showed the staff identified Resident 18 experienced urge incontinence (a sudden and intense need to urinate that can't be delayed), required stand-by assistance with toileting, and used a wheelchair and a walker. This tool showed Resident 18 could understand and follow directions, recognize urinary urge sensation, and learn to control the urge to void. No referral needs to specialists or other disciplines were indicated. The tool showed no documentation on what the facility did to help the resident gain their continence. Review of results for an 01/11/2024 Evaluation for Bowel and Bladder Training showed the staff assessed Resident 18 met criteria for a timed or scheduled voiding program. Review of a 02/04/2024 Urinary Incontinence Tool showed Resident 18 experienced functional incontinence (a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a bathroom) required total physical assistance for toileting, no Post Void Residual (PVR, a test which measures urine volume and can help evaluate incontinence and other urinary symptoms) was completed, and the resident did not recognize or learn to control the urge to void. The tool showed the staff referred Resident 18 to Occupational Therapy (OT) and Physical Therapy (PT). Review of results for an 04/11/2024 Evaluation for Bowel and Bladder Training showed the staff assessed Resident 18 met criteria for a timed or scheduled voiding program. Review of a 05/01/2024 Urinary Incontinence Tool showed the staff identified Resident 18 experienced stress incontinence (when movement or activity puts pressure on the bladder, causing urine to leak, like coughing, laughing, sneezing, running or heavy lifting). This tool showed Resident 18 was able to sense the urge to void, required physical assistance for toileting, and no PVR was completed. The tool showed that even though the resident refused to be toileted prior to a recent hospitalization, the resident now stated that they desired to get out of bed more often. The tool showed Resident 18 recognized and learned to control the urge to urinate. The tool showed the staff referred Resident 18 to OT and PT. Review of results for a 05/01/2024 Evaluation for Bowel and Bladder Training showed the staff assessed Resident 18 was a poor candidate for scheduling or retraining bowel and bladder program. Review of 05/29/2024 OT and PT Discharge Summaries and a 08/06/2024 PT Discharge Summary showed no documentation therapy evaluated Resident 18 for bowel and bladder incontinence. No further OT or PT records were provided by the facility to show the resident was evaluated by therapy to address their incontinence. Review of results for a 07/11/2024 and 10/11/2024 Evaluation for Bowel and Bladder Training showed the staff assessed Resident 18 met criteria for a timed or scheduled voiding program. Review of the bowel and bladder flow sheets from 09/28/2024 to 10/26/2024 showed Resident 18 was incontinent of bowel and bladder at a minimum of two times a day and sometimes up to three times a day. Review of Resident 18's care plan showed a 10/18/2024 care plan that showed the resident required substantial assistance by one staff for toileting hygiene and the resident chose to be incontinent all the time of bowel and bladder and not use the toilet. There were no interventions to show a timed or scheduled program as indicated in the 07/11/2024 and 10/11/2024 Evaluation for Bowel and Bladder Training. The above information was shared with Staff B, Director of Nursing, on 10/29/2024 at 8:54 AM. Staff B acknowledged the conflicting results of the Urinary Incontinence Tools and no interventions in the care plan to instruct the staff on how to decrease or avoid loss of bowel and bladder functions. Staff B stated that they expected to see interventions that encouraged the resident to use the bathroom and clearly show the staff how to manage the resident's incontinence. Reference WAC 388-97-1060 (3)(c).

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (Resident 19 and 38) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . <Resident 19> Per the 10/01/2024 admission assessment, Resident 19 had diagnoses which included heart failure and obstructive sleep apnea (OSA, when you can't breathe while asleep because of a blockage of your windpipe) and needed a CPAP (a machine that uses mild air pressure to keep breathing airways open) due to those conditions. The 09/27/2024 physician order instructed nursing staff to cleanse the CPAP mask with warm soapy water, rinse and air dry daily and as needed. The 02/28/2024 care plan documented Resident 19 used a CPAP for OSA. In an observation and interview on 10/22/2024 at 2:19 PM, Resident 19's CPAP was unclean with white splatter inside of the mask. Resident 19 stated staff had not cleaned their mask, and they cleaned it twice weekly by rinsing it off and running water through the hose. Subsequent observations of Resident 19's CPAP being unclean with white splatter inside of the mask were made on 10/23/2024 at 3:30 PM, 10/24/2024 at 8:11 AM, and 10/25/2024 at 1:28 PM. On 01/28/2024 at 1:28 PM, the CPAP was stored in Resident 19's drawer that was full of crumbs. <Resident 38> Per the 09/20/2024 admission assessment, Resident 38 had diagnoses which included chronic respiratory failure with hypoxia (a condition in which the lungs do not supply enough oxygen to the blood) and asthma and required oxygen due to those conditions. The 09/20/2024 physician order instructed nursing staff to clean the oxygen concentrator filter with soap and water every Sunday. The 10/01/2024 care plan documented Resident 38 needed oxygen related to shortness of breath and asthma. In an observation on 10/22/2024 at 9:51 AM, Resident 38 was sitting in their wheelchair in their room. The resident's oxygen concentrator filter was unclean with thick dust debris. In an interview on 10/28/2024 at 2:32 PM, Staff B, Director of Nursing, stated oxygen filters were to be cleaned weekly, and this was important because the amount of oxygen flowing could be interrupted and cause breathing difficulties. During an interview on 10/29/2024 at 2:34 PM, Staff B stated CPAP machines were to be cleaned daily and as needed and this was important for infection control. Reference: WAC 388-97-1060 (3)(j)(vi)

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

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 dialysis care was provided consistently with professional standards for 2 of 2 sampled residents (Residents 13 and 19) reviewed. Specifically, Resident 13 was not consistently evaluated post-dialysis treatments, and Resident 19 was not given their morning medications on dialysis treatment days. This failure placed residents at risk for unintended health consequences, deterioration of their chronic diseases and decreased quality of life. Findings included . The Life Care Centers of America, Area of Focus: Dialysis policy revised 11/29/2023 documented on the day of dialysis, staff were to check medications the resident was taking and follow physician orders regarding medication administration and complete the Pre/Post Dialysis Communication form before and after treatment. Post-dialysis, staff were instructed to obtain vital signs, transcribe any orders received from the dialysis facility and maintain the communication form in the resident's medical record. <Resident 13> A review of the quarterly assessment dated [DATE] documented Resident 13 had diagnoses including paralysis on one side of their body after a stroke, and end-stage kidney disease dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer work). The 05/23/2023 comprehensive care plan documented Resident 13 was dependent on dialysis and had dialysis sessions every Monday, Wednesday and Friday. Staff were instructed to assess the resident's access site daily and upon return from dialysis, check vital signs (a person's blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation) daily, as needed and upon return from each dialysis session. Staff were to notify the provider of any abnormalities, and document the resident's status in the Dialysis Communication Binder pre and post-dialysis sessions. On 10/22/2024 at 11:45 AM, Resident 13 was observed in their room scooting in their wheelchair. Resident 13 stated they went to dialysis three times a week. Resident 13 stated they took a bag lunch with them to their session, then ate dinner when they returned. They stated staff did not always check on them when they got back from dialysis, just brought them their meal then left their room without checking their vital signs. A review of Resident 13's Dialysis Communication binder for the months of September and October 2024 revealed 9 times the post-dialysis evaluation was not completed: 09/06/2024, 09/11/2024, 09/13/2024, 09/20/2024, 10/02/2024, 10/04/2024, 10/11/2024, 10/18/2024, and 10/25/2024. During an interview on 10/30/2024 at 2:42 PM, Staff D, Resident Care Manager, stated they expected staff to evaluate the resident and document it in the Dialysis Communication binder after the resident returned from their dialysis sessions. Staff D stated this ensured Resident 13 was not having any adverse reactions to their treatments, and the communication binder was one of the ways the facility communicated with the dialysis center so it was important for those evaluations to be documented. <Resident 19> A review of the 10/01/2024 admission assessment documented Resident 19 had diagnoses including heart failure, and end-stage kidney disease dependent on dialysis, The 09/27/2024 comprehensive care plan documented Resident 19 was dependent on dialysis and had dialysis sessions every Monday, Wednesday and Friday and dietary was to provide an early breakfast for them. A 09/27/2024 provider order stated medications orders reflected appropriate times around dialysis (at least two hours prior to or after return). Resident 19 was prescribed insulin before meals, and the provider was to be notified if their blood sugar was greater than 400 or less than 70. In an interview on 10/22/2024 at 2:15 PM, Resident 19 stated they went to dialysis on Monday, Wednesdays and Fridays and ate a bowl of cereal before they left and was unsure if they received their medications before dialysis. Review of the October 2024 medication administration record documented Resident 19 had no blood sugar checks prior to going to dialysis and had not consistently received their scheduled medications on dialysis days. In an interview on 10/29/2024 at 10:27 AM, Staff B, Director of Nursing, stated blood sugars should be monitored prior to the resident leaving for dialysis and this was important to ensure the resident was within the correct parameters. Staff B added Resident 19 should have received their medications when they returned from dialysis unless it was appropriate to give them before they left. During an interview on 10/29/2024 at 9:10 AM with the dialysis clinic, they stated they did not check Resident 19's blood sugar unless they were symptomatic, and they did not administer any medications that were prescribed at the facility. They further added the only medications that could not be received prior to dialysis were blood pressure medications and antibiotics, all other medications could have been given. Reference: WAC 388-97-1900(1), (6)(a-c)

CONCERN (D)

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

Deficiency F0699 (Tag F0699)

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 that 2 of 2 sampled residents (Resident 3 and 25) reviewed for trauma informed care, received culturally competent, trauma-informed care in accordance with professional standards of practice. The failure of the facility to adequately assess, identify potential triggers (a psychological stimulus that prompts recall of a previous traumatic event), and develop and implement a Trauma Informed Care Plan to help limit the residents' exposure to potential trauma triggers, placed the residents at risk for re-traumatization and a diminished quality of life. Findings included . <Resident 3> Review of a 09/06/2024 facility policy titled Trauma-Informed Care showed that residents who have a history of trauma and or post-traumatic stress disorder will receive appropriate treatment and services to correct the assessed problem. Trigger-specific interventions would identify ways to decrease the resident's exposure to triggers which re-traumatize the resident and identify ways to mitigate or decrease the effect of the trigger on the resident. The policy showed the facility should collaborate with the resident's family, friends, or any other health care professional, to develop and implement an individualized plan of care with interventions. Review of Resident 3's medical record showed they re-admitted to the facility on [DATE]. The review showed the diagnoses of several mental health disorders. Review of a 01/03/2024 Trauma Informed Care Evaluation (TIC) showed, Resident 3 personally experienced physical assault and severe human suffering. The evaluation listed no triggers that could possibly re-traumatize the resident. The evaluation showed that in the past month, Resident 3 experienced a little bit of repeated and disturbing dreams of the stressful experience, suddenly feeling or acting as if the stressful experience were actually happening again, had strong physical reactions when something reminded them of the stressful experience, trouble remembering important parts of the stressful experience, had strong negative beliefs about themselves, other people, or the world, and blamed themselves or someone else for the stressful experience or what happened after it. Review of a 07/19/2024 progress note showed, Monitor for psychosocial harm after intimidating staff event. Review of the incident log showed the facility reported the event to the State Agency on 07/17/2024. The associated facility incident report showed Resident 3 reported to the facility that they, had some 'rough' experiences' with a male staff. The resident described the staff appeared to be very agitated and witnessed him throwing his gloves down and aggressively saying he was taking a break, and when the staff returned from break and helped the resident get into bed, was still agitated. The report showed Resident 3 told the facility that they had, had a history of behaviors like this from a male family member and it was very triggering for [the resident]. The resident shared with the facility that the male staff still seemed stressed out days later even with simple tasks and heard some yelling next door between the male staff and another resident. The resident stated that they did not feel comfortable having him as a caregiver and feels somewhat intimidated when they see the male staff in the halls. Review of the progress notes showed no documentation the facility monitored Resident 3 for latent or adverse reaction to the triggering event which occurred on 07/17/2024, until 07/19/2024. The following unrelated progress note was dated 08/07/2024. On 10/28/2024 at 10:27 AM, Staff N, Nursing Assistant (NA)/Shower Aide, stated that they were familiar with Resident 3's care and unaware of any behaviors the resident could exhibit that could impact their care. Staff N stated, I know [the resident] has some trauma from the past but nothing that has made [them] flip out. Staff N shared her knowledge of Resident 3's traumatic childhood events at length. Staff N was unaware of what could trigger Resident 3's re-traumatization. On 10/28/2024 at 10:43 AM, Staff Q, NA, stated that they were familiar with Resident 3's care and unaware of any behaviors the resident could exhibit that could impact their care. When asked if they had knowledge Resident 3 had a history of past trauma, or if there were events or environmental factors that could trigger it, Staff Q stated, Nothing comes to mind. Review of a 07/22/2024 care plan showed Resident 3, has a potential for a psychosocial well-being problem r/t [related to] history of trauma in childhood. The resident will identify coping mechanisms (new and old) by the review date. Review of the care plan showed no documentation what the coping mechanisms were. Additionally, the care plan showed that, When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings, but did not describe what could trigger the conflict. The care plan showed no interventions that instructed the staff on how to prevent re-traumatization and what to do if it occurred. The above findings were shared with Staff A, Administrator, and Staff B, Director of Nursing, on 10/28/2024 at 1:46 PM. Staff A acknowledged the lack of interventions to prevent re-traumatization of Resident 3, to include identification of the triggers, coping mechanisms, and how to de-escalate or manage re-traumatization. Staff A stated that they expected the staff to monitor the resident every shift for latent effects of re-traumatization for a minimum of 72 hours after the event. <Resident 25> Review of a 10/11/2024 quarterly assessment showed Resident 25 re-admitted to the facility on [DATE] with medically complex conditions and diagnoses of mental illness. The staff assessed Resident 25 as cognitively intact. Review of a 02/26/2024 progress note showed, Resident 25 was, getting loud, and yelling around, bringing up [their] past of all different years, and situations. Res consumed with [their] [NAME] Beret time and marriage. Res wants to be 'heard.' The [NAME] Berets are the United States Army Special Forces, a special operations branch of the military, known for their distinctive green berets and for conducting quiet, guerilla-style missions in foreign countries. Review of a 05/04/2024 Preadmission Screening and Resident Review (an evaluation completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition) showed, family may have information about what [the resident] looks like at baseline with mood disorder and help provide information on whether the resident has shown a decline in cognitive function. This evaluation showed the resident was a Nursing Assistant in a hospital during the Vietnam Era. The evaluation showed the resident stated, There were body bag [sic] everywhere and They made me wrap up the corpse and get it down for autopsy. The evaluation showed the resident stated, They gave me shock treatment. I went into seizures from it. Review of Resident 25's progress notes (03/10/2024, 04/11/2024, 04/21/2024, 04/26/2024, 05/13/2024, 05/29/2024, 10/14/2024, and 10/21/2024) showed several disruptive behaviors like banging and yelling in the middle of the night, punching the door leading to downstairs, sexually inappropriate behaviors towards the staff, talking aloud in the hallways sometimes to other residents or themselves, playing the music and TV loudly, verbal aggression toward other residents, yelling at staff, kicking a chair toward a dining room wall heater, and becoming angry at a passing male resident because Resident 25 thought the other resident was looking into their room. A review of a 02/14/2024 TIC showed the staff identified Resident 25 experienced personally a very stressful event or experience but showed no documentation what the event was. The evaluation showed that in the past month Resident 25 felt at a moderate intensity very upset when something reminded [them] of the stressful event, had strong negative beliefs about themselves, other people, or the world, blamed themselves or someone else for the stressful experience or what happened after it, and irritable behavior, angry outbursts, or acting aggressively. The TIC showed only the resident participated in the interview. A review of a 09/17/2024 TIC showed again that the staff identified Resident 25 experienced personally a very stressful event or experience but showed no documentation what the event was. The evaluation asked the staff to list the triggers, but the staff documented feelings of losing control, fearful, etc. The evaluation showed the staff failed to identify triggers that could possibly retraumatize Resident 25. The evaluation showed that the resident experienced 15 out of the 19 possible reactions indicative of a response to a triggering event that ranged in intensity from, A little bit, Moderately, to Quite a bit. The TIC showed only the resident participated in the interview. Review of Resident 25's care plan showed no indication the facility identified the very stressful event or experience the facility assessed in the 02/14/2024 and 09/17/2024 TIC. The care plan showed no Trigger-specific interventions to help prevent re-traumatization and address the 15 out of the 19 possible reactions Resident 25 experienced. The above information was shared with Staff A, Administrator, on 10/30/2024 at 8:56 AM. Staff A acknowledged the facility did not evaluate Resident 25's very stressful event or experience adequately, to include participation of family members or representative. Staff A acknowledged Resident 25's plan of care lacked guidance to the staff to help prevent re-traumatization and stated, I don't see anything documented. No Associated WAC. .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure blood pressures and heart rates were monitored and medications were held when parameters required it for 2 of 5 sampled residents (Residents 10 & 22) reviewed for unnecessary medications. This failure placed the residents at risk for unintended health consequences and decreased quality of life. Findings included . <Resident 10> Review of Resident 10's September and October 2024 Medication Administration Records (MAR) showed an order that instructed the staff to administer metoprolol (a medication used to treat high blood pressure and heart failure) by mouth at bedtime. The order also instructed the staff to hold the metoprolol if the resident's pulse was less than 60 beats per minute. Review of the September and October 2024 MAR showed the staff administered the metoprolol at bedtime even though they assessed Resident 10's pulse was below 60 on 09/01/2024, 09/05/2024, 09/07/2024, 09/13/2024, 10/01/2024, 10/02/2024, 10/03/2024, 10/08/2024, 10/10/2024, 10/15/2024 and 10/29/2024. The above findings were shared with Staff D, Registered Nurse/Resident Care Manager on 10/30/2024 at 10:29 AM. Staff D acknowledged the metoprolol was not required on the days the staff assessed Resident 10's pulse was below 60 and that it, should have been held. <Resident 22> A review of the 07/23/2024 quarterly assessment documented Resident 22 had diagnoses including hypertensive kidney disease (when long term high blood pressure causes kidney damage) and dementia. Resident 22 was severely cognitively impaired and required assistance with their activities of daily living (ADLs) including medication administration. On 06/03/2024, an order was given by the provider to give Resident 22 Carvedilol ( to treat high blood pressure ) 3.125 milligrams (mg) twice daily for high blood pressure. Staff were instructed to hold the medication for a systolic blood pressure (the top number in a blood pressure reading) less than 110 or for a heart rate less than 60 beats per minute. A review of the October 2024 administration record (MAR) through 10/24/2024 documented Resident 22 received their Carvedilol twice daily with no omissions. Further review of the MAR showed there were no areas on the MAR for staff to document Resident 22's heart rate and blood pressure when their medications were administered. A review of the vital signs area of the electronic medical record (EMR) for October 2024 showed Resident 22 did not have their heart rate or blood pressure documented twice daily, if monitored prior to the administration of their Carvedilol. On 10/16/2024, the systolic blood pressure was less than 110, and on 10/07/2024, 10/08/2024 and 10/20/2024, the resident had heart rates documented of less than 60 beats per minute. During an interview on 10/29/2024 at 11:46 AM, Staff J, Licensed Practical Nurse, stated they administered medications to Resident 22. Staff J stated they checked the resident's heart rate and blood pressure, but there was nowhere to document the results on the MAR. Staff J stated Residents had their vital signs taken every other day. Residents in even numbered rooms had theirs taken on even calendar days, and residents in odd numbered rooms had their taken on odd numbered days. During an interview on 10/29/2024 at 12:11 PM, Staff D, Resident Care Manager, stated Resident 22 was to have their heart rate and blood pressure monitored and medication held if indicated, but this had slipped through the cracks. If Resident 22 had a low heart rate or blood pressure, giving the medication opened it up to make those values even lower. Staff D stated if the parameters were not added to the MAR when the order was given, there was nowhere to document the vital signs on the MAR to demonstrate they had been reviewed prior to administration of the medication. Staff D stated this had been corrected. Vital signs had to be taken and entered on the MAR before staff could sign that the medication was given. Reference: WAC 388-97-1060(3)(k)(i)

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

<Improper Handling of Soiled Linen> In an observation on 10/25/2024 at 10:53 AM, Staff R, Nursing Assistant, left a resident's room carrying a bag with a soiled brief and in the other hand a soi...

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<Improper Handling of Soiled Linen> In an observation on 10/25/2024 at 10:53 AM, Staff R, Nursing Assistant, left a resident's room carrying a bag with a soiled brief and in the other hand a soiled gown, and walked down the hall with the items towards the soiled utility room. The soiled gown had not been placed in a bag or other container. At 10:58 AM, when asked if there was anything that had to be done prior to transporting soiled linen/items to the soiled utility room, Staff R stated they should have put the soiled items in a bag to prevent the potential spread of germs. In an interview on 10/29/2024 at 10:25 AM, Staff C, Infection Preventionist, stated all soiled linen were to be placed in bags prior to being removed from a resident's room to prevent the spread of bacteria. <Oxygen Administration> The 09/25/2024 admission assessment documented Resident 38 was able to make decisions regarding their care, had diagnoses which included chronic respiratory failure, and utilized oxygen. Review of Resident 38's records showed on 09/20/2024 the physician had prescribed oxygen to be administered continuously at the rate of two to three liters a minute. On 10/22/2024 at 9:51 AM, Resident 38 was observed in their room sitting in their wheelchair without their oxygen in place. Observation showed the oxygen concentrator was running, and the nasal cannula (tubing that was placed in the nose to deliver oxygen) was lying on the floor near the resident. When asked how they were doing, the resident stated they felt short of breath. At 10/03/2024 AM, Staff S, Nursing Assistant, entered Resident 38's room, picked the nasal cannula off the floor and placed it in the resident's nose. When asked if the nasal cannula being on the floor was an infection control concern, Staff S stated they should have cleaned the cannula or replaced it. In an interview on 10/22/2024 at 10:13 AM, Staff C, Infection Preventionist, stated Staff S should have gotten a new nasal cannula as the floor was not sanitary and using the nasal cannula that had been lying on the floor could introduce bacteria. Reference (WAC): 388-97-1320 (1)(a), (3) Based on observation, interview and record review, the facility failed to develop a complete water management plan, to mitigate the facility's risk factors associated with Legionnaire's Disease (a serious condition, caused by exposure to water sources infected with the Legionella pathogen), failed to ensure soiled linens were transported properly, and failed to ensure oxygen was administered in a sanitary manner and equipment was clean and maintained for 1 of 3 sampled residents (Resident 38) reviewed for respiratory care. These failures placed all residents at risk for exposure to Legionella, infections, respiratory complications, and diminished quality of life. Findings included . <Water Management Program> Review of the facility's water management plan showed it was last reviewed on 03/11/2024. Review of the plan showed it had not been fully developed and, aside from identifying the facility's water source, the facility's contacts, and the facility's characteristics, the rest of the program was either not fully completed or blank. On 10/30/2024 at 12:51 PM, Staff A, Administrator, confirmed the plan was incomplete and needed to include more information.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observation and interview the facility failed to ensure wheelchairs were maintained in a clean manner for 2 of 4 sampled residents (Residents 14 and 19) reviewed for physical environment. This failure placed residents at risk for lack of dignity and diminished quality of life. Findings included . <Resident 14> Per the 10/16/2024 quarterly assessment, Resident 14 had diagnoses which included a stroke and hemiplegia (paralysis on one side of the body), had moderate cognitive impairments and required substantial to total assist for all cares. Review of the 01/25/2023 comprehensive care plan documented Resident 14 was wheelchair bound. During an observation on 10/22/2024 at 10:22 AM, Resident 14 was sitting in their wheelchair in their room. The left armrest of their wheelchair was covered with sheepskin and a netting was placed over it. The sheepskin and netting were unclean and had a brown and red substance on it. In an observation on 10/23/2024 at 8:14 AM, Resident 14 was sitting in the dining room. The sheepskin and netting were unclean with a red and brown substance on it. During an observation on 10/23/2024 at 10:51 AM, Resident 14 was sitting in their room. Their wheelchair was unclean with food debris crusted on the cushion and bottom of the chair. Subsequent observations of the wheelchair and armrest being unclean were made on 10/23/2024 at 2:04 PM and 3:18 PM, 10/24/2024 at 8:05 AM, 10:10 AM, 12:35 PM, and 2:31 PM, 10/25/2024 at 8:43 AM, 10:51 AM and 12:23 PM. <Resident 19> Per the 10/01/2024 admission assessment, Resident 14 had diagnoses which included heart failure and diabetes, was cognitively intact and required substantial to total assist with cares. Review of the 02/28/2024 comprehensive care plan documented Resident 14 was wheelchair bound. In an observation on 10/23/2024 at 2:09 PM, Resident 19 was asleep in bed. Their wheelchair was unclean with food debris. Subsequent observations of the wheelchair being unclean were made on 10/23/2024 at 3:30 PM, 10/24/2024 at 8:11 AM and 2:28 PM, and 10/25/2024 at 1:28 PM. In an interview on 10/28/2024 at 2:24 PM, Staff B, Director of Nursing, stated wheelchairs were to be cleaned weekly and if they were not, it would be a dignity issue for the resident. Reference WAC 388-97- 3220 (1)

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> A 07/26/2024 admission assessment documented Resident 27 had diagnoses including dementia, depression and ag...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> A 07/26/2024 admission assessment documented Resident 27 had diagnoses including dementia, depression and agitation. Resident 27 was severely cognitively impaired and took medications for agitation and depression. The 07/26/2024 care plan documented Resident 27 used antidepressant medication related to depression and anxiety and antipsychotic medication for agitation. Staff were instructed to administer the medication as ordered, observe for and report any adverse reactions and to educate the resident/family/caregivers about the risks, benefits and the side effects of the medication. On 07/23/2024, a provider order was given to administer Lexapro (a medication used to treat depression and anxiety) and Zyprexa (an antipsychotic medication used to regulate mood and behaviors). On 07/23/2024, a consent was signed by Resident 27's representative that agreed to the use of Lexapro and Zyprexa. Resident 27's representative had moderate cognitive impairments and was also a resident of the facility. During an interview on 10/28/2024, Resident 27's representative stated they did not know what medications their family member was receiving and was unaware of the risks and benefits when asked about the Lexapro and Zyprexa. On 07/23/2024, Resident 27's representative signed Resident 27's admission packet, which included financial agreements, consent for treatment, rules and regulations, immunizations, pharmacy authorization and resident records. In an interview on 10/28/2024 at 2:28 PM, Staff B, Director of Nursing, stated consents needed to be signed by cognitively intact representatives and this was important, so they understood what they were signing. <Resident 39> A 10/10/2024 admission assessment documented Resident 39 had diagnoses including depression and insomnia. Resident 39 was cognitively intact and took medications for insomnia. The 10/08/2024 care plan documented Resident 39 used antidepressant medication related to insomnia. Staff were instructed to administer the medication as ordered, observe for and report any adverse reactions. On 10/10/2024, a provider order was given to administer Trazodone (a medication used to treat depression and insomnia). On 10/11/2024, a consent was signed by Resident 39 that agreed to the use of Trazodone. Per the October 2024 medication administration record, Resident 39 received their first dose of Trazodone on 10/10/2024, prior to the consent being signed. In an interview on 10/28/2024 at 10:08 AM, Staff M, Resident Care Manager, stated the consent for the Trazodone needed to be obtained prior to Resident 39 receiving their first dose. During an interview on 10/28/2024 at 10:10 AM, Staff B, Director of Nursing, stated the consent should have been signed prior to the administration of the medication and this was important because the resident needed education on what they were taking. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b). <Resident 13> A quarterly assessment dated [DATE] documented Resident 13 had diagnoses including end-stage kidney disease dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer work), dementia and anxiety. Resident 13 was moderately cognitively impaired and took medications for anxiety and depression. The 01/19/2024 care plan documented Resident 13 used anti-anxiety medication related to anxiety with dialysis. Staff were instructed to administer the medication as ordered, observe for and report any adverse reactions which could be associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looked like dementia. On 12/04/2023, a provider order was given to administer lorazepam (a medication used to treat anxiety that worked by slowing activity in the brain to allow relaxation), 0.5 milligrams every Monday, Wednesday and Friday prior to leaving for the resident's dialysis appointment. On 01/31/2024, a consent was signed by Resident 13's representative that agreed to the use of lorazepam to treat the resident's anxiety related to their dialysis treatment. The consent included why the medication was prescribed, risks and benefits, and non-drug approaches that had been ineffective. A consent dated prior to the initiation of the lorazepam on 12/04/2023 was requested. On 10/29/2024 at 3:27 PM, an email from Staff B, Director of Nursing, confirmed that there was no consent completed prior to the consent dated 01/31/2024. Based on interview and record review, the facility failed to ensure psychotropic medication consents were accurate and obtained prior to their administration (Residents 3, 13, 39) and failed to ensure a consent for treatment and admission were signed by someone able to make those decisions (Resident 27) for 4 of 5 sampled residents reviewed for unnecessary medications. This failure placed the residents or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications and care being provided at the facility. Findings included . <Resident 3> Review of Resident 3's medical record showed the provider ordered the medication sertraline on 07/01/2024 for depression. Review of the October 2024 Medication Administration Record showed the staff administered the sertraline to Resident 3 at bedtime. Review of Resident 3's care plan showed the resident used sertraline related to depression. Review of a 07/02/2024 Medication Informed Consent showed Resident 3 and a facility staff signed the form and the reason for the use of the sertraline was somatization, contrary to the physician order and the care plan. Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. On 10/28/2024 at 1:46 PM, Staff A, Administrator, acknowledged the inaccurate consent and stated that it should have been clarified.

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

<Resident 9> According to the 07/29/2024 quarterly assessment, Resident 9 had moderate cognitive impairments and needed substantial assistance from staff for ADL's, such as personal hygiene. Pe...

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<Resident 9> According to the 07/29/2024 quarterly assessment, Resident 9 had moderate cognitive impairments and needed substantial assistance from staff for ADL's, such as personal hygiene. Per the 04/29/2021 care plan, Resident 9 was to have nail care completed twice weekly during bathing and as necessary. Review of the bathing documentation from 10/03/2024 to 10/28/2024 showed the resident had not refused to be bathed. In an observation on 10/22/2024 at 10:27 AM, Resident 9 was sitting in their wheelchair in their room. Resident 9's nails were unclean with a brown substance underneath them. Subsequent observations of Resident 9's nails being unclean with a brown substance underneath them were made on 10/23/2024 at 8:16 AM and 3:21 PM, 10/24/2024 at 10:07 AM and 12:36 PM, and 10/25/2024 at 8:42 AM and 10/25/2024 at 2:04 PM. In addition, Resident 9's nasal hair was protruding past their nose on 10/23/2024 at 3:21 PM. During an interview on 10/23/2024 at 3:21 PM, Resident 9 was unaware their nasal hair protruded past their nose. The resident stated the staff had not offered to trim it and they would have accepted because they liked to be well kempt. <Resident 19> According to the 10/01/2024 admission assessment, Resident 19 was cognitively intact and needed substantial assistance from staff for ADL's, such as bathing. In an interview on 10/22/2024 at 2:10 PM, Resident 19 stated they were supposed to have two showers per week and sometimes they only had one per week. Per the 09/11/2023 care plan, Resident 19 was to be assisted with showers twice weekly. Review of the bathing documentation from 09/28/2024 to 10/23/2024 documented Resident 19 had been given showers on 09/28/2024, 10/02/2024, 10/05/2024, 10/09/2024, 10/16/2024, 10/20/2024 and 10/23/2024. In addition, the documentation showed the resident had not refused to be bathed. In an interview on 10/28/2024 at 10:47 AM, Staff H, Nursing Assistant, stated showers were to be given twice weekly and this was important for hygiene and skin. During an interview on 10/28/2024 at 10:32 AM, Staff B, Director of Nursing, stated nasal hair was removed as needed during showers and showers were to be given twice weekly. Staff B added this was important because it would be a dignity issue for the residents. Reference: WAC 388-97-1060 (2)(c). <Resident 37> A review of the 07/16/2024 quarterly assessment documented Resident 37 had diagnoses including dementia and paralysis on one side of the body after a stroke. Resident 37 was severely cognitively impaired and required moderate assistance for personal hygiene and extensive assistance for showering. The 10/21/2022 ADL self-care deficit care plan documented Resident 37 was dependent on staff for bathing/showering and was to be given showers twice weekly on Wednesdays and Sundays. The care plan did not provide instructions for staff regarding shaving preferences. Review of the shower binder documentation from 09/25/2024 to 10/24/2024 showed Resident 37 was provided showers on 09/25/2024, 10/02/2024, 10/09/2024, 10/16/2024, 10/20/2024, and 10/23/2024; weekly, not twice weekly as care planned. There was no documentation Resident 37 refused showers. The documentation showed Resident 37 was shaved on 10/09/2024. On 10/22/2024 at 9:10 AM, Resident 37 was observed scooting in the hall in their wheelchair. The resident had several days of whisker growth on their face and neck, and they had a full mustache. Their hair was unkempt. Additional observations of Resident 37 being unshaven were made on 10/23/2024 at 2:05 PM, 10/24/2024 at 8:15 AM, 10/25/2024 at 10:42 AM, and 10/28/2024 at 9:46 AM. During an interview on 10/24/2024 at 8:15 AM, Resident 37 stated they liked their hair kept short so that it was not hanging on their ears. They preferred to be clean shaven but liked to keep their mustache. Resident 37 was unable to recall when they had been showered last. During an interview on 10/28/2024 at 10:38 AM, Staff N, Nursing Assistant/Shower Aide, stated residents were to be showered twice weekly, but showers were not completed on Sundays. If they were care planned to have a shower on Sundays, it would be made up on a Saturday instead. Shaving was completed during showers. Staff N stated Resident 37 was asked when they wanted to be shaved and if the resident refused, other staff offered at a different time. Staff N stated showers were important to keep residents skin intact. This was especially important for Resident 37 because they had frequent periods of incontinence and their skin needed to be kept clean. During an interview on 10/29/2024 at 2:12 PM, Staff C, Assistant Director of Nursing, stated ideally the care plan would have instructions for shaving written out specifically. Each unit had a shower aide, and if unable to be completed on the day shift, the evening shift staff could make them up. Staff C stated they expected the staff to complete the showers as care planned. Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to cleanliness and grooming for 4 of 6 sampled residents (Residents 44, 37, 9, and 19) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 37), nail care (Resident 9), and bathing (Resident 44 and 19), placed the residents at risk for poor hygiene, embarrassment, and a diminished quality of life. Findings included . <Resident 44> Review of a 10/17/2024 assessment showed Resident 44 admitted with medically complex conditions. This assessment showed the staff assessed the resident to be cognitively intact and dependent on the staff for bathing. In an interview on 10/22/2024 at 8:36 AM, Resident 44 stated, Bathing dwindled down to once a week. Resident 44 stated that they preferred a bed bath twice a week. Review of the electronic medical record under Tasks showed an instruction to the staff to provide bathing to Resident 44 twice a week on Mondays and Thursdays. Review of the medical record from 09/27/2024 to 10/26/2024, showed no documentation the staff provided assistance to complete Resident 44's bathing twice a week on 09/30/2024, 10/10/2024, 10/17/2024, and 10/24/2024. Review of a bathing sheets binder maintained on the East Hall of the facility was reviewed with Staff M, Licensed Practical Nurse/ Resident Care Manager on 10/28/2024 at 11:26 AM. Staff M confirmed the binder showed no documentation the staff provided Resident 44 bathing twice a week for the month of October 2024. The above information was shared with Staff B, Director of Nursing, on 10/29/2024 at 10:27 AM. No further information was provided.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMMENDED ON 11/18/2024. Based on observation, interview and record review, the facility failed to ensure residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for 4 of 5 sampled residents (Residents 7, 27, 25 and 254) reviewed for elopement. The facility failed to ensure 1 of 3 sampled residents (Resident 41) had adequate and prompt interventions and supervision to prevent falls. Also, the facility failed to ensure 2 of 2 sampled residents (Residents 24 and 41) reviewed for smoking were adequately supervised, to include safe keeping of smoking materials. These failures placed the residents at risk for injuries related to elopement, falls, and smoking. Findings included . <ELOPEMENT> <Resident 25> Review of a 09/25/2024 facility policy titled Unsafe Wandering and Elopement Prevention showed the facility would assess residents to determine their risk for elopement and implement interventions as appropriate to mitigate risks identified. The policy defined elopement when a resident left the premises or safe area without authorization or without the necessary supervision to do so. The policy identified some of the risks associated with an elopement included heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. The policy showed that a system to help identify residents with the potential for unsafe wandering and elopement included a current photograph of residents and responsible party contact information. The policy instructed the staff to complete an elopement assessment upon admission, re-admission, change in condition, quarterly, and with any unsafe wandering or elopement event. Review of a 10/11/2024 quarterly assessment showed Resident 25 re-admitted to the facility on [DATE]. This assessment showed the staff identified Resident 25 wandered 1 to 3 days of the assessment reference period, did not place the resident at risk of getting to a potentially dangerous place, but significantly intruded on the privacy or activities of others. The assessment showed the wandering behavior worsened from the previous assessment. Review of 05/07/2024, 07/15/2024, and 09/10/2024 Elopement Risk Evaluations showed the staff did not find Resident 25 was at risk for elopement. A 10/23/2024 care plan showed the staff identified Resident 25 was, At risk for elopement. Impaired safety awareness, contrary to the evaluations, and instructed the staff to, Add resident to the Elopement Book. Review of the Elopement Books at the Receptionist Desk and the [NAME] Hall where Resident 25 resided showed no information that alerted the staff the resident was at risk for elopement. The facility provided the Surveyor a list of residents At risk for elopement the morning of 10/30/2024. Along with Resident 25, the list also included 4 other residents: Resident 254 - Review of a 10/24/2024 Elopement Risk evaluation showed the staff identified the resident was at risk for elopement. The 10/22/2024 care plan instructed the staff to, Add Resident to Elopement Book. Review of the Elopement Book at the receptionist area and the East Hall where Resident 254 resided showed no information to alert the staff the resident was at risk for elopement. Resident 27 - Review of a 10/23/2024 Elopement Risk evaluation showed the staff assessed the resident not at risk for elopement and, Pt [patient] wonders [sic] and tries to exit seek occasionally, Pt is easily redirected. The 10/23/2024 care plan showed Resident 27 was, At risk for elopement. Disoriented to place, Resident wanders aimlessly and Add Resident to Elopement Book. Review of the Elopement Book at the receptionist area and the East Hall where Resident 27 resided showed no information to alert the staff the resident was identified at risk for elopement. Resident 7 - Review of a 08/30/2024 Elopement Risk evaluation showed the staff assessed Resident 7 not at risk for elopement. The 10/23/2024 care plan showed the resident was At risk for elopement. Impaired Safety Awareness and Add Resident to Elopement Book. Review of the Elopement Book at the receptionist area and the [NAME] Hall where the resident resided showed no information to alert the staff the resident was identified at risk for elopement. In an interview on 10/30/2024 at 12:47 PM, Staff I, Registered Nurse on East Hall, identified only Resident 253 should be in the Elopement Book, contrary to the care plan instructions for Residents 27 and 254. In an interview on 10/30/2024 at 12:51 PM with three Nursing Assistants on the [NAME] Hall present, Staff Q stated that they knew which residents were at risk for elopement by checking in the [NAME] (abbreviated instructions from the care plan) and we also have alarms on the doors. Staff G stated, There's a binder. Staff T answered, Don't we have wrist bands? The Nursing Assistants then brought out two Elopement Books from the [NAME] Hall. The black Elopement Book had a photo of a female resident. Review of the neon green Elopement Book showed the same photo of the female resident and a male resident. In an interview on 10/30/2024 around 12:55 PM, Staff C, Assistant Director of Nursing, confirmed that the female resident had recently passed and the male resident had recently discharged . Neither binder included resident information on Residents 7 and 25, as instructed by the care plan. The above information was shared with Staff A, Administrator, on 10/30/2024 at 9:02 AM. Staff A stated that an Elopement Book is used to help the staff, understand who is at risk for elopement and if we do have a missing resident, it's a reference for when we make the call to 911. Staff A stated that not including a resident who is at risk for elopement in the Elopement Book, could make it less likely for staff to be aware of the elopement. The above information was shared in a joint interview with Staff B, Director of Nursing, and Staff U, Corporate Nurse, on 10/30/2024 at 1:38 PM. Staff B acknowledged the inconsistencies between the Elopement Risk Evaluations, care plan instructions, and information in the Elopement Books. Staff U stated, We need to update it. <SMOKING> Review of an 11/30/2023 facility policy titled, Area of Focus: Smoking vs [versus] Non-Smoking documented that smoking was not allowed, at any time, inside or outside the building or on the facility property. <Resident 24> An admission assessment dated [DATE] documented Resident 24 had diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause inflammation and difficult breathing) and stroke with paralysis of one upper extremity. Resident 24 was cognitively intact and used tobacco. The 08/12/2024 comprehensive care plan documented Resident 24 was a smoker. Staff were instructed to complete a smoking safety evaluation, provide the resident education on the facility non-smoking policy, instruct the resident on the hazards of smoking and smoking cessation aids that were available, and notify the charge nurse immediately if it is suspected the resident has violated the facility smoking policy. The 08/13/2024 and 09/15/2024 Smoking Safety Evaluations documented Resident 24 was able to appropriately use an ashtray, had demonstrated the ability to safely smoke with supervision and was compliant with the smoking regulations in the facility. On 10/22/2024 at 10:21 AM, Resident 24 was observed in their wheelchair in their room. Resident 24 had a pressure reducing boot on their left foot, their left hand rested in their lap and the resident was unable to move it purposefully. The resident used their right foot to scoot and position their wheelchair. A strong odor of cigarettes could be smelled when standing next to Resident 24. Resident 24 stated when they smoked, they left the facility property because smoking was not allowed on the facility property. Staff did not accompany them. The resident stated they did not have smoking materials; a friend that lived close by met them outside and brought cigarettes and a lighter to them. Resident 24 stated the staff had educated them about the smoking policy. On 10/24/2024 at 3:37 PM, Resident 24 was observed scooting down the hall towards the exit. Resident 24 was met at the exit by Resident 41, and they exited the building, and scooted their wheelchairs directly behind the facility transport van next to the bumper. The van was parked directly outside the exit in the driveway. Resident 41 handed Resident 24 a lighter and cigarette, which Resident 24 lit with their right hand and handed the lighter back to Resident 41. Resident 24 took several long puffs off the cigarette and was observed flicking ashes on to the driveway where they landed on the ground just behind the tailpipe area of the van. Resident 24 extinguished their cigarette when it was half gone, but had their back to the facility entrance, so was unable to see where the cigarette was extinguished. There was no cigarette receptacle next to the resident. Resident 24 handed the half-smoked cigarette back to Resident 41, who put it in their front shirt pocket. Resident 24 went back in the facility and Resident 41 stayed in the driveway and continued to smoke. There were no staff present during the observation. Resident 24 was also observed smoking in the same area on 10/29/2024 at 8:10 AM. There were no staff present, and the resident did not put their cigarette butt in the receptacle by the entrance. During an interview on 10/30/2024 at 1:36 PM, Staff M, Resident Care Manager, stated the facility was a non-smoking facility. Residents were offered smoking cessation aids when they were admitted and a safety evaluation was completed. Staff M stated they assumed someone watched Resident 24 smoke to see if they were safe when smoking. Staff did not accompany residents when they left the facility to smoke. Staff M was unaware Resident 24 smoked in the driveway behind the facility van and was unaware they got their cigarettes from Resident 41. Staff M stated there was no designated smoking area on the property; they were unsure how to honor the resident's preference to smoke without violating the facility policy. <Resident 41> Review of a 09/03/2024 quarterly assessment showed Resident 41 admitted to the facility on [DATE] with medically complex conditions, to include a stroke with one sided paralysis or weakness, and an amputation of the left leg above the knee. This assessment showed the resident was homeless, cognitively intact, had limitation in their range of motion to both upper and lower extremities, used a wheelchair independently, and required supervision or touching assistance for transfers. The assessment showed Resident 41 was dependent on nicotine. In an interview on 10/22/2024 at 12:33 PM, Resident 41 stated that they, can't get back [in the building] in the middle of the night when they go outside to smoke. Resident 41 stated that they got cigarettes and in my pocket and nobody holds it for me, and I smoke on the sidewalk. Resident 41 stated that there was another door they used to access entry to the facility after hours with a code and, Am not supposed to. I knock on the door, and they have to stop and come and get me in. Some guy gave me the code to get back in. An observation on 10/22/2024 at 1:33 PM showed Resident 41 in his room sitting in their wheelchair, with a cigarette lighter in their shirt pocket. Resident 41 stated that they liked to go out and smoke after meals and at bedtime. An observation on 10/25/2024 at 4:05 PM showed Resident 41 outside of the facility in a wheelchair on the sidewalk. The resident leaned over and looked like he picked up something off the sidewalk, then wheeled themselves on to the main road around a black SUV. Cars were observed going around the resident and the SUV. Resident 41 was on the driver's side of the parked SUV. Resident 41 again leaned over a few times as if picking up something off the pavement. An observation on 10/29/2024 at 8:05 AM showed Resident 41 in his wheelchair and on the main road, going past a bulldozer parked next to the sidewalk. There was construction in progress next to the facility with heavy equipment. Traffic was observed going both ways on the road. Resident 41 wheeled himself on the edge of the facility entry way, faced the facility parking lot, and started smoking. Resident 41 put out his cigarette on the wheel of the wheelchair, licked the cigarette, then placed the cigarette in his shirt pocket. Observation and record review on 10/29/2024 at 12:33 PM at the receptionist area showed a binder with alphabetically listed forms titled, Release of Responsibility for Leave of Absence. Record review showed Resident 41 last signed out of the facility on 7/8 at 1PM. This record showed Resident 41 signed out a total of 13 times between 06/21/2024 and 07/08/2024. Review showed no documentation the resident signed back in to the facility. In an interview on 10/29/2024 at 2:04 PM, Staff F, Receptionist, stated that they observed Resident 41 and 2 other male residents, usually go out [to smoke] on the side walk throughout the day. Review of a 09/04/2024 Smoking Safety Evaluation showed the nurse answered Yes to Is resident non-compliant with smoking regulations in the facility? The Summary of Findings showed the nurse answered Yes to Resident has demonstrated ability to safely smoke with supervision. Additionally, the nurse was instructed to answer Yes to Resident exhibits poor safety awareness when smoking and interventions must be put in place to promote smoking safety but the nurse answered No. Under Smoking Cessation the nurse answered, Undecided at this time. In an interview on 10/29/2024 at 1:30 PM, when asked to clarify if Resident 41 required supervision while smoking and was noncompliant with smoking regulations in the facility, Staff C stated, This is not my favorite assessment. The interpretation of what they're asking could be different between nurses. Review of a 10/24/2024 Risks and Benefits forms showed the facility offered Resident 41 a smoking cessation program with identified health benefits and risks contingent on choice. This form was signed by both the resident and a facility staff. Review of a 05/30/2024 care plan showed, Resident is a smoker. The care plan showed no instruction on where Resident 41's smoking materials would be safely stored, or the level of supervision Resident 41 required during smoking. The care plan instructed the staff to, Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. The care plan showed no instruction to the staff on when Resident 41 would go outside to smoke or to encourage the use of the Sign In/Sign out book to account for Resident 41's whereabouts when they left the building to smoke. In an interview on 10/29/2024 at 12:10 PM, Staff G confirmed that Resident 41 smoked. When asked what interventions were in place to ensure safe smoking Staff G stated, I don't know. I know they have to be off premises 'cause it's a non-smoking facility. Staff G stated that Resident 41 had to let staff know when they are going outside to smoke but was unsure if the resident told others when they went outside. Staff G stated that Resident 41 went to smoke outside, all day. Different times, as soon as the door opens, with time outside of the facility between 20 to 30 minutes at a time. When asked where Resident 41 kept their smoking supplies, like the cigarettes or a lighter, Staff G said, I have no idea. I believe it's with the nurses I've never seen them with it, and that they did not know if the resident shared smoking materials with other residents. In an interview on 10/29/2024 at 12:28 PM, Staff V, Registered Nurse, assigned to the [NAME] Hall where Resident 41 resided stated, None of my residents smoke right now. In a joint interview on 10/29/2024 at 12:49 PM, with Staff C and Staff D, Registered Nurse/Resident Care Manager, Staff D stated that they educated the resident about the dangers of smoking in general and offered smoking cessation assistance after a recent fall Resident 41 experienced outside. Staff D stated that Resident 41 does not want to quit smoking and, doesn't want to stop going outside to smoke. Staff D was asked if they knew where Resident 41 kept their smoking supplies and stated, I don't know that [the resident] has any personal smoking belongings. Staff D stated a Risks and Benefits form was completed with Resident 41 because the resident, goes out there to smoke. Staff D stated that Resident 41 told them they did not smoke that much and did not ask Resident 41 where the cigarettes and a lighter were obtained from and kept. Staff D stated that as long as Resident 41 signs out of the facility, they can go outside. During after hours, Staff D described how Resident 41 would go to the employee access door at the East Nurses station, even though [the resident] is not supposed to go there, and knock on the door and staff will let [them] in. On 10/29/2024 at 1:32 PM, Staff C stated that Resident 41 did not have access to money and might be getting their cigarettes by, maybe bumming from construction workers. I never witnessed it, just a theory. In the joint interview, Staff D stated, I don't know, when asked where Resident 41 obtained cigarettes from. Staff D acknowledged the care plan did not reflect Resident 41's current smoking patterns, the level of supervision required, or instructions on how to keep smoking materials in safe keeping when not in use. The above information was shared with Staff B on 10/29/2024 at 2:41 PM. No further information was provided. <FALLS> Review of a 12/04/2023 facility policy titled Fall Management, showed the facility would promote resident safety and reduce falls by proactively identifying, care planning, and monitoring a resident's fall indicators. The policy showed that with each fall event or change in condition, it would identify appropriate interventions to minimize the risk of injury related to falls, and update the care plan, if indicated, upon a fall event and as needed thereafter. Review of progress notes showed the staff identified Resident 41 had poor balance and transferred self independently, despite reminders by staff to use the call light for assistance (05/31/2024, 06/01/2024, 06/01/2024, 06/02/2024, 06/02/2024, and 06/23/2024). Review of a 05/30/2024 Fall Risk Evaluation showed Resident 41 required assistance with toileting needs, was not able to attempt a balance test without physical help and had 3 or more health conditions and one to two medications that contributed to risk for falls. This evaluation showed a score of 18 and that for a score of 10 or above, interventions should be initiated by the staff. Review of the care plan showed Resident 41 required supervision for transfers, was independent with wheelchair locomotion, and was at risk for falls due to above knee amputation, left arm paralysis, incontinence and medication use. The interventions to prevent falls were dated 06/06/2024. The interventions instructed the staff to anticipate and meet the resident's needs, assist with Activities of Daily Living as needed, keep the call light within reach, complete a fall risk assessment, provide adaptive equipment or devices as needed, and refer to therapy to evaluate and treat as ordered or as needed. Review of a 09/05/2024 progress note showed that Resident 41, was found outside of facility laying on the ground next to a bush. The facility was alerted of the resident's fall when a bystander told a Nursing Assistant who was outside at the time that someone was on the ground outside of the facility. The note showed the resident told the staff that they were wheeling backwards in their wheelchair and had toppled over landing on the ground. Review of a 09/05/2024 Fall Risk Evaluation showed a score of 12. The evaluation instructed the staff to initiate interventions for a score of 10 or above. Review of a facility 09/07/2024 Incident Report (IR) associated with the 09/05/2024 fall, showed Resident 41 told the staff that they were attempting to move onto the sidewalk and their wheelchair got caught and fell out of the wheelchair. The IR showed the staff identified Resident 41 often went outside and self-propelled in their wheelchair in the parking lot and sidewalks around the building. The IR showed the facility completed education with Resident 41 and the resident, continues to state, 'I don't care if I get hurt'. The IR concluded Resident 41 often refused to abide by medical recommendations and has no safety awareness and very impulsive. The IR showed the facility reviewed the care plan and encouraged the staff to round frequently and monitor the resident's location. Review of the care plan interventions showed no change or addition to prevent fall recurrence after the 06/06/2024 interventions. Record review showed no documentation the facility referred Resident 41 to therapy services to help ascertain why the resident chose to wheel themselves backwards and if the resident was cleared for safe navigation on uneven terrain. The care plan showed no direction to the staff on how to compensate for the resident's poor safety awareness and impulsivity they identified since 05/31/2024, how to anticipate their needs, or what round frequently should look like to the staff. Review of a 10/20/2024 progress note showed Resident 41 fell out of their wheelchair. Review of a 10/21/2024 associated IR showed the resident fell during the morning hours outside the facility and with no injury. The IR showed that someone driving by let staff know the resident was outside on the cement. Resident 41 told the staff that while they were going up the facility ramp backwards in their wheelchair, the bottom of the ramp caught the wheelchair tire and flipped over the resident, dumping them on their back. The IR showed that the staff identified Resident 41, knows how to get outside . encouraged not to go out the ramp way, but still does. This IR showed the resident was seen at a grocery store half a mile away shortly after they ate their breakfast. The IR showed no conclusion to the investigation or changes to prevent recurrence of falls and associated injury, whether the facility referred the resident to therapy to assess safe wheelchair mobility on out of facility terrain, ascertain why the resident chose to continued to wheel themselves backwards, or how the facility compensated for the resident's poor safety awareness and impulsivity to prevent fall recurrence. Review of a 10/20/2024 Fall Risk Evaluation showed a score of 14. The evaluation instructed the staff to initiate interventions for a score of 10 or above. Review of the care plan interventions showed no change or addition to prevent fall recurrence after 06/06/2024. Review of Occupational and Physical Therapy Discharge Summaries dated 06/07/2024 showed no documentation therapy services assessed and cleared Resident 41 for safe navigation on out of facility or uneven terrain, like the sidewalk or propelling self via wheel hair half a mile to the grocery store, or identified and addressed why Resident 41 would wheel themselves backwards when outside of the facility. In an interview on 10/29/2024 at 2:02 PM, Staff W, Therapist, stated that Resident 41 was not receiving therapy services and, hasn't been on therapy for quite a while. I don't know if there's anyone here who knows [the resident] really well. Review of a 10/20/2024 progress note showed the staff were aware Resident 41 continued to go outside of the facility multiple times a day. The above findings were shared with Staff B on 10/29/2024 at 2:25 PM. Staff B stated Resident 41 started going outside shortly after their admission to the facility. Staff B stated that both of Resident 41's falls were related to the resident hitting something when propelling backwards in their wheelchair outside and the reason the resident propelled backwards in the wheelchair is because they, only got one leg so it's easier to navigate backwards with the one leg. Staff B stated that Resident 41 was referred to therapy services verbally but showed no documentation the facility followed through to ensure closure with the referral, to include recommendations to prevent fall recurrence or their associated injuries. Staff B was asked if the care plan was updated with interventions to prevent fall recurrence as instructed by the Fall Risk Evaluations and stated, I felt all the interventions were already there. Reference WAC 388-97-1060 (3)(g). .

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 medications were disposed of timely, in accordance with currently accepted professional standards, in 2 of 2 medication carts, and needles and lab supplies were securely stored that were in a bistro. The facility failed to maintain temperatures to ensure medications were properly stored in 2 of 2 medication storage rooms. The facility further failed to ensure anti-anxiety medications were stored behind two locks as required and nursing staff were signing the narcotic logs verifying all medications were accounted for at shift change. This failure placed residents at risk for receiving compromised or ineffective medication, placed the facility at risk for potential diversion or misappropriation of psychotropic medications and potential for needlestick injuries. Findings included . On 10/22/2024 at 10:34 AM, an observation was made of a room called The Bistro. The room contained a kitchenette and had multiple cabinets and drawers. The lower unlocked cabinet contained two bottles of red liquid that was used to transport stool samples to assess for pathogens and the bottles were not sealed. The unlocked top drawer contained 8 intravenous (by vein) needles. A lower unlocked cabinet contained sanitizing wipes that stated to keep out of reach of children. There were 2 bottles of a solution that was used to fit test staff for a respirator (a mask) sitting on a stand. There were no residents wandering around the area. During an interview on 10/22/2024 at 11:26 AM, Staff B, Director of Nursing, stated The Bistro was used for family visits, staff breaks, interviews and corporate visits. Staff B stated the lab supplies were stored in that room for quick and easy access by the staff. In an interview at 11:44 AM, Staff B was asked if they were aware there were unsecured needles stored in the drawer and they stated yes. Staff B acknowledged this could be a potential for injury and stated the supplies should be locked up for resident safety. Staff B stated they were unaware there were vials that contained liquid in them. Staff B added the vials, fit testing solution and sanitizing wipes should have been locked up. Staff B stated they were going to remove the items to a locked room. On 10/30/2024 at 10:10 AM, the medication room on the east unit was observed with Staff I, Registered Nurse. The refrigerator contained 2 vials of hepatitis vaccine, 11 vials of influenza vaccine, and 1 vial of covid vaccine which must be stored between 35-46 degrees Fahrenheit. The temperature logs for October 2024 were sitting on the counter and had multiple omissions. In an interview on 10/30/2024 at 10:11 AM, Staff I stated the refrigerator temperatures needed to be monitored because if the vaccines were not in the correct temperature range it would impact the vaccines effectiveness. The unlocked refrigerator contained 2 vials of house stock Ativan (a medication used to treat anxiety) that were contained in an unlocked black box, not behind two locks as required. The only lock was the door leading into the medication room. In an interview on 10/30/2024 at 10:18 AM, Staff I stated they were aware the Ativan needed to be stored behind 2 locks, and this was important to prevent someone from taking the medication. During an interview on 10/30/2024 at 10:24 AM, Staff B stated the refrigerator temperatures needed to be monitored to ensure the viability of the vaccines, and the Ativan needed to be locked behind two locks for security. On 10/30/2024 at 10:31 AM, the medication room on the west unit was observed with Staff B, Director of Nursing. The refrigerator contained 20 vials of influenza vaccines and 3 vials of pneumonia vaccines. The temperature logs for October 2024 were sitting on the counter and had multiple omissions. On 10/30/2024 at 10:37 AM, the west medication cart 3 was observed with Staff J, Licensed Practical Nurse. There was an insulin pen dated 09/04/2024, that was not discarded after 28 days as required, two insulin pens and an Ozempic pen that had no date that had been used, and a bottle of allergy nasal spray that had expired 12/2023. Staff J stated the medication needed to be discarded because it may not be effective after the required timeframe. Review of the narcotic books on west cart 3 showed the nursing staff was not consistently signing at the change of each shift, which verified the narcotic count was accurate. In an interview on 10/30/2024 at 10:50 AM, Staff J stated it was important to count the narcotics to ensure the count was accurate and who was accountable. On 10/30/2024 at 10:59 AM, the west medication cart 1 was observed with Staff K, Registered Nurse. There was an inhaler used for asthma that expired on 04/2024, sodium chloride tablets that expired on 08/2024, calcium tablets that expired on 09/2024, an insulin pen dated 08/25/2024, an insulin pen dated 09/21/2024, an insulin pen dated 09/28/2024, and four insulin pens with no date that had been used. Review of the narcotic books on west cart 1 showed the nursing staff was not consistently signing at the change of each shift. In an interview on 10/30/2024 at 10:59 AM, Staff K stated the narcotic books needed to be signed every shift to ensure that the count was accurate, and drug diversion had not occurred. During an interview on 10/30/2024 at 11:24 AM, Staff B stated the narcotic books needed to be signed to verify who was on shift and who was responsible. Staff B added it was important that insulin and expired medications not be used outside of the required timeframe to ensure the viability of the medication. 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 and interview, the facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service. This failure placed the residents at risk for foodborne illness. Findings included . A 04/30/2024 facility policy titled Associate Conduct and Dress Code showed hair and beard coverings were used when cooking, preparing or assembling food, but not required when distributing foods to the residents at the dining tables or when assisting the residents to dine. An observation on 10/22/2024 at 8:08 AM showed Staff Z, a Dietary Aide, participated in the breakfast tray line. Staff Z had visible facial hair and no beard covering. An observation on 10/25/2024 from 11:30 AM to 11:53 AM showed Staff Y, a Cook, standing in front of the food prep counter. The kitchen staff were getting ready to start lunch tray line. Staff Y wore a pink bandana. About three inches of hair was observed flowing down Staff Y's forehead. The bandana failed to contain Staff Y's hair, with visible hair observed coming out of the bandana around the sides and the back of Staff Y's head. At 11:42 AM, Staff Y stood next to the food prep counter, hands were gloved. Staff Y moved towards the garbage can where they threw in a small indiscernible object, then wiped the right side of their head with their gloves, took a paper napkin and wiped off their gloves, then adjusted their shirt. Staff Y took the temperature of food items on the steamer table with the same gloves on. Staff Y then removed their gloves and tossed them in the garbage can, walked over to the sink where they washed their hands for seven seconds, wiped their hands with a paper towel, and with the same paper towel proceeded to wipe down the steamer table where food items were kept hot for the upcoming lunch. Staff Y then crunched the paper towel into a ball with their left hand and threw it in the garbage can. The above information was shared with Staff X, Dietary Manager, on 10/25/2024 at 12:30 PM. Staff X stated that the kitchen staff was required to always wear head and beard coverings, no matter what they're doing. Someone can be prepping food, and hair can come drifting over. Staff X stated, You gotta' wash your hands and change your gloves. Staff X stated that Staff Y should, wash [their] hands completely 30 seconds at least. Staff X stated that Staff Y should have thrown the paper towel in the garbage can after they dried their hands instead of using it to wipe down the steamer table. An observation on 10/28/2024 at 11:47 AM showed Staff Y with a hairnet. The hair net was placed above the ears exposing Staff Y's hair below the hair net line, with anywhere from one to four inches of hair hanging out, to include a tuft of hair hanging down the staff's forehead. Reference WAC 388-97-1100 (3), -2980. .

Jul 2024 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for accidents, was transferredas directed by the careplan. Resident 1 experienced harm when they were found to have a fractured arm and clavicle the next shift after being assisted to the floor when the wrong transfer method was used. This failure placed the residents at risk for falls and serious injury. Findings included . Review of the facility assessment, dated 05/02/2024, showed Resident 1 had diagnoses to include a stroke which affected their right side, and had difficulty with speech. The resident was alert and oriented. Resident 1 required substantial/maximal assist with transfers. The residents care plan, dated 12/09/2019 and revision date 07/05/2024, showed the resident required two staff to stand and pivot the resident with a gait belt, and/or use a sit to stand lift (designed to assist patients who have some mobility but need help to rise from a sitting position). In an interview and Observation on 07/18/2024 at 10:37 AM, Resident 1 was seated in a wheelchair in their room. The resident had a brace on their right arm. The resident was asked if they fell and they stated yes. When asked about the incident, the resident was not able to explain what happened. Review of the facility investigation, dated 07/03/2024, showed Staff A explained the resident asked to be transferred from their bed to the wheelchair. Staff A placed a gait belt around the resident and started to lift them. The resident's legs gave out and Staff A stated they assisted them to the floor. Staff A was questioned further during the investigation and stated the resident's wheelchair brake had been on but during the transfer, the brake extender was pushed while the resident was assisted to the floor, the wheelchair slid back, and the resident landed on the floor. At the time of the incident, the resident had no pain or abnormalities. Later in the day, the resident complained of pain and an x-ray showed a fractured right arm and clavicle. During an interview on 07/18/2024 at 12:45 PM, Staff B, Registered Nurse (RN), stated they had been told by Staff A that Resident 1 was assisted to the floor during a transfer. Staff B stated they completed an assessment on Resident 1 and they had no complaints of pain or signs of injury. On the following shift, the resident started to complain of pain and an x-ray showed a fractured arm and clavicle. Staff B stated they asked Staff A if they had reviewed the resident's [NAME] ( informational filing system that is used as a quick reference for nurses and nursing assistants ) ,which showed the resident transferred with two staff, and Staff A stated they hadn't. During an interview on 07/18/2024 at 1:35 PM, Staff C, Director of Nursing, acknowledged Staff A had not followed Resident 1's care plan and the resident had sustained a fractured arm and clavicle. Reference: WAC 388-97-1060(3)(g)

Jun 2024 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 8 out of 9 residents (Resident 1, 2, 3, 4, 5, 6, 8, and 9) related to not honoring residents food choices and not following resident meal cards (cards that show likes, dislikes, allergies, and fluids to be served). Failure to promptly resolve grievances resulted in on-going dietary complaints from residents and a diminished quality of life. Findings included . <Resident interviews> On 05/29/2024 at 1:00 PM, Resident 1 stated they attended the food committee monthly and residents had been told they don't fill out menus correctly and that was why they didn't get the food they ordered. Resident 1 stated they were served food they hadn't circled on the menu and was often served their dislikes. The resident stated kitchen management told the committee changes would be made and it didn't happen. On 05/29/2024 at 1:14 PM, Resident 8 stated the food wasn't good. The resident stated it didn't matter what was filled out on the menu, the kitchen didn't serve it and would argue with you. Resident 8 went to the food committee meetings and they were told how the menu should be filled out and it would be correct going forward, it didn't get fixed. Resident 8 stated the committee had a meeting with Staff D, Administrator. The kitchen doesn't go off [Resident] preferences. Nothing is getting done. Resident 8 stated they resorted to buying their own food. On 06/12/2024 at 10:25 AM, Resident 4 stated the taste of the food had gotten better. The resident stated they didn't fill out a menu and was just served the meal for the day. Resident 4 stated if they rejected the food served, staff would get rude. Resident 4 stated they would become ill if they ate cucumbers and on a couple of occasions received them. I just pick them out of the food. The resident's food card was on their bedside table and reviewed. Under allergies it had cucumbers. On 06/12/2024 at 11:30 AM, Resident 6 stated they ate soft food because they had no top teeth. Most meals are terrible. Resident 6 stated they would fill out a menu sometimes but the kitchen didn't go by what they wrote down. On 06/12/2024 at 12:35 PM, Resident 9 was laying in bed eating a packaged protein bar. Resident 9 stated the food had too many carbohydrates and not enough protein, so they ate the food they bought. Resident 9 stated the facility had menus you filled out but you don't always get the items you circled. On 06/12/2024 at 1:25 PM, Resident 5 was in their room in a wheel chair. Resident 5 stated they went to the food committee monthly but the suggestions the residents made didn't happen or if it did happen it took forever. Resident 5 received menus and they would chose their meal but you don't get it. Resident 5 stated they were told the cooks didn't read the menus. On 06/12/2024 at 12:10 PM, Resident 3 was in their wheel chair in their room. Resident 3 stated the items they circled on the menu was not served. Resident 3 stated they required protein drinks and they were to be served from the kitchen for two of their meals. Resident 3 stated they maybe got it once a week. When Resident 3 asked the kitchen staff, they told the resident it was back ordered. At 12:25 PM, Resident 3 had been served their meal. The resident's meal card had sugar free health shake and ice tea under liquids, neither were on the tray. <Resident Grievances> Review of the facility grievances showed the following grievances related to food: On 04/05/2024 an anonymous reporter wrote a concern the residents were not getting the food they requested from their menu. The reporter felt the kitchen was not reading the menus and many residents felt the same as them. The response by Staff E, Dietary Manager, was residents that had orders for easy to chew food couldn't get salads. Staff E had educated cooks to talk with residents to find out what foods they wanted. On 04/30/2024 Resident 2 reported they did not get the items they had ordered. Resident 2 wrote it was an ongoing issue, not getting what they ordered, and when the resident called the kitchen, they would get the food after their tray had sat and was cold. The written response to the grievance, by Staff E, was staff were educated to pay more attention to the meal tickets. On 05/07/2024 during resident council, Staff F, Activities Director, had filled out a grievance that stated residents were frustrated that topics discussed in food committee did not result in any resolution. Staff D wrote under investigation steps things were not fixed, residents and staff were still confused about filling out menus. The response was to educate staff to pay attention to everyone's tickets. <Food Committee> The following were notes from the food committee: On 03/05/2024, only those that attended the meeting was documented. On 04/09/2024, less eggs was written. On 05/8/2024, residents were concerned with menus and wanted to know why residents needed to write their dislikes on the menu when the kitchen had that information. In addition, residents had issues with not getting food items they ordered. Staff E documented it was explained to residents cooks don't have time to look everyone's dislikes up, when residents ordered specialized food, and it would be helpful for residents to write their dislikes on the menu. During an interview on 06/12/2024 at 1:44 PM, Staff E stated when a resident admitted to the facility, activities staff asked resident likes/dislikes. Staff E stated residents would fill out a menu each week. If a resident didn't fill one out, the cooks would go off their likes/dislikes list for that meal. Staff E stated the process to serve food was for the kitchen aides to call off the residents diet, which was on a meal card, and the cook would plate the food. Staff E stated there was a food committee that met monthly. In March and April Staff E was not able to attend and their assistant was not very detailed on the notes. Residents had concerns related to the menu process. Residents didn't understand if an item was ordered that wasn't on the menu, such as chef salad, the resident needed to write on the menu what they didn't like and that item would be left off. Staff E stated the cooks shouldn't have to search for each residents dislikes. Staff E stated the cooks were more familiar with residents food allergies rather than resident dislikes. For Resident 4, being served food they were allergic to, it was looked into because it happened on two different occasions. They found the resident was served the wrong meal tray and that was why the food they were allergic to was on it. During an interview on 06/12/2024 at 2:24 PM, Staff E, Activities Director (AD), stated they attended the resident council meetings and the food committee, which was immediately after. Staff E stated if there was a concern brought up, they would fill out grievance cards and give them to Social Services. Staff E stated the residents don't feel the food issue had been resolved. The residents had concerns with not getting what they wanted and the kitchen not paying attention to their dislikes. On 06/12/2024 at 3:00 PM, Staff D stated they had been brought into the food committee in May. The residents were frustrated about the menus and filling them out. Residents felt the staff were not reading their meal cards. Staff D confirmed the food concerns had not been resolved. Reference: WAC 388-97-0460

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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Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse and/or neglect for 4 of 6 residents (Resident 4, 5, 6, and 7), reviewed for abuse and/or neglect. This failure placed residents at risk for further abuse and/or neglect and a diminished quality of life. Findings included . <Resident 4> According to the facility assessment, dated 06/03/2024, Resident 4 had diagnoses to include heart disease. Resident 4 was able to make their needs known. On 06/12/2024 at 10:25 AM, Resident 4 was sitting in a wheel chair in their room. The resident was asked if they had any concerns with staff and replied not that they could recall. Resident 4 stated if they did, it was probably one of the agency people that worked weekends, because they didn't know the residents very well. Review of the facility grievance log showed Resident 4 had filed a nursing concern on 05/14/2024. Review of the grievance form, dated 05/14/2024, showed Resident 4 had a concern about Staff A, Licensed Practical Nurse (LPN), who was rough and rude to them. Under Facility investigation and response Staff B, Director of Nursing (DNS) documented they spoke with the resident, abuse/neglect was ruled out, and education was done. There was no documentation to show a thorough investigation had been done to include resident and staff interviews and how it was concluded abuse/neglect was ruled out. <Resident 5> According to the facility assessment, dated 05/22/2024, Resident 5 had diagnoses to include Diabetes and paraplegia (unable to move the lower extremities). Resident 5 was able to make their needs known. During an interview on 06/12/2024 at 1:35 PM, Resident 5 was in their room sitting in a wheel chair. Resident 5 stated they had filled out a grievance card about two different nurses at the facility. Resident 5 stated one was rude and the other made them feel hesitant to ask for medication because of how they treated them. Resident 5 stated another grievance they filled out had to do with not getting out of bed for three days. The resident stated a staff member told them they didn't have time to get them up and some staff stated they didn't know how to work the Hoyer lift (mechanical lift used to transfer the resident). Review of the facility grievance log showed Resident 5 had filed a nursing concern on 03/26/2024 and 03/29/2024. Review of the grievance dated 03/26/2024 showed Resident 5 wrote the resident was told they couldn't get out of bed for three days because staff did not have time. Under Facility investigation and response Staff B wrote they spoke to Resident 5 about the concerns. The action was to educate staff and adjust staffing on the weekends. The grievance dated 03/29/2024 showed Resident 5 filed a grievance about a staff member who was rude and when Resident 5 filled out a blue card (the facility's grievance form) the staff member was confrontational with them. There was no documentation to show the allegations of abuse and/or neglect had been thoroughly investigated, to include resident and staff interviews. <Resident 6> According to the facility assessment, dated 03/29/2024, Resident 6 had diagnoses to include respiratory disease. Resident 6 was able to make their needs known. On 06/12/2024 at 11:30 AM, Resident 6 was observed sitting in a recliner in their room. Resident 6 stated they had written up care givers three different times. Resident 6 stated the facility did not have enough staff and one time they filled out a card because they couldn't find any staff to help them when they were sick and throwing up. Resident 6 stated they didn't get follow up after filling out the cards. Review of the facility grievance log showed on 04/12/2024 Resident 6 had filed concerns about nursing. Review of the grievance, dated 04/12/2024, showed Resident 6 reported there wasn't any aides or nurses to be found on their side of the building. The resident ended up finding one aide that told them they were new and couldn't handle everyone. The staff member assisting the resident to fill out the card wrote they tried looking for an aide or nurse and couldn't find them either. The staff member was not able to do direct care. Under Facility investigation and Response Staff B wrote they spoke with staff. Staffing was good, nurses were doing medication pass, and the nursing assistants were providing care. There was no documentation to show a thorough investigation had been done to include resident and staff interviews, and a conclusion if abuse and/or neglect had been ruled out. <Resident 7> According to the facility assessment, dated 03/28/2024, Resident 7 had a disease of the central nervous system. Resident 7 was able to make their needs known. During an interview on 05/29/2024 at 12:30 PM, Resident 7 was sitting in their wheel chair at the side of their bed. Resident 7 stated some care was good, some bad. Resident 7 stated staff had some trouble knowing who took care of what. Review of the facility grievance form showed Resident 7 filed a grievance on 04/12/2024. Review of the grievance, dated 04/12/2024, showed Resident 7 was upset because there was only one nursing assistant in the hallway and their call light had been on for 50 minutes. A staff member helped Resident 7 fill out the card and the resident told them they didn't think they had a nursing aide or nurse assigned to them. The staff member who helped fill it out the grievance wrote they could only find one aide on the floor at the time of the incident. Under Facility investigation and Response Staff B wrote they spoke with staff and staffing was good, nurses were doing medication pass, and nursing aides were caring for residents. There was no documentation to show a thorough investigation had been done to include resident and staff interviews, and a conclusion if abuse and/or neglect had been ruled out. During an interview on 05/29/2024 at 12:53 PM, Staff C, Social Services Director (SSD), stated when a grievance came in for nursing, they would log it and give it to nursing. Nursing would then address the concern, the Administrator would sign off, and a copy would be placed in the grievance book. On 06/12/2024 at 2:37 PM, Staff G, Resident Care Manager, stated if a grievance came in for nursing, social services would bring it to them and it would be discussed in the morning meeting. The issue would be looked into and determined how to handle the concern. Staff D stated if they received a grievance about concerns related to a staff member being rude or rough, they would talk to the nurse and resident, and then the DNS would come and take care of it from there. On 06/12/2024 at 3:00 PM, Staff D, Administrator and Staff B were interviewed. They stated when a resident had a grievance, they would fill out a blue card, or a staff member could assist them if needed. The card would be given to Social Services, there was also a drop box in the hall they could put it in, or sometimes it would be slipped under their door. It was logged and then looked at to determine what department it would go to. If it was a nursing issue, it would go to staff B. If it was an allegation of abuse and/or neglect then the process would be followed which would be to log it in the state log, call it to the State Survey Agency, and conduct an investigation to rule out abuse and/or neglect. Staff B confirmed the grievances above were not investigated as allegations of abuse and/or neglect. Reference WAC: 388-97-0640 (6)(a)(b)

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to consistently monitor and documented condition changes for 1 of 3 residents (Resident 1), reviewed for change in condition. This failure placed residents at risk for worsening medical conditions and unmet care needs. Findings included . Review of a facility assessment, dated 11/29/2023, showed Resident 1 had diagnoses which included heart and lung disease, difficulty swallowing, and dementia. Resident 1 had difficulty making their needs known and required extensive assistance with Activities of Daily Living (ADL's). Review of a facility document titled Alert Charting Guidelines showed residents with a change in condition were to be charted on every shift until the condition resolved, the resident was sent out, or the resident returned to their baseline (their medical condition prior to having a change). Review of a progress note by Staff A, Physician Assistant (PA), dated 01/10/2024, showed staff had asked Staff A to assess Resident 1 for a decline in their condition. Review of nursing progress notes from 01/09/2024 through 01/13/2024 showed the only documentation which showed the resident had a decline or change in condition was on 01/13/2024. Staff documented the resident was sent to the hospital related to a decrease in their level of consciousness (alertness), was unable to drink, eat, or take medication without effort, and had an increased effort to breath. Review of Speech Therapy (ST) notes, dated 01/10/2024 by Staff B, ST, showed the resident needed total assistance with their diet. Resident 1 coughed during the meal and staff had to wake the resident in order to eat. On 01/12/2024 Staff B documented the resident was in their wheel chair, in the dining room, with their eyes closed. Resident 1 would open their mouth only when instructed to do so. Hospital records were reviewed dated 01/13/2024. The records showed Resident 1 presented to the hospital after several days of a decrease in the resident's level of consciousness and a fever while at the facility. There was a concern for sepsis (an infection in the blood). The resident was diagnosed with aspiration pneumonia (when liquid was breathed into the lungs instead of swallowed) in both lungs. During an interview on 02/06/2024 at 10:36 AM, Staff C, Licensed Practical Nurse (LP), stated if a resident had a change in condition, the physician would be notified along with the Director of Nursing (DNS) and Residential Care Manager (RCM). The resident would then be placed on alert charting. When Staff C was asked about Resident 1, they stated they had not taken care of Resident 1 prior to going to the hospital but the resident had been eating less and coughed when they drank liquids. During an interview on 02/06/2024 at 10:40 AM, Staff D, RCM was asked what the process was when a resident had a change in condition. Staff D stated the nurse would assess the resident, report to the RCM who would also evaluate the resident. The provider was to be notified and the resident was placed on alert charting. Staff D was hired after Resident 1 discharged to the hospital. Staff D stated the expectation when a resident was on alert charting was to write a progress note at least every day, if not each shift, which depended on what they were being monitored for. Staff D showed a binder for alert charring that would identify who was needing to be monitored. Staff D was not able to find the page that showed Resident 1 on alert prior to being sent to the hospital. During an interview on 02/06/2024 at 11:00 AM, Staff E, DNS, stated residents on alert charting would have their names placed in a book. Daily charting was to be done by nursing staff on their condition. Staff E stated they were not able to find Resident 1 had been on alert charting prior to going to the hospital. Staff E confirmed with Resident 1's changes, the resident should have been placed on alert and progress notes written related to those changes. During an interview on 02/06/2024 at 11:20 AM, Staff B stated they were asked to do a swallowing evaluation (a test which showed what the throat and esophagus [an organ that food travels through to reach the stomach] does while you swallow) for Resident 1. Staff B stated they had often worked with Resident 1 while they were in the facility, related to swallowing. Staff B stated the last few days Resident 1 was at the facility, staff had to feed the resident, which was a change for the resident. Reference: WAC 388-97-1060(1)

Nov 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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure they staffed enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 7 sampled residents (Resident 1, 2, 3 ,4, and 5), reviewed for sufficient staffing. This failure placed residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living, revised 08/2023 showed residents would receive assistance as needed to complete activities of daily living. The policy further showed the facility must ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident choices. Review of the facility assessment revised 10/17/2023 showed the facility had an average daily census of 47.9 residents and no wander management system. The assessment showed 22 residents required two staff assist for dressing, 18 residents required two staff assist for transfers, 15 residents required two staff assist for toileting, and 13 residents required two staff assist for bathing. The desired number of staff, emergency staffing numbers needed and backup plan if unable to meet emergency staffing number sections of the assessment were left blank. Review of an e-mail Staff A, Administrator, sent on 10/25/2023 at 2:48 PM, to Staff I, Staffing Coordinator, showed the facility was overstaffing. The e-mail acknowledged a census of 50 and clarified staff to resident ratios to be followed for each shift based on census and financial reasons. Review of September, October, and November 2023 staffing schedules showed: -September 2023, 9 night shifts with 4 nursing assistants, 19 night shifts with 3 nursing assistants and 2 night shifts with only 2 nursing assistants (9/6/2023 and 9/16/2023) -October 2023, 4 nights shifts with 4 nursing assistants, 23-night shifts with 3 nursing assistants, and 4-night shifts with only 2 nursing assistants (10/27/2023, 10/28/2023, 10/29/2023, and 10/30/2023) -November 1-15, 2023, 7-night shifts with 4 nursing assistants and 8 nights shifts with 3 nursing assistants <Resident 1> According to the 09/20/2023 quarterly assessment, Resident 1 had diagnoses of stroke with hemiparesis that affected the dominant side (weakness or inability to move one side of the body), left below knee amputation, and right above knee amputation. Resident 1 required extensive staff assist for bed mobility, dependent on staff for toileting and transfers. Resident 1 was able to make their needs known. Review of the care plan revised on 09/13/2022, showed Resident 1 was incontinent and required staff to check and change incontinence products. Resident 1 had pain that was aggravated by lying in one position for too long that was alleviated by repositioning. In an interview on 10/26/2023 at 1:42 PM, Resident 1 stated the facility did not have enough staff to take care of them and had to wait a long time to get help. Resident 1 further stated that staffing on weekends and night shifts was really bad. Resident 1 got teary when asked if they needed help with toileting. <Resident 2> According to the 10/18/2023 quarterly assessment, Resident 2 was always incontinent of bowel and bladder. The assessment further showed they were dependent on staff for bed mobility and toileting hygiene. Resident 2 was cognitively intact and able to make their needs known. Review of the care plan revised 04/17/2023, showed Resident 2 was dependent of two staff for toileting. The care plan instructed staff to give Resident 2 choices on how they would like their personal care provided. In an interview on 10/26/2023 at 2:31 PM, Resident 2 stated the facility did not have enough staff, evenings and nights shifts regularly had less staff and staffing on the weekends was the worst. Resident 2 stated there was only one nurse on night shift for the entire building and they had to wait a long time for requested pain medication. Resident 2 further stated they preferred not to be changed by male staff, but the facility did not ensure they staffed two female staff to provide their care and often felt rushed by staff during cares. Further review of Resident 2's care plan did not show their preference for personal cares to be performed by female staff. <Resident 3> According to the 09/15/2023 comprehensive assessment, Resident 3 had diagnoses of right below the knee amputation, muscle weakness, and abnormal posture. The assessment further showed they had falls prior to admission. Resident 3 was able to make their needs known. Review of the care plan revised on 05/26/2023, showed Resident 3 required extensive staff assist for bed mobility, dressing, personal hygiene, toileting and was dependent on 2 staff for mechanical lift transfers. The care plan showed Resident 3 was at risk for falls related to poor insight, poor judgement, and poor safety awareness with falls sustained in the facility. Review of 09/2023 through 10/2023 fall reports showed Resident 3 sustained four out of six falls on night shift: -On 09/05/2023 at 2:29 AM, Resident 3 was noted to be active, confused, and restless while sitting on the edge of the bed prior to their fall out of bed. -On 10/08/2023 at 2:45 AM, Resident 3 was noted to be confused and slid off the edge of the bed. -On 10/21/2023 at 3:00 AM, Resident 3 slid out of bed x 2. Resident 3 sustained a swollen right eye that was painful to touch and was transferred to the hospital for further evaluation secondary to sustaining a head injury while on anticoagulants. <Resident 4> According to the 11/10/2023 admission assessment, Resident 4 admitted to the facility on [DATE] with diagnoses of dementia with daily wandering and encephalopathy (brain dysfunction that affects thinking). The assessment further showed they had severe cognitive impairment with inattention, disorganized and delusional thinking. Review of pre-admission hospital discharge paperwork dated 11/08/2023, showed Resident 4 was confused, forgetful, illogical, impulsive, restless, and did not follow commands. The notes further showed Resident 4 required 1:1 staff monitoring to maintain safety due to impulsive behaviors. Review of 11/2023 progress notes showed daily notes since admission that Resident 4 required continuous monitoring and care of one staff to maintain safety related to poor safety awareness, confusion, and exit seeking behaviors. Notes showed Resident 4 had poor to no memory of safety education provided and wandered aimlessly around the facility. On 11/13/2023 at 5:14 AM, Staff D, Nursing Assistant (NA), was observed pushing Resident 4 continuously in their wheelchair around the building. <Resident 5> According to the 09/29/2023 quarterly assessment, Resident 5 had diagnoses of quadriplegia (form of paralysis that affects torso and all four limbs), neurogenic bowel (loss of normal bowel function due to nerve problem), and autonomic dysreflexia (syndrome in spinal cord individuals with a sudden and exaggerated increase in blood pressure). The assessment further showed they required extensive to dependent staff assist to perform most activities of daily living. Resident 5 was cognitively intact and able to make their needs known. Review of the care plan revised on 10/12/2022 showed Resident 5 had a specific bowel program related to neurogenic bowel to improve or maintain continence. The bowel program could take approximately two hours to complete; detailed instructions for staff to follow was provided which included: insertion of suppository, rectal digital stimulation x 3, and resident attempt to have a bowel movement. The care plan further showed staff were to follow Resident 5's prompting related to their bowel program. The care plan also instructed staff to consult with Resident 5 on preferences regarding their customary routine. In an interview on 11/16/2023 at 12:27 PM, Resident 5 stated there was not enough staff especially on weekends and night shift. The facility only staffed three nursing assistants and only one nurse for the entire building on night shift, that was not enough especially when the facility did not replace staff when they called in sick. Resident 5 further stated that their customary routine was to go to bed around 1 AM and acknowledged it took a seasoned staff member 30-45 minutes to complete but took an agency or new staff up to an hour and 20 minutes to complete. When asked if Resident 5 has concerns about their care, they became visibly upset, began raising their voice, yell, left leg began to spasms, and became more animated with hands when speaking. Resident 5 acknowledged they had been a quadriplegic for 27 years and had a long-standing specific bowel program for 25 years prior to being admitted to the facility. They explained their bowel program in detail which included insertion of suppository, digital stimulation x 3 and took about two hours to complete, but the facility was not performing the bowel program per care plan or per Resident 5's prompting because it took too long to perform. Resident 5 further explained that they normally had an XL bowel movement with the bowel program they had for 25 years without episodes of bowel incontinence but since their program had been altered by the facility, they have only had up to large bowel movements which caused them to become incontinent of stool when up in their wheelchair. Resident 5 stated for dignity purposes they did not like to be incontinent of stool, acknowledged they were angry about the unwanted change to their bowel program, and worried about becoming impacted (constant constipation when stool is stuck inside the rectum) with stool without the appropriate bowel program being performed. In an interview on 11/13/2023 at 5:09 AM, Staff B, Licensed Practical Nurse, stated they were the only nurse working that night shift with three nursing assistants but that was not enough staff to take care of the residents, sometimes it was very difficult. Staff B stated it was normal for night shift to only be staffed with only one nurse and three nursing assistants. In an interview on 11/13/2023 at 5:14 AM, Staff D, Nursing Assistant (NA), stated Staff C, NA, called them in early and they came in at 4 AM to provide 1:1 assistance to Resident 4 because there was not enough staff on night shift. Staff D stated they typically worked day shift but routinely came in at 5 AM instead of 6 AM to help night shift because the facility acuity was too high and there was not enough staff to provide care. Review of time clock entries for Staff D, NA, from 10/27/2023 through 11/16/2023, showed Staff D clocked in early for their day shifts 18/18 times worked, consistently clocking in between 4:33 AM and 5:02 AM. The report showed Staff D worked 68.6 hours of overtime during that period. In an interview on 11/13/2023 at 5:19 AM, Staff C, NA, stated they only had three NAs working that night shift with one nurse, but one floor staff had been pulled off the floor (leaving only two NAs on the floor for the rest of the residents) to provide 1:1 monitoring for Resident 4 until Staff D came in early to help. Staff C explained that Resident 4 was new and required 1:1 staff monitoring due to their cognitive impairment, poor safety awareness, aimless wandering, and lack of sleep. Staff C acknowledged the facility did not ensure two female staff were scheduled to provide care to Resident 2. Staff C also acknowledged they were not able to provide two staff assist to residents that required it because of lack of staffing. Staff C stated sometimes staff were busy providing care to Resident 5 for up to 2.5 hours because of their specific routine which left the floor with one less staff to provide care to all the other residents. Staff C acknowledge numerous falls occurred on night shift. In an interview on 11/13/2023 at 5:29 AM, Staff E, Phlebotomist, stated they routinely went into the facility on Mondays, Wednesdays, and Fridays around 4:30 AM to draw blood. Staff E stated the facility normally only staffed one nurse and two or three NAs for night shift. Staff E further stated when they were in the building last week, they noticed a night NA nearly in tears because of short staffing and being overwhelmed. In an interview on 11/13/2023 at 5:42 AM, Staff F, NA, stated they worked night shift with only one nurse and three NAs that night, but one NA was pulled off the floor to provide 1:1 monitoring to Resident 4 most of the night. Staff F stated the facility acuity was high and explained that three residents had specific times to be changed, two residents required 45 minutes for toileting, and Resident 5 typically took 1.5 hours to put to bed. Staff F further stated that most of the time they could not provide two staff assist to the residents that required it because of lack of staffing. Staff F stated night shift was typically staffed with only one nurse and three NAs but that was not enough because of acuity. In an interview on 11/13/2023 at 5:55 AM, Staff G, LPN, stated night shift was typically only staffed with only one nurse which was not safe because there are numerous high need residents. Staff G explained if the only nurse had to attend to an emergency, then the rest of the building was left vulnerable to issues such as excessive wait times to receive pain medications. Staff G acknowledged the facility acuity was under looked by management. In an interview on 11/16/2023 at 9:47 AM, Staff J, Resident Care Manager, stated care plans told staff how to provide care to residents and staff were expected to follow care plans so residents received the care they need. Staff J further stated insufficient staff could potentially lead to increased falls or skin issues if incontinent care was not provided timely. In an interview on 11/16/2023 at 10:01 AM, Staff I, Staffing Coordinator, acknowledged they staffed according to census, not facility acuity, and followed the staff to resident ratios set per the e-mail sent by Staff A on 10/25/2023. Staff I stated care plans told staff how to take care of a resident and should be followed for resident safety. Staff I further stated increased falls, choking, unsafe wandering, staff burn out, and unmet resident needs were potential risks of not having enough staff. In an interview on 11/16/2023 at 10:10 AM, Staff K, Administrator in Training, stated care plans provided staff information on how much assistance a resident needed, and staff were expected to follow care plans, it was not negotiable for staff not to follow care plans. Reference WAC 388-97-1080 (1), 1090 (1)

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure sufficient preparation for a safe discharge for 1 of 3 residents (Resident 1), reviewed for discharges. Resident 1 was discharged without adequate knowledge on using a glucometer (a machine that measures blood sugar levels) or injecting insulin (a medication that controls blood sugar). This failure placed the resident at risk for medical complications. Findings included . Review of the facility assessment, dated 08/10/2023, showed Resident 1 was admitted with diagnoses which included Diabetes. Resident 1 was able to make their needs known. Per record review, the resident was admitted from the hospital on insulin. The resident was to continue to use insulin after discharge. Per interview on 09/18/2023 at 12:50 PM, Staff A, Resident Care Manager, stated if a resident was going home with new equipment or medication they should receive education/training prior to discharge. With Resident 1, the teaching wasn't done on the glucometer and insulin until the day of discharge. Teaching should have started weeks prior to discharge. On 09/18/2023 at 2:05 PM, Staff B, Resident Care Manager, stated residents should receive education on medications and equipment one or two weeks before discharge. The resident should be able to self administer the medication and demonstrate use of the equipment. Staff B stated Resident 1 received training on how to use an insulin pen and the glucometer the day of discharge. During an interview on 09/18/2023 at 2:40 PM, Staff C, Director of Nursing, confirmed teaching Resident 1 about the insulin and glucometer the day of discharge was not adequate and the discharge education should have been taught in advance. Reference: (WAC) 388-97-0120(3)(a)

Jul 2023 18 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to recognize pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), accurately and thoroughly assess skin integrity: which potentially delayed the initiation and treatment and thoroughly document or measure wounds for 1 of 2 sampled residents (Resident 202), reviewed for pressure ulcers. These failures resulted in actual harm to Resident 202, who developed additional pressure ulcers to the right medial ankle, left heel and great toe after being admitted to the facility, and placed other residents at risk for untreated skin issues, pressure ulcers, and a decreased quality of life Findings included . Review of the 03/31/2023 facility policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, showed staff should complete a comprehensive skin evaluation of the patient upon admission/re-admission to the facility, and then weekly thereafter. Skin observations were also to occur when providing care by the nursing assistants (NAs). Per the policy, any open areas were to be reported to the nurse. The NAs were to report to the nurse if a dressing over the wound was soiled, saturated (full of drainage), or came off. The nurse would then complete an inspection/assessment and provide treatment if needed. If nursing staff identified a new skin concern, they were to perform wound observations and measurements and complete a weekly Skin Integrity Report upon initial identification of altered skin integrity, and/or with the decline of a wound. A Braden scale (used to identify a resident's risk of skin breakdown) was to be completed upon admission, weekly for the first four weeks after admission, then monthly (or whenever there was a change in the resident's condition). Resident 202's Braden scale on 06/14/2023, the day of admission, was 12 (showing they were at high risk for skin breakdown). Per the 06/16/2023 admission assessment, Resident 202 had severe cognitive impairment, but was able to direct their own activities of daily living (ADL), and had medically complex conditions which included: malnutrition (an imbalance of nutrients from your food and drinks that are needed to keep your body healthy and functioning properly), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). In addition, the assessment showed the resident required extensive to total assistance from staff for activities of daily living (ADL) such as repositioning, and toileting. Review of Resident 202's care plan, dated 06/14/2023 showed the resident had skin impairment of the right medial (inside) of the heel/ankle and coccyx/sacrum (a small triangular bone at the base of the spinal column). The interventions included assessing the location, size, and treatment of the skin injury, to report abnormalities, failure to heal, as well as reporting signs and symptoms of infection to the physician. There were no measurements of the coccyx or left heel until after the observation on 06/29/2023. A review of the Resident 202's orders on 06/14/2023 showed staff were to apply Prevalon boots (boots designed to reduce the risk of ulcers by keeping the heels floated) to the feet and to be worn at all times; cleanse the buttocks and perineal area with soap and water and apply calazyme (a cream to protect the skin from wetness urine or stool) every shift, and with incontinent episodes. Review of the admission/readmission collection tool, dated 06/14/2023, showed Resident 202 had a pressure ulcer to the coccyx and the right and left heel. No other descriptions or measurements of the wounds were documented on that date as required by the facility policy. Review of Resident 202's wound observation tool, dated 06/16/2023, showed the pressure ulcer to the right heel had resolved but there was no documentation of the left heel or coccyx pressure ulcers on that document. Review of 202's skin assessment, dated 06/19/2023, showed blanchable (i.e., redness disappears when light finger pressure is applied, indicating that the local capillaries are undamaged) redness to both heels and the coccyx. Review of Resident 202's 06/22/2023 and 06/26/2023 wound observation tools showed no documentation of pressure ulcers to the heels or the coccyx. During an observation on 06/29/2023 at 10:45am with Staff C, Assistant Director of Nursing (ADON), Resident 202 was lying in bed. Staff C stated there were no pressure ulcers on the resident's heels. During this time Staff C and the surveyor observed that the resident had a deep tissue injury (an injury to the underlying tissue below the skin surface that results from prolonged pressure in an area of the body) to their left heel, a pressure ulcer to the left great toe with an intact scab, bruising to the top of left foot, a stage I pressure ulcer (pressure related to alteration of intact skin with non-blanchable redness of a localized area, usually over a bony prominence) to the right medial ankle and a stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer) to the coccyx. New areas not previously identified by the facility included; the right medial ankle, left heel and left great toe. During an interview on 06/29/2023 at 11:05 AM, Staff C stated that upon admission the right heel pressure ulcer was identified, but not the left great toe. Staff C stated that if the pressure ulcer to the left great toe was new, it would not have a scab. On 06/29/2023 (after the observation), Staff C documented and measured the above pressure ulcers on a wound observation tool. The right medial ankle was 1.0 centimeter (cm.) x 0.6 cm., the left heel was 0.3 cm. x 1.0 cm., and the left great toe was 1.0 cm. x 0.7 cm., and the coccyx was 0.3 cm. x 0.6 cm. Observations made on 07/03/2023 at 11:31 AM and 1:58 PM showed Resident 202 was lying in bed without their Prevalon boots on, and both heels were resting on the mattress. During an interview on 07/05/2023 at 10:05 AM, Staff C stated that residents with pressure ulcers were seen weekly during wound rounds and were discussed in the resident at risk meeting (a meeting in which residents with skin issues are discussed). Staff C stated that a resident with a pressure ulcer on their buttocks or bedbound would qualify for an air mattress, and Resident 202 refused repositioning. During an interview on 07/06/2023 at 3:38 PM Staff B, Director of Nursing, stated NA's report skin issues to the nurse, and the nurse notifies management. Staff B added that pressure ulcers and wounds are measured by the nurse when found, and the wound healing (a team that evaluates skin issues and pressure ulcers) is notified, and completes all other measurements and assessments. Per the United Wound Healing record, Resident 202 was last assessed on 06/22/2023 for an elbow wound, but had not evaluated Resident 202 since that date. Staff B stated that pressure ulcers were to be assessed and measured weekly by nursing staff. Reference: WAC 388-97-1060 (3)(b)

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who experienced multiple accidents that resulted in injury was evaluated for the need for increased supervision, and resident-specific fall preventative measures were added timely to care plans for 2 of 3 sampled residents (Residents 31, 11), reviewed for falls. Resident 31 experienced harm when they had multiple falls resulting in a fractured arm, abrasions to the chin and elbow, and a fractured hip, and this failure placed other residents at risk for falls with injury. Findings included . <Resident 31> According to the 05/04/2023 admission assessment, Resident 31 had severely impaired cognitive skills and required assistance of one to two people with most activities of daily living (ADLs), including transfers and toileting. Per the assessment, the resident had some weakness and instability that put them at risk for falls, as well as a history of recent falls. A care plan related to the resident's fall risk was initiated on 05/02/2023. Interventions included to complete a fall risk assessment, assist with ADLs as needed, keep the call light within reach, and orient the resident to their room. No other safety interventions were included. A review of the accident log showed Resident 31 fell on [DATE], 06/12/2023 and 06/29/2023. Review of the facility investigations for the following dates showed the fall on 05/25/2023 resulted in a humerus fracture (upper arm) and a right periorbital (around the eye) contusion. The resident was transferred to the hospital for care. The fall on 06/12/2023 resulted in four abrasions to their chin and elbow. The fall on 06/29/2023 resulted in a left hip fracture in which resident was transferred to the hospital and had surgery. Review of the facility investigations for the falls on 05/25/2023, 06/12/2023 and 06/29/2023 showed that the Resident 31 was cognitively impaired, did not wait for assistance, and attempted to self-transfer without staff present. Review of the care plan dated 05/02/2023 showed interventions were added, after each fall, however, the care plan was not updated to include the need for increased supervision or measures to prevent the resident from transferring unassisted. The interventions of reminding the resident to ask for help and to use their call light were on the care plan; however, the resident was not cognitively intact and could not remember to use the call light or ask for help. In an interview on 07/03/2023 at 3:10 PM Staff B, Director of Nursing Services (DNS), was made aware that Resident 31 had a fall risk assessment completed on 06/14/2023 with a score of 28, indicating they were a high risk for falls. Staff B was asked why the resident's current fall risk assessment after the hip fracture showed a score of 13. Staff B stated the assessment was inaccurate, and the assessment on 06/14/2023 remained accurate. In an interview on 07/05/2023 at 2:26 PM Staff H, Nursing Assistant, stated Resident 31 was impulsive. In an interview on 07/05/2023 at 2:29 PM Staff G, Registered Nurse, stated Resident 31 was very forgetful and they continued to self-ambulate after being reminded not to do so. Additionally, Staff G stated nursing staff would assist the resident to the bathroom, but Resident 31 continued to attempt to take themselves. In an interview on 07/05/2023 at 2:37 PM Staff B was asked when a resident would need increased supervision to prevent falls . Staff B stated with the facility's current staffing issues, they thought increased supervision would not be possible. Staff B stated Resident 31 was not cognitively intact enough to realize their risk for falls. In an interview on 07/06/2023 at 4:04 PM, Staff B was asked if increased supervision would have decreased Resident 31's falls, and they stated it may have. Resident 31 readmitted to the facility on [DATE], after having surgery and hospitalization for a left hip fracture on 06/29/2023; no care plan updates/revisions were completed upon their return. <Resident 11> Per the 05/30/2023 admission assessment, Resident 11 was able to make decisions regarding their care, had diagnoses which included a fractured left arm, and needed assistance from staff to complete ADLs such as repositioning and moving from one position to another, and moving from the bed to the wheelchair. In addition, the assessment showed the resident utilized a wheelchair to move about the facility, had fallen prior to admission, and had one fall without injury since admission on [DATE]. On 06/26/2023 at 10:18 AM, the resident was observed lying on a stretcher being wheeled down the hallway by emergency personnel, who were transporting the resident to the hospital to be evaluated after falling out of their wheelchair. The resident was observed to have yellow, purple, and blue bruising to the eyes, nose and cheek areas of their face. Per Staff EE, Registered Nurse, the resident had fallen six times since admission. A review of the facility investigations, progress notes, and Resident 11's record from 05/26/2023 through 07/05/2023 showed the following: - On 05/27/2023 at 6:09 PM, the facility investigation showed the resident attempted to self-transfer from the wheelchair to the bed and was assisted to the floor by a family member. The care plan was revised at that time to inform staff a sign was placed in the resident's room, to remind the resident to use the call light and wait for assistance. -On 06/13/2023 at 1:20 PM, the facility investigation showed the resident fell out of the wheelchair while reaching for an item on the floor. The resident was given a reacher (a long pole with a claw-like grabber on the end) to assist with picking items off the floor. - On 06/16/2023 at 11:00 PM, the facility investigation showed the Resident 11 was found on the floor beside the bed, was unable to transfer into the bed, and laid on the floor. Per the investigation, the resident continued to be a high risk for falls. At 2:50 PM the same day, a progress note showed the resident had taken themselves to the bathroom, and was sitting in their wheelchair looking at the toilet. The staff then assisted the resident onto the toilet. - A progress note on 06/21/2023 at 9:03 PM showed the resident was scared these falls were going to cause them to get kicked out of the facility, and staff provided reassurance to the resident and their spouse that the facility's goal was to determine why the falls were occurring and to find a way to keep the resident safe. - On 06/23/2023 at 9:49 AM, a progress note showed an occupational therapy consult was ordered to evaluate the wheelchair for safety, due to the Resident 11's recent falls. - On 06/24/2023 at 2:58 PM, the facility investigation showed Resident 11 stated they blacked out and fell from the wheelchair after reaching down to pick up their glasses from the floor. The investigation documented the care plan was revised to include educating the resident to use the call light when assistance was needed, remind the resident to use the reacher to get items that were hard to get, and to encourage the resident to be in areas of high visibility. - On 06/26/2023 at 10:41 PM, the facility investigation showed the resident fell out of their wheelchair hitting their forehead, which was swelling. According to the investigation, the care plan was revised to instruct staff to put the bed in the lowest position and a place a fall mat on the floor next to the bed while the resident was sleeping. Review of a progress note dated 06/27/2023 at 11:52 AM by Staff FF, Physician's Assistant, showed Resident 11 had been assessed and stated the facial bruising was due to recurrent falls, that the resident's impulisve nature was a challenge, but the resident's current medication and environment did not seem to be a problem. Review of a progress note dated 06/27/2023 at 4:14 PM showed Resident 11's spouse expressed frustration with the continued falls, and expressed worry that continued falls would end up badly. Review of a progress note dated 06/28/2023 at 6:42 PM showed the occupational therapy evaluation of the wheelchair that was ordered five days previously (on 06/23/2023), and had been completed - two days after the resident had again fallen out of their wheelchair. Review of the care plan dated 07/05/2023 showed fall interventions were implemented at admission on [DATE], but only instructed staff to assist with activities of daily living as needed, have the call light within reach, and orient the resident to the room. The care plan informed the licensed nursing staff that the resident had poor insight, judgement, and awareness, but did not inform the nursing assistant staff, nor was the information regarding the resident having poor insight, judgement, and awareness found on the NA's [NAME] (a care card that contained the interventions and tasks from the resident's care plan that the NA's were responsible for). Further review of the care plan showed the fall care plan had not been revised to include the additional fall interventions that were stated in the facility investigations and the progress notes. Additional fall interventions were not added until 06/25/2023, 06/27/2023, and 06/28/2023. In an interview with Staff N, Restorative Assistant, the care plan and [NAME] had the information to inform the staff what the resident care needs were. On 07/05/2023 at 9:51 AM Staff F, Resident Care Coordinator, confirmed Resident 11's care plan had not been updated timely to include additional fall prevention interventions. In an interview on 07/07/2023 at 10:15 AM Staff B, Director of Nursing, stated the fall care plan did not include resident-specific goals and interventions, did not provide instructions to all appropriate nursing staff, nor had it been updated timely to include additional fall interventions. When asked if other interventions had been considered to increase the supervision, such as frequent checks or one on one monitoring for Resident 11 to mitigate further falls, Staff B stated the facility had a staffing shortage, and did not have the staff to be able to do that. See F725 for additional information. Reference: WAC 388-97-1060(3)(g)

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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Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 41), reviewed for unnecessary medications, was informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the resident at risk of not being fully informed of the potential risks and benefits of taking the medications. Findings included Per the 04/04/2023 admission assessment, Resident 41 was able to make decisions regarding care, and had diagnoses which included depression. In addition, the assessment showed the resident received psychotropic medication daily (defined above). A review of the Order Summary Report showed on 05/30/2023, the physician had prescribed a psychotropic medication (Venlafaxine) to treat depression. Review of the May and June 2023 Medication Administration Records (MARS) showed the medication was given daily as ordered. Review of Resident 41's record did not show documentation that the risks and benefits of the medication were discussed, either verbally or written, with the resident or their representative, prior to the resident receiving the medication. In an interview on 06/26/2023 at 9:01 AM, Resident 41 was asked if the nursing staff had provided education on the risks and benefits of the Venlafaxine or signed a consent form agreeing to the medication. Resident 41 stated they were aware of their medications, but did not recall any education being provided before taking the Venlafaxine. In an interview on 07/03/2023 at 11:12 AM Staff E, Licensed Practical Nurse, stated informed consents for psychotropic medications were obtained prior to giving the medication and should be in the resident's record. On 07/05/2023 at 9:47 AM, Staff F, Resident Care Coordinator, stated informed consents should be obtained prior to the resident receiving the first dose of the medication, and confirmed no consent was in Resident 41's record. Reference (WAC) 388-97-0260

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide a clean, homelike environment for 3 of 9 sampled residents (Residents 6, 14, and 202), reviewed for durable medical equipment, on 1 of 2 nursing units (east), that had large sections of wallpaper peeling off the walls, and in 1 of 2 nourishment kitchenettes (east) that was unclean and had unpleasant odors. These failures placed the residents at risk for a decreased quality of life. Findings included . <Wheelchairs> The 06/09/2023 quarterly assessment showed Resident 6 had diagnoses including heart failure, required the assistance of one staff for mobility on the nursing unit, and used a wheelchair. The 05/15/2023 quarterly assessment showed Resident 14 had diagnoses including paralysis on one side of their body following a stroke, and required extensive assistance of one staff to transfer them from their bed to their wheelchair. The 06/16/2023 admission assessment showed Resident 202 had diagnoses including dementia and weakness, and was dependent on two staff to transfer them from their bed to their wheelchair. On 06/22/2023 at 9:14 AM, Resident 14 was observed seated in their wheelchair in their room. The left armrest of the wheelchair was wrapped in gauze and a netting-type covering. The gauze and netting had dried food and stains on them. The wheels of the wheelchair had dried matter in the spokes and in the wheel treads. The wheelchair remained in the same condition throughout the remainder of the survey. On 06/28/2023 at 4:21 AM, a tilting-style wheelchair and a wheelchair with a pink metal frame were observed at the end of the hallway on the east nursing unit. The tilting wheelchair had dust and debris in the wheel spokes, tire treads and on the seat cushion. The pink framed wheelchair had dried food and crumbs on the seat cushion. During an interview on 06/28/2023 at 5:26 AM Staff R, Nursing Assistant (NA), stated the tilting wheelchair belonged to Resident 202, and the pink-framed wheelchair belonged to Resident 6. Staff R stated the night shift staff were responsible for washing the wheelchairs, but usually did not have time so that had an impact on the cleanliness of the equipment. Staff R stated they tried to wipe the seats if they had not been cleaned. During an interview on 07/06/2023 at 4:34 PM Staff B, Director of Nursing Services, confirmed that night shift was supposed to clean wheelchairs. Per Staff B, there was a rotating cleaning schedule, and they were cleaned on night shift to allow them to dry. Staff B stated staffing challenges made this difficult, and new employees and agency staff may not have been aware. <East Nursing Unit Kitchenette/Wallpaper> On 06/22/2023 at 9:32 AM, the east nursing unit kitchenette was observed. The floor and trim were dirty with grey-brown stains and debris, especially in the area between the refrigerator and cabinets. The refrigerator handle was broken and had pieces missing. When opened, the refrigerator smelled sour, and there were spills and drips on the shelves. The freezer was full of crumbs, and the area where the refrigerator door sealed had food debris and sticky matter on it. Similar observations were made on 06/23/2023 at 9:29 AM and on 06/26/2023 at 8:56 AM. On 06/22/2023 at 9:45 AM, the wallpaper around the doors to the shower room and hallway bathrooms on the east nursing unit were observed to have multiple large sections of wallpaper peeling off. The peeling sections were left hanging down and exposed the drywall beneath. It was observed in the same state for the duration of the survey. During an interview on 07/03/2023 at 10:55 AM, Staff W, Maintenance Director, stated the plan for the wallpaper was they were going to try to skim and texture the area with drywall paste, then paint over it. Staff W stated there had been other building concerns that took priority, stated the wallpaper had been that way since they were hired in 09/2022. They confirmed it was to be repaired, it just depended on when that was to happen, and confirmed it did not look homelike. During an interview on 07/03/2023 at 3:51 PM Staff O, Licensed Practical Nurse, Resident Care Manager, stated housekeeping and kitchen staff were responsible for cleaning the refrigerator and kitchenette, and confirmed this had not been done. Reference: WAC 388-97-0880

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure incidents of potential abuse, such as financial exploitation, were identified as such, and reported to the State Survey Agency as required, for 1 of 3 sampled residents (Resident 3), reviewed for abuse. Failure to report allegations/incidents of abuse placed the resident at risk for additional abuse. Findings included . Review of the facility Abuse Prevention policy, last revised 10/04/2022, showed it was the policy of the facility to prevent, prohibit, identify, and thoroughly investigate allegations of abuse, neglect, and exploitation of residents, along with misappropriation of resident property. The policy further showed, The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. The facility will ensure that all staff are aware of reporting requirements. Per the 05/10/2023 quarterly assessment, Resident 3 was cognitively intact to make decisions regarding care and had medically complex diagnoses which included depression and post traumatic stress disorder (a disorder in which people have intense, disturbing thoughts and feelings related to their experience that last long after a traumatic event occurred). Review of Resident 3's record showed a progress note dated 06/09/2023 by Staff F, Resident Care Coordinator, showed a family member had called the facility and expressed concern that a friend of the resident maybe be attempting to take advantage of them. The family member was worried that the friend was trying to convince the resident to move from the safety of the facility in an attempt to access the resident's money, and stated the friend had done this before. Further review of the resident's record and the June 2023 Facility Reporting Log did not show that the incident (which was an allegation of financial exploitation) had been called into the State Survey Agency, as required. In an interview on 07/03/2023 at 3:24 PM, Staff F confirmed the family member had called and expressed concern. When asked if the incident/concern should have been called into the State Survey Agency, Staff F stated they were unsure, but had reported the incident to administration. On 07/06/2023 at 3:46 PM Staff B, Director of Nursing, stated they were not aware of any issues with the resident's visitor. When informed of the concern expressed of possible exploitation, Staff B confirmed the incident should have been reported to the State Survey Agency, as required. Please see F610 for additional information Reference WAC 388-97-0640 (5)(a)

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to identify and thoroughly investigate an allegation of potential exploitation for 1 of 3 sampled residents (Resident 3), reviewed for abuse. Failure to identify and investigate an allegation of potential exploitation for the resident placed them at risk for further exploitation. Findings included . Review of the facility Abuse Prevention policy, last revised 10/04/2022, showed it was the policy of the facility to prevent, prohibit, identify, and thoroughly investigate allegations of abuse, neglect, exploitation of residents, and misappropriation of resident property. Per the 05/10/2023 quarterly assessment, Resident 3 was cognitively intact to make decisions regarding care and had medically complex diagnoses which included depression and post-traumatic stress disorder (a disorder in which people have intense, disturbing thoughts and feelings related to their experience that last long after a traumatic event occurred). A review of the progress notes from 02/01/2023 thorough 07/04/2023 showed the following entries: - On 06/02/2023 at 2:22 PM, an outside consultant documented the resident was debating moving to a skilled nursing facility in Idaho to be closer to a friend. - On 06/08/2023 at 2:24 PM, Staff BB, Licensed Practical Nurse, documented a friend of the resident borrowed money to buy a tire and promised to repay it as soon as possible. - On 06/09/2023 at 3:29 PM Staff F, Resident Care Coordinator, documented a family member was worried the resident's friend was trying to talk the resident into moving closer to them in an attempt to gain access to the resident's money. The family member stated the friend had done this before. - On 06/10/2023 at 8:18 PM, Staff AA, Licensed Practical Nurse, stated the resident had a visitor that played with the resident's phone and spoke to them about money. - On 06/17/2023 at 6:41 PM, Staff AA documented that around 9:20 AM, the resident's friend called the facility stating they needed to speak to the resident. The friend was told the resident still sleeping and two hours later when the friend arrived, the resident was still in bed. The friend waited until the resident was up and Staff AA heard them ask the resident about money. The resident gave them money and when the friend asked for more, the resident stated no. After the friend left, Staff AA asked about the relationship and was told the friend was unemployed and sometimes they (the resident) helped them Review of the facility reporting log for June 2023 showed no incidents had been logged for possible abuse/exploitation for Resident 3. Further record review found no documentation that showed the facility did an investigation to determine if exploitation had occurred. In addition, no documentation was found to show the resident had been asked about the nature of the relationship with the friend or assessed for possible exploitation, until the progress note on 06/17/2023 by Staff AA, eight days after the facility was notified of possible exploitation by a family member. In an interview on 06/22/2023 at 12:17 PM, Staff BB stated the friend had been a problem in the past, and had not been around again until recently. On 06/26/2023 at 11:09 AM, Resident 3 was observed sitting in their recliner watching television in their room. When asked about their friend, Resident 3 stated they had no problem putting their foot down and saying no. During an interview on 07/03/2023 at 3:24 PM, Staff F, Resident Care Coordinator, confirmed a concern had been expressed about a friend of the resident, and staff had informed them there had been problems with this visitor getting money from the resident in the past. When asked if an investigation had been completed, Staff F stated they were not sure, but believed it had been done. In an interview on 07/06/2023 at 3:46 PM Staff B, Director of Nursing, stated they were not aware of any concerns regarding a friend of Resident 3. When informed of the documentation and concern of possible exploitation expressed by a family member, and observations by staff, Staff B confirmed the incident should have been investigated and had not been. Please see F609 for further information Reference WAC: 388-97-0640 (6)(a)(b)

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide care and services according to professional standards for 1 of 6 sampled residents (Resident 22) reviewed for medication administration, and for 3 of 3 sampled residents (Residents 27, 43, 202), reviewed for oxygen therapy. Failure to consistently change resident 22's dressing for the PICC (a thin catheter inserted into a large vein to enable the administration of intravenous medications), and failure to change resident 27, 43, and 202's oxygen tubing and clean the filters for the oxygen equipment, placed the residents at risk for infection, medical complications, and a diminished quality of life. Findings included . According to the article, Central Line Management, published by the National Library of Medicine on 05/26/2023, dressing changes for a central venous access line (such as a PICC) should occur every five to seven days with a transparent dressing or every two days if a gauze dressing was used, and the dressing needed to be changed sooner if it was no longer adherent, it's integrity was compromised, or it was visibly soiled. The 12/03/2022 Oxygen Administration/Safety/Storage/Maintenance facility policy documented oxygen supplies were to be changed weekly and when visibly soiled; and equipment was to be dated when set up or changed out. Concentrators were to be cleaned weekly. External filters were to be checked daily, all dust removed, and washed weekly and as needed, with soap and water. <Resident 22> A facility policy, dated 2021, showed PICC line dressing changes were to be completed weekly. Record review showed an order dated 05/19/2023 that instructed nursing staff to change Resident 22's PICC dressing weekly. In an observation on 06/28/2023 at 1:08 PM, Resident 22 was observed to have a PICC line dressing on their left arm that was dated 06/19/2023. Review of the resident's Medication Administration Record (MAR) showed the PICC line dressing was to be changed every Sunday, and had been changed on 06/25/2023. During an interview and observation on 06/28/2023 at 1:33 PM, Staff C, Assistant Director of Nursing (ADON), observed that Resident 22's PICC dressing was dated 06/19/2023. Staff C stated PICC line dressings needed to be changed every seven days, and the dressings were dated to show when they had last been changed. <Resident 27> The 06/08/2023 quarterly assessment showed Resident 27 had diagnoses including pneumonia and chronic obstructive pulmonary disease (a lung disease that blocks airflow causing difficult breathing), and received oxygen therapy. A review of Resident 27's orders showed on 06/09/2023, the provider ordered the resident to receive oxygen via a nasal cannula continuously at 3 liters (L) per minute, and the oxygen tubing was to be changed every Sunday. No orders were found in the resident's record for the care, cleaning, or maintenance of the oxygen concentrator (a machine that converts room air to oxygen) and filter. Review of the June 2023 Medication/Treatment Administration Record (MAR/TAR) showed the oxygen tubing had not been changed on 06/11/2023 or 06/18/2023, and was last changed on 06/25/2023. On 06/23/2023 at 9:17 AM, Resident 27 was observed in their room sitting in their wheelchair receiving oxygen via a nasal cannula from a portable oxygen concentrator. A non-portable oxygen concentrator was observed at the resident's bedside. The filter on the back of the concentrator had visible dust on the entire filter and a dark circle of heavy dust with dirt accumulation in the center. <Resident 43> A review of the 06/07/2023 admission assessment showed Resident 43 had diagnoses which included COPD and was dependent on oxygen. Review of the physician orders showed on 06/09/2023 oxygen was ordered as needed, and on 06/11/2023, staff were instructed to change the oxygen tubing every Sunday. No orders were found for the maintenance and care of the oxygen equipment/concentrator until 06/25/2023 when staff were instructed to clean the oxygen concentrator filter with soap and water every Sunday. Review of the June 2023 MAR and Treatment Administration Record (TAR) showed the oxygen tubing was not changed on 06/11/2023 or 06/18/2023, and was last changed on 06/25/2023. Resident 43 was observed wearing oxygen on 06/22/2023 at 3:17 PM, 06/23/2023 at 9:16 AM, and on 06/29/2023 at 9:15 AM. During all observations, the tubing was not labeled with the date to show when it was last changed. <Resident 202> A review of the 06/16/2023 admission assessment showed Resident 202 had diagnoses which included heart failure (fluid in the lungs which causes difficult breathing) and utilized oxygen prior to admission to the facility. Review of the physician orders showed on 06/19/2023 oxygen was ordered as needed, and instructed staff to change the oxygen tubing every Sunday. No orders were found in the resident's record for the care, cleaning, or maintenance of the oxygen concentrator and filter. On 06/22/2023 at 10:41 AM, Resident 202 was observed lying in bed wearing oxygen. The tubing was not dated. On 06/23/2023 at 9:55 AM, the resident was again observed wearing their oxygen, with tubing that was dated 06/23/2023. A review of the June 2023 MAR and TAR showed the oxygen tubing was changed on 06/25/2023. On 06/27/2023 at 9:56 AM, the resident was observed wearing their oxygen while lying in bed, and the tubing was not dated. During an interview on 06/29/2023 at 11:04 AM Staff Q, Licensed Practical Nurse (LPN), stated oxygen tubing was to be changed weekly and dated when done. During an interview on 07/03/2023 at 11:53 AM, Staff T, Nursing Assistant, stated oxygen tubing could be changed by the nurse or the nursing assistant, and they would put a piece of tape around the tubing and write the date on it. Staff T was unsure if there was a schedule for this; many times, the tubing was changed on the day shift. Staff T was unsure about the concentrator filters and had never changed one. During an interview on 07/03/2023 at 2:47 PM Staff O, LPN/Resident Care Manager, stated they expected residents receiving oxygen to have orders to monitor their oxygen saturations, how many liters of oxygen they were to receive, orders to change the oxygen tubing, and orders to make sure the concentrators worked properly, and filters were cleaned and changed. Staff O stated staff were to change and date the tubing on Sundays on the night shift. During an interview on 07/03/2023 at 2:47 PM, Staff C, Assistant Director of Nursing Services, stated a resident could have respiratory issues if their equipment was not cleaned, and they would put in an order for Resident 27 to have their concentrator filter cleaned and changed, and the order got missed. Reference WAC: 388-97-1620(2)(b)(i)(ii) (6)(b)(i)

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

<Resident 22> According to the 05/22/2023 admission assessment, Resident 22 was cognitively intact to make decisions regarding care, and required assistance from one staff for activities of dai...

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<Resident 22> According to the 05/22/2023 admission assessment, Resident 22 was cognitively intact to make decisions regarding care, and required assistance from one staff for activities of daily living such as dressing, transferring, and bathing assistance. In an interview on 06/22/2023 at 9:47 AM, Resident 22 stated that upon admission to the facility, they went three weeks without a shower, and it hasn't improved much. The resident added that there was not enough staff to ensure cares were provided, and they would like at least two showers per week. Review of the bathing documentation from 05/22/2023 to 06/28/2023 showed the resident's scheduled shower days were Wednesday and Saturday, and the documentation showed they had been bathed once a week, and not twice a week as preferred or scheduled. In addition, the documentation showed the resident had not refused to be bathed. During an interview on 07/03/23 at 10:51 AM Staff O, Resident Care Coordinator, stated residents were asked how many showers they would like upon admission, their preferences were added to the shower book, and they should be bathed accordingly. During an interview on 07/05/2023 at 8:45 AM Staff T, Nursing Assistant confirmed Resident 22 does not refuse their showers. Please see F725 for additional information Reference: WAC 388-97-1060 (2)(c) Based on observation, interview, and record review, the facility failed to provide dependent residents services to maintain their nutrition and personal hygiene for 2 of 4 sampled residents (Residents 14 and 22), reviewed for activities of daily living ADLs for dependent residents. Resident 14 had difficulty manipulating their eating utensils and was not assisted or reassessed, and Resident 22 did not receive showers twice weekly as scheduled and requested. Findings included . <Resident 14> A review of the record showed Resident 14 had diagnoses included paralysis of one side of the body after a stroke, difficult swallowing, and a contracture (hardening of muscle and rigidity of a joint) of the right elbow and hand. A 05/15/2023 quarterly assessment showed the resident was severely cognitively impaired, required extensive assistance of one staff for most ADLs, needed supervision and set-up help for eating, and did not cough or lose food or fluids from their mouth when eating. The 07/2019 Comprehensive Care Plan included the following care areas: -ADL self-care performance deficit and swallowing problem related to previous stroke. Interventions included to provide a lipped plate, cue as needed, able to feed self independently with set-up assistance opening containers and cutting food, alternate small bites and sips, check mouth after meal for pocketed food and debris, upright position for meals, observe and report any signs/symptoms of pocketing, choking, coughing, drooling, and refer to speech therapy for a swallowing evaluation. Resident 14's orders showed the resident was to receive a consistent carbohydrate diet (eating the same amount of carbohydrates every day to avoid sugar spikes) with regular food textures and thin consistency liquids, and to use a lipped plate. An Occupational Therapy (OT) Evaluation and Plan of Treatment showed Resident 14 received OT services from 04/24/2023 through 05/08/2023 for improved upright sitting posture and adaptation of the right arm deck on their wheelchair. The wheelchair was modified to have a lower profile arm deck and a deep solid backrest with lateral supports, which provided decreased lateral side leaning and prevented the arm from resting between the resident's side and the inner aspect of the armrest. The annual nutrition assessment completed on 05/03/2023 showed Resident 14 had not had a change in their weight, used a lipped plate, preferred to eat in their room, and had no problems swallowing. There were no new recommendations, and the current interventions were to be continued. On 06/22/2023 at 12:57 PM, Resident 14 was observed in their room seated in their wheelchair with their lunch on the overbed table in front of them. Resident 14 attempted to pick up their fork twice, had trouble holding it, and it dropped. They gave up and picked up their cake with their left hand, and ate it with their fingers. Resident 14 then attempted to get a drink of their juice, which was in a glass with a straw. They were unable to grip around the glass, so they slid the glass to the edge of their meal tray, leaned forward over their tray and drank from the straw without lifting the glass. The resident coughed after taking a drink. There were no staff present during the observation. On 06/23/2023 at 8:51 AM, Resident 14 was heard coughing from the hallway. The resident was observed seated in their wheelchair with their breakfast tray on their overbed table in front of them. The resident had scrambled eggs with ham pieces, cold cereal, cranberry juice, and coffee on their tray. Staff N, Restorative Nursing Assistant, entered the resident's room. Resident 14 was observed leaning over their tray with food pieces on their mouth, their nose was running, and they continued to cough. Staff N provided the resident with a tissue. Resident 14 stated they swallowed wrong. The resident was offered their juice and they continued to clear their throat. The juice glass was full and had a straw in it, and as the resident lifted the glass over their plate to get the straw to their mouth, juice spilled on their plate. Staff N asked if Resident 14 wanted the straw removed and the resident stated they did not, saying that it was easier to drink with the straw. The resident's coughing stopped at that time. Staff N exited the room. At 8:57 AM the same day, Resident 14 attempted to eat cereal. The spoon tilted away from the resident and when brought towards their mouth, the cereal fell off the spoon and on to their shirt. On 06/27/2023 at 12:36 PM, Resident 14 was observed in their wheelchair with their overbed table in front of them. The resident's lunch included potato salad, a lettuce salad with meat and tomatoes on it, and a fruit crisp dessert. A nursing assistant cut the potatoes in smaller pieces then left the room. At 12:43 PM, the resident pushed food around their plate with their knife, dropped the knife and it fell across their food. A nursing assistant walked by, entered, and encouraged Resident 14 to use their fork then left the room. The resident leaned over their plate, their head tilted forward and to the right. The resident ate potato salad, and drool came out of the corner of their mouth and on to their shirt. At 12:55 PM, Resident 14 struggled to get pieces of salad on their fork, set the fork down and picked up tomatoes with their fingers and ate them. At 1:00 PM, Resident 14 cleared their throat, and picked up their spoon. They attempted to get the lettuce salad on the spoon and it spilled over the edge of their plate and off the spoon. There was no salad on the spoon when they brought the spoon to their mouth. At 1:07 PM, Resident 14 scooted their dessert dish close to them and their nose and mouth were next to the dish. The dessert was in a large clump and fell off the spoon when they attempted to bring the spoon to their mouth. Resident 14 attempted then to scoop the dessert from the dish right into their mouth and the dessert fell over the edge of the dish on to their tray. During an interview on 07/03/2023 at 10:43 AM Staff T, Nursing Assistant, stated Resident 14 was to have their meals set up and used straws for their drinks. Staff T stated Resident 14 had trouble using their silverware so sometimes the resident would just ditch them and use their fingers. Staff T stated staff tried to feed the resident in the past, but Resident 14 got upset by that. Staff T stated they were unsure when the resident worked with speech therapy and OT last. During an interview on 07/03/2023 at 11:04 AM, Staff S, Speech Language Pathologist, stated they last saw Resident 14 for swallowing difficulties in 09/2021. Staff S stated Resident 14 was last seen by OT for adjustments to their wheelchair. Staff S stated 90% of Resident 14's difficulties were related to their positioning; if their arm came off the support, their trunk and neck would not be in alignment and that created swallowing difficulties. Staff S stated no one had approached them regarding Resident 14, and if Resident 14 had their tray set up correctly and they were in the right position, they were able to eat better. Staff S and the surveyor observed Resident 14 at that time in their wheelchair and confirmed the back support and arm trough were in place for the resident. Staff S stated that Resident 14 did not have their hips under them however, and this also caused the resident to lean to the side and it was a safety concern. Staff S stated Resident 14 might do better in the assisted dining room, and food spilling on their clothes and table was not a very dignified way to eat their meals. During an interview on 07/03/2023 at 2:16 PM, Staff N stated Resident 14 required set-up help which meant to get food ready, cut it up, open packets, and prepare drinks. Staff N did not think Resident 14 liked straws so Staff N did not put them in the resident's drinks. Staff N did not think Resident 14 had declined but because the resident ate in their room, and then stated the unit nursing assistants might notice this more than Staff N. Staff N stated Resident 14 was supposed to be seated upright, and Staff N was not aware if the resident coughed often. Staff N thought they mentioned the resident coughing to Staff S, and the resident's nurse on 06/23/2023. During an interview on 07/03/2023 at 2:35 PM with Staff O, Licensed Practical Nurse/Resident Care Manager and Staff C, Assistant Director of Nursing, Staff O stated Resident 14 was to have a lipped plate to assist them at their meals, and their record did not specify if the resident was to use straws. Staff O stated none of the staff had notified them of the resident's coughing but staff might have referred it to Resident 14's nurse. Staff O expected staff to notify them if a resident had difficulty eating. Staff C then stated orders had just been entered to have Resident 14 seen by OT and ST.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 202> Resident 202 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, and a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 202> Resident 202 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, and a history of urogential implants (a device used to treat urinary incontinence). The 06/16/2023 admission assessment showed Resident 202 had a urinary catheter (a thin flexible tube placed in the bladder to drain urine). The assessment did not include a diagnosis that would medically justify the need for the urinary catheter. Per review of Resident 202's medical record, there was no documentation that showed the facility had attempted to remove the catheter and perform a voiding trial. The hospital record showed the urinary catheter had been placed during Resident 202's hospital stay. During an interview on 07/05/2023 at 11:16 AM Staff FF, Physician's Assistant, stated urogenital implants was not an appropriate diagnosis for a urinary catheter. Staff FF added when a resident admitted to the facility without a proper diagnosis, the catheter was discontinued and a voiding trial was started. Staff FF confirmed this was not done for Resident 202. Reference: WAC 388-97-1060 (3)(c) Based on interview and record review, the facility failed to follow-up on a doctor recommended treatment timely for 1 of 1 sampled resident (Resident 3) reviewed for urinary tract infections. In addition, the facility failed to assess whether a urinary catheter was medically necessary for 1 of 1 sampled residents (Resident 202) reviewed for urinary catheters. These failures placed the residents at risk for increased pain, infection, and unmet care needs. Findings included . <Resident 3> Per the 05/10/2023 quarterly assessment, Resident 3 made decisions regarding their care and had medically complex conditions which included impaired kidney function and diabetes (a disease caused by the inability of the body to convert the food we eat into sugar needed for the cells). On 06/22/2023 at 10:16 AM, Resident 3 was observed in their room sleeping in a recliner with their legs elevated. A similar observation was made at 12:17 PM that same day with the resident sleeping in their recliner. Per Staff BB, Licensed Practical Nurse, the resident was recovering from a recent surgical procedure, and had been sleeping a lot due to weakness. A copy of an office consultation note dated 02/10/2023, showed the resident had an appointment with a Urologist, (a doctor that specialized in the treatment of the body parts that produce urine, such as the bladder and kidneys). The assessment showed the resident's right kidney was decreased in size and there were kidney stones present. The doctor recommended a ureteroscopy and laser lithotripsy (a procedure which uses a scope and laser to break apart large kidney stones) be performed. The consultation note was signed by Staff CC, the facility's Medical Director at the time, which indicated the doctor was informed of the recommendation. Review of the progress notes from 02/10/2023 through 04/24/2023, showed no documentation that the ureteroscopy and laser lithotripsy had been scheduled. A provider note on 04/25/2023 at 5:26 PM by Staff CC showed the resident had been seen the previous day for a routine visit and during the visit, the resident had asked if the lithotripsy was going to be done. The note stated the resident had kidney stones, and was followed by urology, but no additional orders had been written to schedule the procedure. A progress note on 05/13/2023 at 7:31 PM showed the resident had fallen, and was sent to the hospital for evaluation. On 05/18/2023 at 6:40 PM, a progress note documented the resident had returned to the facility from the hospital and was being treated for a urinary tract infection. Review of the 05/18/2023 hospital discharge note showed the resident was admitted on [DATE] and found to have a urinary tract infection, and an antibiotic was started. The note further showed the resident had been to the urologist in February 2023, and a ureteroscopy with laser lithotripsy had been recommended, but did not appear to have been completed. On 05/15/2023, the hospital contacted the urologist's office to schedule the procedure. On 06/02/2023 at 3:00 PM, a progress note documented that the urologist's office had called the facility and the resident was scheduled to have the procedure on 06/06/2023, almost 4 months after the urologist's recommendation. In an interview on 07/03/2023 at 3:30 PM, when asked about the delay in getting the ureteroscopy and laser lithotripsy procedure scheduled for Resident 3, Staff F, Resident Care Coordinator, stated the resident had fallen in May 2023 and while at the hospital, was found to have a urinary tract infection and needed the lithotripsy. When informed of the urologist's initial recommendation for the procedure on 02/10/2023, Staff F stated they had only been employed since March 2023, was not aware of that, and would need to follow up to find out why there was a delay. In a follow-up interview on 07/05/2023 at 10:13 AM, Staff F stated they were told the delay was due to the urologist schedule being booked out for months. When asked if there was any documentation to show that attempts had been made to schedule the procedure, Staff F stated they would need to follow-up since it occurred before they were employed. On 07/05/2023 at 10:33 AM, Staff DD, Nursing Assistant, stated that up until a couple of months ago, they scheduled resident appointments. Staff DD stated when orders were received for an outside appointment, they called the provider to schedule. Paperwork from the outside provider would be given to the scheduler upon return to the facility, a copy of the paperwork made, any additional appointments would be scheduled, and the paperwork was then given to nursing for follow-up. Staff DD remembered Resident 3 going to the urology appointment on 02/10/2023, but did not recall any follow-up appointment being ordered. Per Staff DD, a recommendation was not an order - a recommendation required nursing to obtain an order from the doctor, and then it could be scheduled. In an interview on 07/06/2023 at 3:54 PM, the delay with scheduling Resident 3's procedure was discussed with Staff B, Director of Nursing. Staff B stated they had also started employment with the facility in March 2023, and shortly afterwards, became aware there were some issues with appointments not being scheduled, so changes to the scheduling process had been made. With regard to Resident 3's delay, Staff B stated they were unsure what the cause of the delay was.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> Review of the records showed Resident 27 was initially admitted on [DATE], was hospitalized twice and was mo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> Review of the records showed Resident 27 was initially admitted on [DATE], was hospitalized twice and was most recently readmitted on [DATE] with diagnoses including severe calorie malnutrition, diabetes, and end-stage kidney disease which required dialysis (see previous definition). An assessment completed on 06/08/2023 showed Resident 27 had mildly impaired cognition, and weighed 174 pounds (lbs). The 05/05/2023 comprehensive care plan documented the following care areas: -risk for weight loss related to end-stage renal disease (ESRD). Interventions were to assist with meals as needed, consistent carbohydrate diet (to prevent sugar spikes) with regular texture and thin liquids, dialysis on Monday-Wednesday-Friday, dietary to provide sack lunch, weigh per protocol, Resident at Risk (RAR) team review as indicated. The care area was updated on 06/09/2023 by Staff D, Registered Dietician (RD), to include double portions due to severe malnutrition. -dialysis related to acute kidney injury; interventions were to provide dialysis treatments as ordered, do not take blood pressure on arm with shunt (connection of an artery and vein in an arm that is accessed during dialysis), dry weights obtained from dialysis center (weights prior to dialysis), observe access site for bleeding, and therapeutic diet as ordered. Resident 27 had the following orders: -05/25/2023 the dialysis provider scanned in an order which stated to please continue to work on potassium restriction in patient diet for a diagnosis of hyperkalemia (high blood levels of potassium, which creates risk for heart rhythm abnormalities). -06/06/2023 consistent carbohydrate diet (see definition above), regular texture, thin consistency, double portions. -06/06/2023 dialysis, send Monday-Wednesday-Friday, do not take blood pressure in right arm with shunt. -06/06/2023 Assess shunt site for thrill/bruit (sounds heard through a stethoscope in a properly functioning shunt) and bleeding, upon return from dialysis. Resident 27's 05/2023 care plan and orders from the facility's physician did not instruct staff to restrict fluids, potassium or sodium, or to monitor the resident's oral fluid intake. There were also no instruction related to who was to provide and maintain the access site dressing changes, who to contact for dialysis related complications, monitoring of vital signs, complications to monitor for such as low blood pressure or fluid overload, or how the facility would communicate with the dialysis center. A nutrition assessment completed on 06/07/2023 by Staff D, RD, documented Resident 27 was severely malnourished, currently weighed 173.4 lbs., and required 2180-2545 calories per day based on an ideal body weight of 72.7 kilograms (kg., equivalent to159.9 lbs.); the fluid needs were 25-30 milliliters (mls.) per kg. of their ideal body weight daily (1820-2181 mls.). The recommendation was for the resident to receive double portions at their meals. A review of the resident's weights showed on initial admission on [DATE], the resident weighed 152.7 lbs. On 06/02/2023, the resident weighed 174.2 lbs., a 12% increase from admission, and 184.6 lbs. on 06/21/2023, a 17% increase from initial admission, and 24.7 lbs. heavier than the ideal body weight of 159.9 lbs. assessed by the RD on 06/07/2023. Review of Resident 27's meal intakes revealed there was no documentation of the amount of oral fluids the resident was consuming each day. A review of Resident 27's Dialysis Communication Binder (a binder the residents receiving dialysis brought back and forth with them to their sessions to document communication between the dialysis center and facility) revealed the following: -the resident's dialysis access site was via a catheter inserted in their chest; they had no shunt. -the 06/02/2023 correspondence from the dialysis center noted Resident 27 had 2.6 liters (L) of fluid drawn off since their session two days prior, and to please make sure they were restricting fluid intake to 1500 milliliters (ml., equivalent to 1.5 L) daily. -the 06/16/2023 pre-treatment facility correspondence documented Resident 27 was wheezing and congested. There were no vital signs documented. -multiple pages in the communication book were missing - 05/15/2023, 05/17/2023, 05/22/2023, 05/29/2023, 06/07/2023, 06/21/2023, and 06/23/2023. -multiple pages in the communication book were incomplete and missing entries from the dialysis center regarding each session, and post-treatment documentation by the facility on 05/19/2023, 05/24/2023, 05/26/2023, 06/14/2023, and 06/16/2023. One page was undated and was missing pre-treatment facility documentation. A request for the missing communication pages was made on 06/28/2023 at 7:32 AM, and again at 9:49 AM. None were provided. On 06/23/2023 at 9:17 AM, Resident 27 was observed in their room finishing their breakfast. They stated they went to dialysis three times a week and came back, ate then went to bed, because their sessions made them so tired. In a follow-up interview on 06/28/2023 at 8:03 AM, Resident 27 stated they never had a shunt in their arms. The resident stated they used to have a catheter in their neck, then it got moved to their chest. Resident 27 pulled their shirt over to reveal a white dressing under their right collar bone. The dressing was clean and intact. Resident 27 stated they were not on a fluid restriction, and they ate a lot of ice chips. Resident 27 stated they were told often at the dialysis center to watch how much fluid they were getting but was not told that at the facility. During a telephone interview on 06/28/2023 at 10:03 AM, the staff Registered Nurse (RN) at the dialysis center, stated the facility communicated with the dialysis center via the communication sheets in the resident's binder. If the sheets were not sent with the resident nothing was filled in. The RN stated the 06/02/2023 communication sheet requesting the facility follow a 1500ml. fluid restriction would have been accurate because Resident 27 came to their dialysis sessions with a significant amount of fluid on board. The center had been trying to establish a dry weight (a baseline weight without the excess fluid that built up between dialysis sessions) for the resident, and if they were drinking more than 1500 mls. each day, the extra fluid leaked into the resident's lungs and extremities, and they would not be able to get rid of it during their sessions. The Charge RN joined the interview and stated the communication sheets if sent with the resident, contained a resident's vital signs, how much food was eaten, any medications that were administered, and any recommendations. The Charge RN stated a 1500 ml. renal diet that restricted fluids, potassium and sodium was standard for their dialysis residents, and they were not aware Resident 27 had not been on a fluid restriction. During an interview on 06/29/2023 at 12:31 PM Staff R, Nursing Assistant (NA), stated to prepare Resident 27 for dialysis, staff were to obtain the resident's vital signs, weigh the resident, and add those to the resident's communication binder. When the resident returned from dialysis the binder was to be put at the desk for the nurse to review. During an interview on 06/29/2023 at 1:01 PM Staff D, RD, stated the provider ordered fluid restrictions for residents, and the dialysis center had not recommended one for Resident 27. Staff D had recommended 25-30 mls./kg. (1820-2181 mls.), per the resident's ideal body weight. Staff D stated they communicated often by phone or fax with the dialysis center, and the dialysis center was in charge of the resident's orders. Staff D did not review the communication binders, and was not aware of the 06/02/2023 correspondence requesting facility staff maintain a 1500 ml. fluid restriction. If there were other recommendations on the communications sheets, Staff D would not have seen them. The nutrition care plans were created by the food services manager and were reviewed quarterly. Staff D did not attend any meetings regarding care plans, but care plans were discussed at the Resident at Risk (RAR) meeting. Staff D stated Resident 27's weight gain was concerning, but the resident had a good appetite and was on double portions. Staff D stated they would have to call the dialysis center to learn what the resident's dry weight was, that it was likely lower than the resident's current weight, and the dry weight was something that was important to include in the care plan. During an interview on 06/29/2023 at 4:19 PM, Staff V, NA, stated there was no place in the computer where fluid intake was documented, and there was no book to record fluid intake and output (I&O's) either; they recorded what percent of the meals the residents ate. Staff V had worked at the facility for four years and had never been shown to document how much fluid a resident received. During an interview on 07/03/2023 at 3:11 PM with Staff O, Licensed Practical Nurse/Resident Care Manager (RCM), and Staff C, Assistant Director of Nursing, Staff O stated the providers gave staff orders for fluid restrictions or the dialysis center would, and Resident 27 did not have one ordered. Staff O and Staff C stated they did not review the communication binders when they came back from dialysis. Staff O stated fluid intakes were only monitored if there was an order to do so, but it would be important to monitor the fluid intake for Resident 27. They were unsure why they never received an order for a fluid restriction for Resident 27 from the dialysis center. Staff O stated the communication sheets did not always get completed prior to a resident's dialysis appointment because the transportation picked up the resident before they were completed. Staff O stated they needed to do something about that. Staff C stated Resident 27 did not have a shunt for their dialysis access so assessing for a thrill and bruit did not apply to the resident. They were not doing any chart audits for their dialysis residents. During the same interview, Staff C stated all services had access to the care plans, and all services created them. Per Staff C, the nurse that admitted the resident was to start the care plan. Care plans were reviewed quarterly and Resident 27's care plan had not been reviewed yet. Staff C stated items that should have been included in Resident 27's care plan included knowing where their access site was, who was to monitor it, and to provide the access site dressing changes, what to do if the dressing became soiled or removed, what facility their dialysis treatments occurred at, who to contact for dialysis related complications, and what complications to monitor for such as fluid overload or low blood pressure. Staff C stated they were adding those elements to Resident 27's care plan at the time of the interview. During an interview on 07/06/2023 at 4:11 PM Staff B, Director of Nursing Services, stated residents had a binder they took to their dialysis sessions that were to include pre-and post-treatment communications and the dialysis center added what happened during the session and the dry weight. The facility had not been monitoring the resident's fluid intake, but it was a nursing standard of practice to monitor fluids for residents receiving dialysis. Staff B expected the nurses to review the communication binders when the residents returned from their sessions and follow up on any concerns or orders included. Staff B had recently implemented a system to double check a resident's orders, and also stated resident care plans were to include resident specific goals and interventions. Reference: WAC 388-97-1900(1)(6)(a-c) Based on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 2 of 3 sampled residents (Residents 11, 27), reviewed for dialysis. In addition, the facility failed to process a medication order from the dialysis center timely for Resident 11, which resulted in a delay in the medication being administered. These failures placed the residents at risk for unmet care needs and medical complications. Findings included . <Resident 11> The 05/30/2023 admission assessment showed Resident 11 was cognitively intact to make decisions regarding cares, had medically complex conditions, and diagnoses which included kidney disease, and diabetes (a disease caused by the inability of the body to convert the food we eat into sugar needed for the cells to use as energy). In addition, the assessment showed the resident received dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys stopped working properly). Review of the 07/23/2018 agreement between the facility and the dialysis center showed care of residents receiving dialysis was to be coordinated between the facility and the dialysis center, to ensure continuity of care and the resident's well-being. The facility dialysis policy showed the facility must ensure that residents who required dialysis received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The policy further instructed nursing staff to follow physician orders regarding medication administration prior to and after dialysis, and to transcribe any diet, medication, and/or orders received from the dialysis facility. In an interview on 06/22/2023 at 10:10 AM, Staff BB, Licensed Practical Nurse, stated the resident went to dialysis on Mondays, Wednesdays, and Fridays. On 06/23/2023 at 10:42 AM, Resident 11 was observed sitting in their wheelchair at the sink in their room. The resident stated they were getting ready to go to their dialysis appointment. Review of the dialysis care plan showed interventions were implemented on 05/26/2023, but did not include the dialysis center's contact information or address, nor were instructions provided to the nursing staff on what to do or who to contact at the dialysis center in the event of an emergency, medical complications, or change in the resident's condition. Review of the resident's record showed a medication order from the dialysis center was received on 06/19/2023 that prescribed a medication to decrease phosphorus levels (a mineral in the body found primarily in the bones and teeth). Review of the Resident 11's record showed an order was received from the dialysis center on 06/19/2023 that prescribed a medication (Sevelamer) to decrease phosphorus levels. The Order Summary Report, dated 06/29/2023, showed the resident had not started to receive the Sevelamer until 06/27/2023, eight days after being prescribed. In an interview on 06/30/2023 at 1:19 PM, the dialysis center's Registered Dietician (RD), stated the resident had been started on a phosphorus binder (Sevelamer) on 06/19/2023, to help keep their phosphorus levels within normal range. When informed the medication had not been started until 06/27/2023, the RD stated they were not aware of that. In an interview on 07/03/2023 at 11:33 AM, when asked how the facility communicates with the dialysis center, Staff E, Licensed Practical Nurse, stated each dialysis resident had a binder with communication forms that was sent with and brought back from the dialysis appointments. The pre-section of the form was filled out by the nurse prior to the resident leaving, then the dialysis staff documented any concerns that occurred during the treatment, and upon return from the appointment, the nurse was to complete the post-section. When asked about the delay with the resident receiving the Sevelamer, Staff E stated they did not know why the medication was started late. Review of Resident 11's dialysis binder showed the dialysis communication forms from 05/26/2023 through 06/29/2023 were not consistently filled out. Out of 15 dialysis treatments during that time frame, the forms were fully completed only four times, no post assessment/section was completed six times, and there was no form found for five of the treatment days. In an interview on 07/03/2023 at 3:59 PM Staff F, Resident Care Coordinator, confirmed the dialysis binder went with the resident during their appointments, the communication forms needed to be completed so the facility and dialysis center were informed of any concerns and/or changes in the resident's condition, and the nurse should be checking the binder upon the resident's return. When asked why there had been a delay with the Sevelamer being started, Staff F stated they were not aware that the order from the dialysis center had been sent back with the resident in their binder. Staff F stated they had checked the binder on 06/27/2023, found the order, and processed it immediately. In a follow-up interview on 07/05/2023 at 9:51 AM, after discussion and review of Resident 11's dialysis care plan, Staff F acknowledged it did not include contact information for dialysis center, or instructions to nursing staff on what to do in an emergency.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to acquire and administer medications timely for 2 of 6 sampled residents (Residents 8, 203), reviewed for pharmaceutical services. This failure resulted in a delay of medication administration, and potential for worsening medical conditions. Findings included . <Resident 8> Per the 04/17/2023 assessment, Resident 8 was admitted with diagnoses to include dementia and dysphagia (a swallowing disorder). Per a progress note on 04/03/2023 at 12:08, an outside provider phoned the facility with an order for Protonix (a medication that treats heartburn, ulcers, and acid reflux - a condition in which stomach acid goes into the esophagus), related to ulcers being found. Resident 8 was already receiving famotidine, a medication that treated the same conditions. A review of the physician orders and progress notes from 04/03/2023 through 05/04/2023 showed the medication was unavailable and not provided (due to a need for a prior authorization), the physician was aware, and the resident did not receive the Protonix during that time period. A progress note on 05/05/2023 at 8:09 PM showed Resident 8 vomited a small amount of blood and a small amount was of blood was also seen in the trash. The on call provider was notified and ordered to increase the famotidine. The resident denied abdominal tenderness, had emesis earlier in the shift and no blood was noted. A progress note written on 05/06/2023 at 2:43 PM showed the Protonix was discontinued and Prilosec (a medication in the same drug class as Protonix) was ordered. <Resident 203> Resident 203 admitted to the facility on [DATE] with diagnoses to include anxiety, and nicotine dependence. A 06/26/2023 Provider progress note showed the resident had smoked two packs of cigarettes daily for many years. Resident 203 was admitted with orders for a Nicotine Step 2 transdermal (applied to the skin) patch, apply once daily and remove prior to placing the next patch. During an interview on 06/22/2023 at 2:56 PM, Resident 203 stated their nicotine patch was wrinkled so they took it off. Resident 203 stated they had reported it to the nurse, and it was not replaced. Resident 203 added that it still had not been replaced at the time of the interview. Resident 203 was observed to be anxious and tearful and requested help from the surveyor to get a replacement patch. A progress note written on 06/22/2023 at 11:36 AM documented a nicotine patch was not available for Resident 203. During an interview on 06/22/2023 at 4:44 PM, Staff O, Resident Care Manager, stated they thought the Administrator in Training (AIT) had gone earlier to purchase the nicotine patches. Staff O stated they would find out what was happening with the patches. Staff O and the surveyor met with STaff GG, AIT, who stated they would leave now to obtain the replacement patch. On 06/22/2023 at 4:57 PM, Staff GG, AIT approached surveyor and stated that they purchased the Nicotine patches and gave them to the nurse. During an interview on 06/23/2023 on 8:22 AM, Resident 203 stated the nurse placed a Nicotine patch on them the prior evening on 06/22/2023. During an interview on 07/05/2023, Staff B, Director of Nursing, stated when a new admission arrived, their orders were faxed to the pharmacy and medications were usually delivered at 8:00 PM the same day. The expectation was that nursing staff were to follow up with the pharmacy if medications did not arrive and were to report any concerns. Staff B added that if the medication was able to be purchased over the counter it was obtained the same day. Staff B stated that the issues with the medications should have been addressed sooner. Reference: WAC 388-97-1300 (1)(a)

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure proper monitoring of medication which affected blood pressure was consistently done for 1 of 5 sampled resident (Resident 3), reviewed for unnecessary medications. This failure placed the resident at risk for potential adverse side effects and medical conditions. Findings included . Per the 05/10/2023 quarterly assessment, Resident 3 had diagnoses which included high blood pressure and atrial fibrillation (an irregular heart rhythm). Review of the Order Summary Report from 01/01/2023 through 06/30/2023 showed the physician ordered a blood pressure medication (Metoprolol) on 05/18/2023 to be given twice a day. The order instructed nursing staff to hold the medication if the heart rate was below 55 beats per minute or if the top number of the blood pressure (systolic) was under 110, to recheck the blood pressure in an hour, and to notify the doctor and document a nursing note in the resident's record. Review of the June 2023 Medication Administration Records (MARS) showed the AM dose of Metoprolol was held on 06/02/2023, 06/05/2023, 06/08/2023, 06/09/2023, 06/10/2023, 06/15/2023, 06/16/2023; and the PM dose was held 06/07/2023, 06/11/2023, 06/12/2023, 06/13/2023, 06/15/2023, 06/16/2023, 06/18/2023, 06/20/2023, 06/21/2023, 06/22/2023, and 06/23/2023. In addition, the record showed the Metoprolol was given despite the systolic blood pressure being below 110 for the AM dose on 06/19/2023, 06/24/2023, and 06/27/2023, and the PM dose on 06/10/2023, and 06/24/2023. Review of Resident 3's record which included progress notes and vital sign records showed no documentation that the resident's blood pressure had been rechecked on the dates that the medication had been held or that the physician had been notified. In an interview on 07/06/2023 at 3:27 PM Staff F, Resident Care Coordinator, stated the expectation was that the physician's order would be followed, the medication held, blood pressure rechecked, and a progress note and call to the physician should have been made. When informed of the findings related to Resident 3's Metoprolol and blood pressure values, Staff F stated they were not aware and would need to follow-up with nursing staff. Reference (WAC): 388-97-1060 (3)(k)(i)

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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Based on observation, interview, and record review, the facility failed to ensure 1 of 8 sampled residents (Resident 205) reviewed for medication administration, was free from significant medication errors. Failure to completely process a medical provider's order for a narcotic pain medication caused increased sedation for Resident 205, and placed the resident at risk for medical complications, and unmet care needs. Findings included . Per the 06/16/2023 admission assessment, Resident 205 had moderate cognitive impairment, was able to make needs known, and had medically complex conditions which included anxiety, depression, and chronic pain. In addition, the assessment showed the resident had frequent pain and received a narcotic pain medication daily. A progress note on 07/04/2023 at 10:53 PM documented that a visiting family member informed the nurse that something was wrong with the resident. The resident was observed to be sweating profusely, weak, shaky, and intermittently responsive. Vital signs were within normal values, but the resident's respirations had become slower and shallower during the assessment. Emergency personnel was called, and due to possible sedation from the prescribed evening medication, the resident was sent to the emergency room to be evaluated. Review of the 07/04/2023 Emergency Department Encounter showed the resident was assessed due to an altered mental status, was sleepy, but followed commands and verbal stimuli, and was in no respiratory distress. Per the form, the resident was given Narcan (a medication used to reverse or decrease the sedating effects of narcotic medication), and the resident's altered mental status resolved. The above form determined the resident's change in mental status was likely due to receiving multiple medications which included the Trazodone and Hydrocodone. After a short observation, the resident returned to the facility early the following morning on 07/05/2023. On 07/06/2023, Resident 205 was observed lying on the bed in their room. When asked how they were doing, the resident stated they had been sent to the hospital recently for being too sedated. The resident further stated they believed the nurse gave them too much pain medication and before they could get the medication back, they had to be seen by the doctor. Review of the 07/06/2023 Order Summary Report showed on 07/03/2023, the medical provider had prescribed a narcotic pain medication (Hydrocodone-Acetaminophen) 7.5-325 milligram (mg.) to be given four times a day to treat the resident's chronic pain. On 07/04/2023, the dose was increased to 10-325mg. Review of the June 2023 Medication Administration Record (MAR) showed the order to change the pain medication dose from 7.5-325mg to 10-325mg was transcribed on 07/04/2023 at 9:56 AM, however, the order to discontinue the 7.5-325mg dose was not done until 2:25 PM. Review of the narcotic ledger (a book used to sign out and track the number of doses given of a narcotic medication or medication that is of high risk for abuse) showed Resident 205 received the 10-325 mg. dose of the pain medication on 07/04/2023 at 1:28 PM and four minutes later, at 1:32 PM, the resident also received the 7.5-325 mg. dose. This caused the resident to receive an excess of narcotic pain medication and resulted in a significant medication error. Further review of the June 2023 MAR showed the resident received the pain medication at 8:00 PM on the evening of 07/04/2023 as prescribed. In addition, the MAR showed the resident also received medication to treat depression (Trazodone), and medication to treat anxiety (Pregabalin), all of which are known to cause the side effect of drowsiness. In an interview on 07/07/2023 at 11:50 AM Staff B, Director of Nursing, acknowledged the order changing the dose of the pain medication was not processed completely, an investigation into the medication error was in process, and confirmed the error was a significant medication error. Reference: (WAC) 388-97-1060(3)(k)(iii)

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, the facility failed to ensure one of two medication rooms (east), had the narcotic box affixed that was placed in the refrigerator, as required. This failure placed unintended access by others to drugs because they were not locked up and/or unmovable. Findings included . In an observation on 06/26/2023 at 3:08 PM, Staff B, Director of Nursing (DON), provided access to the medication room on the east unit to the surveyor. The refrigerator was locked, and the unlocked narcotic box, inside the refrigerator, which contained Marinol (a schedule III medication used to treat nausea and increase appetite), was not permanently affixed, as to prevent potential drug diversion. During an interview on 06/06/26 at 3:15 PM Staff B stated the narcotic box should have been locked, and was unaware it needed to be permanently affixed. Staff B added that the issue would be resolved. Reference WAC: 388-97-1300(2), 2340

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 F0725 (Tag F0725)

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 ensure sufficient staff were available to meet the care needs for 4 of 17 sample residents (38, 22, 11, 31), reviewed for activities of daily living (ADLS), timely administration of medications, a clean and homelike environment, and supervision to prevent accidents. These failures placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . <ADLS and Resident Interviews> In an interview on 06/22/2023 at 9:47 AM, Resident 22 stated there was not enough staff to ensure cares are provided. During an interview on 06/22/2023 at 10:12 AM, Resident 18 stated there were not enough staff to provide cares. Resident 18 added they would like more showers but there was not enough staff. In an interview on 06/22/23 10:25 AM, Resident 45 stated they did not get changed timely during the night shift because there was not enough staff at night. They said they usually needed to be changed twice during the night but sometimes it only happened once. On 06/23/23 at 9:48 AM, when asked if the facility had enough staff to provide assistance timely, Resident 32 stated staff used to respond promptly, but now it took a while. It seemed they did not have enough staff at night, and Resident 32 stated they knew staff were tired, they worked over to help. During Resident Council on 06/26/2023 at 1:56 PM, Resident 46 stated staffing was poor, and it took a half hour or more for their call light to be answered. Resident 41, 44 and 4 nodded their heads in agreement. Resident 46 added that night shift was impacted the most. <Timely medication administration> Review of the record showed Resident 38 was admitted with diagnoses including right tibia (shin bone) fracture and restless leg syndrome. A 05/24/2023 comprehensive admission assessment documented Resident 38 was cognitively intact, received as needed pain medications, and day to day activities were limited due to pain. A review of the provider orders showed Resident 38 could receive oxycodone (pain medication) and Robaxin (a muscle relaxer) every 6 hours as needed for pain and muscle spasms. Staff were to stagger the Robaxin with the oxycodone to increase the pain control. A review of the 06/2023 medication administration record (MAR) showed that Resident 38 received Robaxin and oxycodone on 06/20/2023 at 4:41 PM. On 06/21/2023 at 3:23 AM, Staff K, Licensed Practical Nurse (LPN) entered an administration code 1 indicating the resident refused the Robaxin and oxycodone at that time. During an interview on 06/22/2023 at 11:10 AM, Resident 38 stated on the night shift, they were not receiving their pain medications and muscle relaxers when they were due. Resident 38 stated they got muscle spasms frequently during the night that caused them pain and interrupted their sleep. In a follow-up interview on 06/23/2023, Resident 38 stated on 06/20/2023, they requested their medication at 11:30 PM and Staff K brought the requested medications to the resident on 06/21/2023 close to 4:00 AM. Resident 38 stated it was so close to the dayshift by then that they refused to take the medications. They wanted to wait until the day shift staff arrived because they were better at bringing in the medications timely. Resident 38 stated that was not the only time they waited for their medications, it was just the most recent example. During an interview on 06/28/2023 at 4:16 AM, Staff K stated they were the only nurse in the facility at that time and on the shifts when they worked nightshift. Being the only nurse made it difficult to get their work completed. During an interview on 07/03/2023 at 2:56 PM, Staff O, LPN Resident Care Manager, stated if Resident 38 was due for a dose of their medications when they requested them, but did not receive them until 3:23 AM, that would not be timely. Staff O stated their current staffing pattern called for one nurse on the night shift, but Staff O did not think that was sufficient. Staff O stated the staff would report that one nurse and 2 or 3 nursing assistants was a heavy load, and they had a hard time keeping up with their tasks. <A clean and homelike environment> On 06/28/2023 at 5:26 AM, Staff R, NA, stated they came in every morning at 5:00 AM just to help out and the facility was aware. Staff R confirmed that night shift was responsible to clean the wheelchairs, but with only two or three NAs, it could not be done. <Supervision to prevent accidents> A review of the facility accident and incident logs showed that on the weekend of 06/23/2023 through 06/26/2023, there were six resident falls. Review of the staffing schedules for the same time frame showed five NA staff called in, an NA member who had been terminated 06/16/2023 was still on the schedule to work on 06/23/2023, and three NAs walked off the job. On 06/26/2023 at 12:50 PM, Staff J, Nursing Assistant, stated they worked the day shift and a lot of times, when they came to work, would find that night shift only had two nursing assistants. That happened on the night of 06/24/2023. StaffJ stated when they arrived for their shift on 06/25/2023, there were only two nursing assistants, because one had left halfway through the shift. Review of the staffing schedule confirmed that on the night of 06/24/2023, there were 2 NAs on duty when Staff J arrived to work. In addition, the schedule showed Staff J walked off the job shortly after arriving for their shift. On 06/28/2023 at 04:00 AM, the following observations were made through out the facility-there was one licensed nurse and three nursing assistants to provide resident cares to all 57 residents. On 06/28/2023 at 4:45 AM, when asked if there was enough staff to provide resident care, Staff II, Nursing Assistant, stated staffing was horrible, usually there were only two NAs on night shift and that was not enough. A lot of residents required two NAs for care and there were several residents that needed cares multiple times throughout the shift. Staff II stated that with just two NAs, often times one of the staff was not available, so care ended up being provided by just one staff, otherwise the resident was neglected because they did not receive the care they needed. Staff II further stated that the concerns about the staffing had been expressed, and the response from management was that when the resident census reached 52, then four NAs would be scheduled, but when it reached 52, then we were told 54, then 55, and then it was 57, and now it had been changed to 60. In an interview at 5:26 AM on the same day, Staff JJ, Nursing Assistant, stated on Friday night (06/23/2023), there were three NAs on the schedule, but there were only two, since the third NA was no longer employed at the facility, but had not been removed from the schedule. Review of the staffing schedule confirmed what Staff JJ stated. On 06/28/2023 at 5:27 AM, Staff K, LPN, stated tonight was the first night that they had worked with three NAs, usually there were only two NAs. Staff K further stated it was hard being the only nurse on night shift; they never knew who the staff was going to be or if there would be enough staff. In a follow-up interview on 06/28/2023at 5:28 AM, Staff II stated on Sunday (06/25/2023), Staff KK, NA left work at 3:15 AM, 15 minutes before last rounds (the last check done on residents to see if cares were needed) started. Staff II was concerned night shift would be short staffed, since Staff KK had not been taken off the schedule, and was scheduled to work tonight. This was also confirmed after review of the staffing schedule for the night of 06/24/2023 and morning of 06/25/2023. In an interview on 07/06/2023 at 4:37 PM, Staff B, Director of Nursing, confirmed that the facility had a staffing shortage. When asked if the staffing shortage contributed to the falls, Staff B stated they believed it did and further stated some residents were heavy care and took a lot of time. Please see F584, F677, and F689 for additional information Reference: WAC 388-97-1080(1)

CONCERN (F)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Staff D, the Registered Dietician (RD) had proper qualifications. This failure placed residents at risk for nutritional mis-management and potential decline. Findings included . The 05/23/2023 Facility Assessment tool showed the facility residents required and were to be provided nutrition care that included individualized, liberal, or specialized diets, assistive devices, cultural or ethnic dietary needs, and fluid monitoring or restrictions. A dietician or other clinically qualified nutrition professional was to serve as the director of food and nutrition services. The 07/01/2016 Agreement for Dietary Consulting Services showed the Consultant certifies that the Consultant is licensed by and registered in the state in which the Facility is located and has all other approvals and certificates required by state and federal agencies in order to qualify for and participate in Medicaid and Medicare and other healthcare programs. The Consultant was to provide a Registered Dietician to assist in providing nutrition and dietary services. A review of credentials for Staff D, RD, showed they held an Idaho license as a dietician issued by the Idaho State Board of Medicine. During a telephone interview on 06/28/2023 at 12:56 PM, a representative from the Washington State Department of Health (DOH, the agency responsible for professional licensing oversight) stated that a license was required to practice as a Registered Dietician in the State of [NAME]. During an interview on 06/29/2023 at 1:01 PM, Staff D, RD stated they had been an RD since 2019 and practiced in both Idaho and [NAME]. Staff D stated they did not have a license from Washington State; their boss told them they did not need one, but they were planning on applying for one. Reference: WAC 388-97-1160(1)

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 and interview, the facility failed to label and date food products, and to discard of food products on or before the expiration date. This failure placed the residents at risk for food-borne illness. Findings included: <Food labeling and storage observation> Observation of facility kitchen dry food storage area on 6/22/2023 at 09:00AM showed expired food which included: 1 can of chili with an expiration date of 3/2023 6 cans of chili with an expiration date of 4/2023 15 packages of tortillas with and expiration date of 4/2023 2 cans of pork and beans with an expiration date of 3/2023 1 can of butterscotch pudding with and expiration date of 4/2023 3 cans of chow Mein noodles with and expiration date of 7/18/2022 5 bags of raisins with an expiration date of 1/2023 2 bags of marshmallows with an expiration date of 5/2023 Observation of facility kitchen pantry on 06/28/2023 at 5:33 AM, 4 expired food items, as well as 26 open food containers with no use by date and/or opened date were found. In an interview on 07/03/23 at 12:16 PM with Kitchen Staff Member Z, and in an interview on 07/06/2023 at 2:29 PM with kitchen Staff Member U, they both stated the use by dates should be written on the food packages when the items are put into the food storage areas, and the person opening a food item should write the opened date on the food item package. They stated food items should be monitored for expiration dates weekly and if a food item was open and had no opened date or use by date written on it, it should not be used and should be thrown away. On 06/22/2023 9:32 AM, an observation was made of the east nursing unit kitchenette. Inside the upper cabinet there was an open bag of potato chips.The manufacturer expiration date was 01/2023. The refrigerator was opened, and multiple outdated or unlabeled food items were observed: -two small cartons of milk in the door with expiration dates of 05/31/2023, -a denture cup in the door rack that contained butter labeled with a resident name and a date of 02/11/2023, -a cardboard pizza box that contained leftover pizza dated 6/11/2023, -a sandwich bag that contained half an egg salad sandwich dated 06/19/2023, -a half gallon container of apple juice that was half full, labeled with a resident name and a date of 04/10/2023, and -a grocery bag that contained dirty crushed leftover oriental take out food that was not labeled with a resident name or date. On 06/23/2023 at 9:29 AM, the outdated foods were no longer observed in the refrigerator. On 06/26/2023 at 8:56 AM, the refrigerator contained an empty sandwich bag, lying on top of other food containers that had a use by date of 06/25/2023 written on it, and a franchise pizza paper bag with handles that contained leftovers in a plastic salad-type bowl, and a soda drink inside it. The bag was not labeled with a resident name or date. During an interview on 07/03/2023 at 3:11 PM Staff C, Assistant Director of Nursing, stated housekeeping staff and kitchen staff were responsible for maintaining the east nursing unit kitchenette. During an interview on 07/06/2023 at 2:29 PM Staff U, Food Services Manager, stated everyone was responsible to check for out-dated foods. Staff U stated they wiped down the east nursing unit kitchenette refrigerator, and if there was a spill, they got housekeeping to help clean it up. Staff U expected staff to label foods in the refrigerators with a resident's name and date. Reference: WAC 388-97-1100(3)

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

<Medication Pass> During an observation on 06/26/2023 at 7:05 AM Staff HH, Licensed Practical Nurse, was passing medication. Staff HH had given Resident 4 their medications except for eye drops....

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<Medication Pass> During an observation on 06/26/2023 at 7:05 AM Staff HH, Licensed Practical Nurse, was passing medication. Staff HH had given Resident 4 their medications except for eye drops. Staff HH sanitized their hands and donned a pair of gloves. Staff HH leaned forward to give the eye drops, when the urinary catheter bag fell onto the floor. Staff HH picked up the catheter bag and hooked it to the side of the bed, and then proceeded to give Resident 4 their eye drops without performing hand hygiene and changing their gloves. During an interview on 06/26/2023 at 7:18 AM, Staff HH stated they should have completed hand hygiene and changed their gloves prior to giving the resident their eye drops as this could have placed them at risk for an infection. Reference (WAC): 388-97-1320 (1)(c), (2)(a) Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment. Failure to ensure hand hygiene was completed and gloves were changed between clean and dirty tasks while medications were given for 1 of 6 sampled residents (Resident 4) reviewed for medication administration, and to ensure staff were informed and preventative measures were implemented to prevent the spread of bed bugs, prior to admitting a resident (Resident 153) placed the residents at risk for infectious diseases and a decreased quality of life. Findings included . <Safe and Sanitary Environment> Observations showed the following: - On 06/22/2023 at 8:32 AM, a mobile cart was sitting in the corner of the conference room that had been provided to the survey team. On the second shelf of the cart, a box without a lid was full and contained used COVID-19 tests. In addition, a quarter full drink cup containing green liquid was sitting on the cart. Staff B, Director of Nursing, was present and when the survey team requested the cart be removed, stated they didn't know the cart was there and promptly removed it. The room was accessible to residents, and was often used to allow visitors to meet with them. - On 06/22/2023 at 9:01 AM, the mobile cart containing the box of used COVID-19 tests was in the copy room which was next to the conference room that had been provided to the survey team. The room was not locked and was easily accessible to residents. - On 06/22/2023 at 9:22 AM, a treatment cart containing personal protective equipment and COVID-19 test kits (located in the hallway near the east nursing station by the side entry door to the facility, and easily accessible to residents) had a small red bucket on the top, containing six used COVID-19 tests, and visible coffee ring stains. A sign on the bucket stated processed tests would be collected in the AM. On 06/26/23, observations showed: - 8:39 AM, the box containing the used COVID-19 tests was no longer on the mobile cart in the copy room, but a plastic container with cupcakes was sitting on the counter next to the cart. - 8:42 AM, the red bucket still contained the six used COVID-19 tests. There were three tests dated 06/23/2023 that did not have visible staff names, one test dated 06/20/2023 for Staff LL, Dietary Aide, and two tests for Staff MM, Cook, dated 06/16/2023 and 06/23/2023. - 8:54 AM, the coffee ring stains had been cleaned from the top of the treatment cart, but the red bucket still contained the used COVID-19 tests. On 06/27/2023 at 7:56 AM, the red bucket was observed to be empty. At 11:15 AM, food crumbs were observed on the counter at the west nurse's station. On 06/29/2023 at 12:36 PM, an undated/named used COVID-19 test was observed sitting on a paper towel on a counter at the west nurse's station. During the observation, Staff GG, Administrator In Training, walked by and confirmed the used test should not be on the counter, and tests should be discarded after use. <Preventative Measures> On 06/22/2023 at 4:00 PM, Resident 153 was observed lying in bed. The resident stated they had been in the hospital recently, and was unable to return home due to having increased falls, and because the home had bed bugs. On 06/28/2023 at 5:18 AM Staff NN, Nursing Assistant (NA), stated the night after Resident 153 was admitted , they observed bugs on the floor under the resident's wheelchair, and notified the nurse. On 06/28/2023 at 5:26 AM Staff R, NA, stated the nursing staff were not informed about the bed bugs before the resident admitted , and when the bugs were observed, the staff closed the door, the resident's belongings were triple bagged and taken to the laundry, the resident was showered, and then moved to a new room. No further bugs were observed afterwards. A progress note on 06/08/2023 at 3:26 PM showed the resident was showered that day and moved into a new room, while the previous room was being sprayed for bed bugs brought in by Resident 153's wheelchair. In an interview on 07/07/2023 at 12:53 Staff B, Director of Nursing, stated the facility was aware of the bed bug infestation of Resident 153's home prior to their admission to the facility, and the hospital discharge plan was to send the resident to the facility without their wheelchair or personal belongings, but the resident arrived at the facility with their belongings. Staff B stated the discharge plan had not been communicated to the nursing staff prior to the resident's admission.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 assess and document wound characteristics (size, depth, and tissue appearance) from 05/05/2023 to 05/25/2023 for a diabetic ulcer (open sores usually caused by diabetic complications, related to the body being unable to produce adequate insulin, resulting in fluctuating blood sugar levels and poor circulation) on the bottom of the foot for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure related skin wounds. The facility also failed to assess and document the condition of a wound between the toes of the same resident. Failure to thoroughly assess and document the wound appearance, to determine the effectiveness of treatment, and if the wounds were better or worse, placed the resident at risk for unmet care needs and potential worsening of the wounds. Findings included . According to the 06/08/2023 assessment, Resident 1 was admitted with diagnoses to include kidney disease, a lung infection, and diabetes (defined above). Resident 1 was able to make their needs known and required extensive assistance with most activities of daily living. Review of Resident 1's care plan, dated 05/05/2023, showed the resident had a non-pressure ulcer on the foot and toes, related to diabetes. Per the care plan, staff were to assess the location, size, and treatment of the skin impairments. Per the care plan, abnormalities, failure to heal, and/or signs or symptoms of infection were to be reported to the physician. During an interview on 06/08/2023 at 10:45 AM, Resident 1 was sitting up in a wheelchair in their room. The resident had a non-skid sock on the left foot, covered by a canvas shoe. Resident 1 stated their biggest worry was their foot. Resident 1 stated numerous times it was discussed they might have to amputate the foot. Resident 1 said they were worried about not receiving proper care of their foot while in the facility, and having to have the foot amputated. On 06/13/2023 at 2:47 PM, Staff A, Registered Nurse (RN), entered the room with the surveyor. Resident 1 was observed sitting up in their wheelchair with the left foot elevated on a chair. Staff A removed the canvas boot and non-skid sock. The dressing change had been completed earlier that day, and the resident requested the dressings not be removed. The resident had gauze packed between the 4th and 5th toes, a dressing on the bottom of their foot, and on the left heel. Review of the facility form titled Admission/readmission Collection Tool,dated 05/05/2023, showed Resident 1 was admitted with a wound on the bottom of the left foot, which measured 7.0 centimeters (cm.) x 3.0 cm. x 2.0 cm. The document showed the wound was tunneling (an opening underneath the skin), 3.5 cm. deep. The resident also had a tunneling wound between the 4th and 5th toes, which measured 3.0 cm. deep. Review of the electronic medical record showed Resident 1 was at the hospital from [DATE] until readmission on [DATE], after hip surgery for a fracture. The Admission/readmission Collection Tool, dated 05/13/2023, showed the resident had several areas of skin impairments identified which included the left bottom foot and between the pinky and 4th toe. The only description of the wound was tunneling. There was no further assessment of the wounds to include measurements or the appearance of the wound (color, drainage, tissue condition). Review of nursing progress notes from 05/13/2023 to 05/25/2023 showed the dressing changes were completed. There were no assessments documented, with the exception of progress notes, dated 05/17/2023, 05/22/2023 and 05/23/2023, which showed drainage present, no signs of infection, but no other description. On 05/25/2023, an outside wound consultant visited Resident 1. The visit notes from that date were reviewed, and showed the left bottom foot was evaluated. The size of the wound measured 7.5 cm. (slightly larger than the last recorded measurement) x 3.0 cm. x 0.0 cm, and documented the wound had slough (dead tissue usually cream or yellow in color), a moderate amount of drainage, with no signs of infection. The wound specialist debrided the wound (removal of damaged tissue), and recommended a new treatment to the foot. The consultation did not show the area between the 4th and 5th toes had been evaluated. Review of a wound observation form, dated 05/25/2023, was completed by the facility and corresponded with the outside wound consultant's measurements and descriptions of the wound. Resident 1 was sent to the hospital for a lung infection on 06/03/2023 and readmitted on [DATE]. The resident's Admission/readmission Collection Tool, dated 06/06/2023, described Resident 1's wound as a large foot wound and small wound between the 4th and 5th toes, without further assessment or description. A Wound Observation form dated 06/09/2023, showed the left bottom foot wound measured 7.2 cm. x 3.0 cm x 0.0 cm with 76-100% slough and some drainage. The form included Resident 1's wound between the 4th and 5th toes which measured 1.1 cm. x 1.2 cm. x 1.8 cm, with 11-25% slough, and exposed the connective tissue and muscle. These were the first measurements and description of the toe wound since admission on [DATE], over 30 days later. The description of visible connective tisue and muscle had never been mentioned previously. During an interview on 06/13/2023 at 12:15 PM, Staff B, Resident Care Manager (RCM), stated the cart nurses did wound care treatments, and every week an outside wound consultant visited the building. When asked who was followed by the outside wound consultant, Staff B stated it would depend on the severity of the wound and what was going on with a wound. Per Staff B, Resident 1 was not initially evaluated by the wound team because they were in and out of the hospital several times. In a follow-up interview at 2:12 PM, Staff B was asked prior to the outside wound consultant seeing Resident 1 on 05/25/2023, who assessed the resident's wounds for healing and/or measured the wounds. Staff B stated Resident 1 had treatments being done, as ordered by the physician, but no further assessment to include measurements were being done. During an interview on 06/13/2023 at 3:35 PM, Staff C, Administrator, stated if a resident was not being seen by the outside wound consultants then the cart nurses or RCM's could go in and asses and measure resident wounds. The resident would also be evaluated in the resident at risk meetings. The meetings evaluated resident nutritional needs due to having a wound, and they would review the wound notes. Resident 1 was currently reviewed in the at risk meetings. Additional information was requested to show that more frequent assessments of Resident 1's wounds had been done, to include measurements and descriptions of the wounds. Nothing further was provided. Reference: WAC 388-97-1060(1)(3)(b)

May 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

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 personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines by 12 staff (A, D, E, F, G, H, I, J, K, L, M, N), when reviewing infection control practices. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. In addition, failure to ensure fit testing (a test done to ensure an N95 mask [a particle filtering device worn over the mouth and nose] formed a tight seal) was completed for 9 of 12 staff (A, D, F,G, H, I, J, L, N), reviewed for fit testing, further placed residents and staff at risk for contracting COVID-19. Findings included <Mask Placement> According to the 03/16/2022 CDC publication, How to use Your N95 Respirator, N95 masks must form a seal to the face to work properly. The document showed the mask should be placed under the chin, with the nose piece bar at the top, with the top strap pulled over the head and placed near the crown, and the bottom strap at the back of the neck, below the ears. The straps should lay flat, be untwisted, and not be crisscrossed. The Facial Hairstyles and Filtering Facepiece Respirators guide published by the CDC in 2017 showed a beard does not allow for a tight-fitting seal for a respirator type mask (such as an N95). On 05/16/2023 at 4:10 PM a sign posted at visitor check-in desk in the facility lobby showed, Effective May 4, 2023, all visitors and staff must wear an N95 and googles and/or a face shield. At 4:12 PM, Staff A, Administrator confirmed the facility had a COVID-19 outbreak that started 05/02/2023, and all residents and staff had recovered. Staff A was observed to be wearing an N95, and had a visible beard with facial hair present on both sides of the face around the edges of the mask and under the chin and neck. On 05/17/2023 at 10:04 AM, Staff E, Nursing Assistant was observed wearing an N95 with both mask straps behind their neck. At 10:05 the same day, Staff F, Licensed Practical Nurse, was observed wearing eye protection and an N95 with the top strap placed on the top of their head; no bottom strap was present. On 05/17/2023 at 10:23 AM, Staff D, Resident Care Manager, was observed wearing an N95 with the top strap placed on the top of the head; no bottom strap was present while talking to a resident in room [ROOM NUMBER]. On 05/17/2023 at 10:30 AM, Staff G, Occupational Therapist, was observed wearing an N95 over a visible beard with facial hair present on both sides of the face, around the edges of the mask. When asked about the placement of the straps, Staff G reached up and checked the straps, confirmed the top strap should be above the ears and moved the strap. Staff G stated they got a good seal with the N95 with their beard, and were fit tested about three or four months ago, and had a beard at that time. On 05/17/2023 at 10:37 AM, Staff D was again observed wearing an N95 with the top strap placed and no bottom strap behind the neck as required. The mask had visible gaps on the sides, and was turned sideways, with the metal nosepiece resting just to the side of the nose and not over the bridge of the nose. When asked about the straps and if they had been fit tested, Staff D stated they had a good seal, did not need the second strap, and had been fit tested with just the top strap in place. Staff D readjusted the mask several times while talking. On 05/17/2023 at 10:43 AM, Staff N, Nursing Assistant, was observed going into room [ROOM NUMBER] while wearing an N95 and eye protection that was resting on the top of the head and not covering the eyes. At 10:47 AM, Staff N confirmed eye protection needed to be worn. On 05/17/2023 at 11:24 AM, Staff J, Nursing Assistant was observed wearing an N95 with both mask straps placed behind their neck. On 05/17/2023 at 2:36 PM, Staff F was again observed wearing an N95 with the top strap placed on the top of their head, and no bottom strap in place. Staff L, Registered Nurse, was observed standing at the medication cart wearing an N95 with both mask straps placed on the top of their head, and no eye protection in place. On 05/17/2023 at 2:38 PM, Staff H, Occupational Therapist, was observed wearing an N95 with the straps positioned correctly, but Staff H had a full beard that grew past the chin. On 05/17/2023 at 2:40 PM, Staff M was observed wearing a colorful tie-dyed N95. When asked if they had been fit tested, Staff M stated they had, but the mask they had been fit tested for dug into their skin and they couldn't breathe, so they were wearing the other mask because it was more comfortable. On 05/17/2023 at 2:45 PM, Staff L was again observed wearing both N95 straps on the top of the head. When asked about the placement of the straps and whether they had been fit tested, Staff L stated they had not been fit tested or been educated about how to wear the mask. After being informed about the proper strap placement, Staff L adjusted the straps correctly. On 05/17/2023 at 2:50 PM, Staff K, Nursing Assistant, was observed wearing a loose fitting N95, with the sides of the mask folded over causing gaps and the metal nose piece not pinched on the bridge of the nose. Staff K stated they had not received any education about how to wear the mask. After being informed the nose piece needed to be pinched and the mask needed to lie flat against the skin, Staff K made the adjustments and stated they could tell a difference. On 05/18/2023 at 8:17 AM, Staff I, Nursing Assistant, was observed wearing an N95 over visible facial hair, and with both mask straps behind their neck. At 9:20 AM, Staff I stated they knew the top strap needed to be on the top of the head, but the bridge of their nose was raw from the mask and sore, so they were trying to make sure the mask was more comfortable, and their nose and mouth were covered. When asked about fit testing and if any education had been given related to beards and wearing an N95, Staff I stated they had not received any education about beards, and fit testing was done at their previous place of employment. Staff I stated the mask they were wearing was not the one they had been fit tested for, the facility ha three types of N95, so you could pick which one to wear. On 05/18/2023 at 11:20 AM, Staff J was observed wearing an N95 with the mask straps behind the neck. Staff J stated they had been fit tested at their previous place of employment, but did not think the mask they were wearing was the same one. When asked about the strap placement, Staff J stated the correct placement for the straps, but stated wearing them like that made the mask too tight, and it was causing a blister to the top of their nose. <Fit Testing> Review of the N95 fit testing documentation provided by the facility found no documentation that Staff A, D, F, G, H, I, J, L, and N had been fit tested yearly, as required. In an interview on 05/18/2023 at 1:54 PM with Staff A, Administrator, and Staff C, Infection Preventionist, Staff C acknowledged that fit testing for all staff had not been completed. Staff C stated they attempted to get all staff tested in March 2023, but the company doing the testing would not accept the medical clearances from some of the staff, and would not test some of the male staff, due to the presence of facial hair. At 2:05 PM the same day, when informed of the multiple observations of staff not properly wearing N95, and concerns about staff not wearing the N95 they had been fit tested for, both Staff A and Staff C acknowledged that facial hair such as beards, interfered with an N95 creating a proper seal, and staff education regarding masks and proper PPE usage had been ongoing. Reference (WAC): 388-97-1320 (1)(a)

Dec 2022 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Dec 2022 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

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 monitor non-pressure skin conditions for 1 of 3 sampled residents (4), reviewed for skin integrity. This failure placed the resident at risk of worsening skin conditions and complications. Findings included . Review of a 10/28/2022 comprehensive assessment showed Resident 4 admitted to the facility on [DATE] with medically complex conditions, and no alteration to skin integrity. A 10/28/2022 summary associated with the comprehensive assessment showed that, according to the 10/28/2022 weekly skin check, Resident 4 does not have any current skin issues. The summary showed Resident 4 was at risk for impaired skin integrity, related to decreased mobility, incontinence, and use of high-risk medications. Review of a 10/21/2022 admission skin assessment showed the staff assessed Resident 4's skin was not intact. The staff assessed Resident 4 admitted with a surgical incision and open area/wound. The assessment showed staff identified Resident 4 had an open area to right thumb, unable to fully examine secondary to contracture [chronic loss of joint mobility], Coccyx [tail bone] - maceration [skin broken down by moisture], Right toe(s), dry, flaky with open areas noted between toes, and Left toe(s) - dry, flaky with open areas noted between toes. The skin assessment showed no indication of the extent of the impaired skin integrity, the size, or where the open areas were located between the toes. Review of a 10/21/2022 care plan showed the staff identified Resident 4, has potential/actual impairment to skin integrity r/t [related to] incontinence, poor mobility, severe-protein malnutrition, dementia, anemia, right hand contractures, redness/yeast to scrotum/buttocks. The care plan showed the intervention included: Assess location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs/symptoms] of infection, maceration etc. to MD [doctor]. Date Initiated: 10/21/2022. Review of progress notes from 10/21/2022 to 12/09/2022 showed the staff assessed Resident 4 admitted to the facility with, a red and excoriated gluteal fold [fold of the buttocks] [10/21/2022], Groin creases and perineum [thin layer of skin between the genitals like between the scrotum and anus] very raw and red with rash [10/24/2022], Redness to groin creases scrotum [10/25/2022], [Resident] buttocks is reddened [10/29/2022]. The progress notes showed no information on the status of the open areas to the right thumb, between the right and left toes, or additional information on the coccyx maceration. Review of the October, November, and December 2022 Treatment sheets showed the staff applied an antifungal ointment to Resident 4's, Groin, testicles, perineum topically two times a day for redness apply until rash is resolved. Review of the November 2022 Treatment sheets showed staff applied an antifungal cream to both feet at bedtime from 11/08/2022 to 11/27/2022 for a fungal rash. On 11/28/2022, staff started monitoring for callouses to Resident 4's right inner palm every shift. Review of weekly skin checks between 10/28/2022 and 12/9/2022 showed the staff assessed Resident 4's skin integrity as intact or with no impairment, even though the staff continued to apply ointments to areas with a rash. On 12/13/2022 at 5:58 AM, Staff C, Registered Nurse, stated that they were familiar with Resident 4's care. Staff C stated, [Resident 4] has issues with [their] hand. It's mostly [sic] has it clamped and has skin issues there. Staff A stated that Resident 4 had a right inner palm callous and that staff apply antifungal cream to help with that since it's been clamped down [contracture] for so long. I don't think it's too bad of an issue anymore and we treat it with a carrot device that keeps it [the palm] separated and some skin treatment. Staff C stated that they applied some stuff to Resident 4's groin and that there is no redness or issues with Resident 4's buttocks or groin. Staff C added that Resident 4 arrived at the facility with, a tear to tip of the member [penis] and that is still an issue. It's catheter related. [They] came with that. Staff C was unaware of any open areas to Resident 4's toes. On 12/13/2022 at 5:58 AM, Staff C was asked how the staff monitored skin issues. Staff C stated, Weekly in PCC [electronic record]. Review of Resident 4's record showed no documentation of staff knowledge of or that they monitored the impaired skin integrity to Resident's 4's penis, or orders to apply ointment to Resident 4's right palm. The above findings were shared with Staff A, Director of Nursing, and Staff B, Nurse Consultant on 12/12/2022 at 10:42 AM. Staff A stated that when the staff identified a skin issue, they should, Notify the provider right away, they should be monitoring weekly, and also have a monitoring daily. Staff A and B acknowledged the lack of monitoring or assessment of non-pressure skin conditions. 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

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 interview and record review, the facility failed to provide the necessary respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (1), reviewed for change in conditions. The facility failed to show they assessed Resident 1's respiratory status when the resident initially complained of difficulty breathing. In addition, the facility failed to show they re-assessed Resident 1's respiratory status and delegated the respiratory assessments to an unlicensed staff. This failure placed Resident 1 at risk for unmet care needs associated with changes to their respiratory status. Findings included . Review of a 07/18/2022 comprehensive assessment showed Resident 1 re-admitted to the facility on [DATE] from the hospital. The assessment showed Resident 1 admitted with medically complex conditions, to include respiratory failure with hypoxia (a state in which the supply of oxygen is not sufficient for normal life functions) and hypercapnia (excessive carbon dioxide in the bloodstream), coronary artery disease, high blood pressure, diabetes, and asthma. The assessment showed the staff assessed Resident 1 was cognitively intact. Review of Resident 1's medical record showed Special Instructions to staff that, if resident complains of SOB [shortness of breath], please assess the resident immediately. [Resident 1's] cardiac events are precipitated by SOB. A 03/17/2022 care plan showed Resident 1 required oxygen therapy related to multiple medical conditions. The care plan instructed the staff to observe for any signs and symptoms of respiratory distress and report them to the doctor as needed. Review of Resident 1's July 2022 Treatment Administration Records showed Resident 1 received oxygen, at 2 -4 liters/minute continuously, and the staff monitored oxygen saturation levels (a measurement that defines blood oxygen content and oxygen delivery. A value lower than 90% is considered low and requires external oxygen supplementation) every shift. Review of July 2022 vital signs showed Resident 1's oxygen saturation level at 91% and above. Review of a 07/04/2022 progress note showed that the night shift aide reported to the nurse that Resident 1, was having a hard time breathing this morning, and the nurse spoke with the resident at approximately 6:30 AM. The note showed Resident 1 stated that they, didn't feel like [they were] getting enough oxygen. The note showed the nurse exchanged the tubing for a shorter one to see if that would help the resident and verified that the oxygen concentrator (a machine that delivers oxygen) appeared to be working at that time. The note also showed the nurse asked the aide to let them or the cart nurse know what [the] resident's oxygen saturation was and if [their] breathing was getting better. Review of the medical record showed no documentation the nurse assessed Resident 1's respiratory status at the time they complained of a lack of oxygen, to include a measurement of the oxygen saturation level, at 6:30 AM or shortly afterwards. Although record review showed the staff measured Resident 1's saturation level and vitals signs at 9:00 AM, 2.5 hours after Resident 1's initial complaint of difficulty breathing, no other documentation was found to support the nurse monitored or re-assessed Resident 1's respiratory status, to include any changes in the respiratory condition, chest movement and respiratory effort, the identification of abnormal breath sounds, signs of cyanosis (bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of blood), or the presence of behavioral changes that could reflect a low oxygen level, like anxiety, apprehension, or a change in level of consciousness. A 07/04/2022 progress note written at 10:50 AM showed Resident 1 complained again of difficulty breathing. The progress note showed the staff assessed Resident 1 was breathing, talking, on oxygen, slightly anxious, sweating heavily, and pale. The note showed the staff, quickly obtained all vitals, which were normal except the O2 [oxygen saturation level], so the nurse quickly called RN [Registered Nurse] for assistance and to call an ambulance. Review of the medical record showed no documentation of what Resident 1's oxygen saturation level was when the staff identified it was not normal. Review of a 07/04/2022 hospital note showed Resident 1, complained to [their] nursing home staff this morning of being short of breath. [The resident] was found to have oxygen saturations of 40-50%. [The resident] was given a breathing treatment and 911 [EMS] was summoned. The above findings were shared with Staff A, Director of Nursing, and Staff B, Nurse Consultant, on 12/12/2022 at 10:21 am. Staff B stated, I would reassess the resident. I would not leave [the resident] until it got better. Reassess until stable. Staff A acknowledged the lack of complete respiratory assessments and monitoring, and that respiratory assessments should be completed by a nurse and not delegated to an aide. Reference: WAC 388-97-1060 (3)(j)(vi) .

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 3 of 3 sampled residents (1, 2, 3), reviewed for hospitalizations. This failure placed the residents at risk for care that was not provided at the hospital. Findings included . Resident 1 Review of 07/04/2022 progress notes showed the staff called 911 [Emergency Medical System, EMS] . due to [Resident 1] not breathing and being cyanotic [change of body tissue color to a bluish-purple hue as a result of having decreased amounts of oxygen]. The note showed EMS staff took Resident 1 to the hospital. Review of the medical record showed no documentation to support that when the facility transferred Resident 1 to the hospital, the minimum and appropriate information was communicated to the hospital, including: The basis for the transfer, the specific resident need(s) that could not be met, facility attempts to meet the resident needs, or the information provided to the receiving facility to include contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. Resident 2 An 08/25/2022 progress note showed Resident 2 was transported to [local hospital] via [ambulance] at 5:15 AM. The note showed Resident 2 complained of chest pain and that the resident opted for a hospital transfer. Review of the medical record showed no documentation to support that when the facility transferred Resident 2 to the hospital, the minimum and appropriate information was communicated to the hospital. Resident 3 Review of an 11/11/2022 progress note showed Resident 3 sustained a fall with injuries to the forehead. The note showed Resident 3 was, transported at 1930 [7:30 PM] to [the local hospital]. Review of the medical record showed no documentation to support that when the facility transferred Resident 3 to the hospital, the minimum and appropriate information was communicated to the hospital. The above findings were shared with Staff A, Director of Nursing, and Staff B, Nurse Consultant, on 12/12/2022 at 10:25 AM. Staff A stated that when the staff transfer a resident to the hospital, they should complete an E-Interact form, a form that included pertinent information about the resident and their care needs. Staff A stated that the E-Interact form was part of the electronic record of the resident. Staff A and B acknowledged the medical records of Residents 1, 2, and 3 showed no documentation to support the staff conveyed the required information at the time of transfer to the hospital. No further information was provided. Reference: WAC 388-97-0120. .

Oct 2019 33 deficiencies

CONCERN (D)

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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2. According to a 09/06/19 admission assessment, Resident #32 had diabetes, and was cognitively intact. In an interview on 10/22/19 at 11:10 AM, Resident #32 stated that she took both metformin (oral medication used to treat diabetes), as well as injectable insulin. The resident stated the facility took her off metformin without informing her, which she was upset about. Review of the resident's record showed an 08/30/19 physician's order for metformin to be given twice a day, as well as a 09/10/19 order to discontinue it. In a follow-up interview on 10/29/19 at 9:02 AM, the resident confirmed the facility had not notified her when the metformin was discontinued. She added she eventually noticed it was missing from the pill cup the nurses brought to her, mentioned it to staff, and it was restarted. A progress note from nursing staff or the physician, as to why the medication was being discontinued at the time the order was written, was not found. Per a 09/30/19 progress note written by Staff X, Nurse Practitioner, almost three weeks after the metformin had been discontinued, showed the medication had been discontinued for some reason, possibly related to insurance coverage (although the resident had been on the medication for some time prior to admitting to the facility), but that it would be restarted. Review of the resident's Medication Administration Record showed she was restarted on the medication on 10/01/19, after not receiving it for three weeks. In an interview on 10/29/19 at 12:55 PM, Staff B, Director of Nursing, stated that residents were to be notified of any medication changes, allowed to accept or refuse the change, and then monitored for any potential adverse side effects to the change, with documentation of both in progress notes. Staff B stated that she thought the resident's metformin had been discontinued by the physician, due to some concerns related to her kidney function. Reference: WAC 388-97-1000 (1)(a) Based on interview and record review, the facility failed to ensure two of 37 sample residents (#40, 32), reviewed for care planning, were provided an opportunity to be involved in making decisions about care and treatment. This failure placed the residents at risk for a diminished quality of life, as a result of not being allowed involvement in planning their care. Findings included . 1. According to the record, Resident #40 was re-admitted to the facility in July 2019 with diagnoses including major depressive disorder, anxiety, and chronic pain. The 08/16/19 quarterly Minimum Data Set (MDS), an assessment tool, showed the resident had no cognitive impairment, occasionally experienced feeling down, depressed, or hopeless, and did not exhibit behavioral issues during the assessment look-back period (of seven days). In an interview on 10/22/19 at 2:28 PM, Resident #40 stated she recently had medication changes, which were not discussed with her first. Resident #40 stated she learned about the changes several days after they were implemented, had not had any input in the decision to change her medication, and stated it concerned her. Per record review of a 09/13/19 report by Staff MM, Pharmacist, showed a recommendation for a dosage reduction of Resident #40's depression medication (sertraline). The recommendation, per Staff MM, showed a reduction had not been attempted, as required, in two separate quarters, and nursing staff reported the resident did not appear depressed. A provider note (nurse practitioner or physician) was not located in the electronic or paper records, which showed the change in dosage was discussed with Resident #40. A review of the September 2019 MAR (medication administration record) showed the resident began the reduced dose on 09/24/19. A nursing progress note, dated 10/01/19 (eight days after dosage change), by Staff M, Licensed Practical Nurse, showed during the medication pass, Resident #40 expressed she was unhappy about the medication change, and did not agree with the provider reducing her medication without consulting her. Although Staff M documented her concern in the record, the note did not show the information was shared with the resident's medical providers (the physician or nurse practitioner). Review of physician orders and a progress note dated 10/24/19, (23 days after the resident expressed dissatisfaction with not being included in her care) showed after a routine visit, the physician increased the antidepression medication back to the original dose. In an interview on 10/ 29/19 at 1:00 PM, Staff F, Social Services, stated she was responsible for the monthly behavioral health meetings. She stated medication reduction recommendations by nursing or pharmacy were discussed in those meetings. If changes were recommended, then the resident or guardian were asked for input, and allowed to approve or disapprove the changes. She stated she was not aware Resident #40's medication had changed. In an interview on 10/29/19 at 2:30 PM, Staff E, Unit Manager, stated Resident #40 experienced anxiety about any medication changes, and the discussion would be documented by staff prior to a change. A request for further information regarding the dosage change for Resident #40's antidepressant was requested from the facility. No further information was received.

CONCERN (D)

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

Deficiency F0555 (Tag F0555)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of five sample residents (#47), reviewed for choices, was afforded the opportunity to choose her own physician. This failure placed the resident at risk for a diminished quality of life. Findings included . According to a 09/18/19 admission assessment, Resident #47 was cognitively intact, and able to make her needs known. In an interview on 10/22/19 at 10:38 AM, Resident #47 stated that she preferred to be followed by her own physician, but was told by the facility that was not allowed. Per review of the facility's Resident admission Agreement, last updated 2018, residents had the right to choose their own attending physician. In an interview on 10/28/19 at 9:52 AM, Staff X, Nurse Practitioner, who worked with the facility's medical director, confirmed that the resident talked to her about wanting to see her own primary care physician. Staff X stated that residents were not supposed to see their own primary care physicians, because it caused a lot of headaches. Staff X added she and the medical director acted as the resident primary care providers while they resided in the facility, and insurance would not pay for two. In an interview on 10/28/19 at 1:24 PM, Staff A, Administrator, stated that residents should have the option of choosing their own primary care physician. Staff A added that he was not aware Resident #47 requested to use her own. Reference: WAC 388-97-0200 (1)

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 provide requested mobility equipment for one of two sample residents (#34), reviewed for accommodation of needs. This failure placed the resident at risk for a loss of independence and dignity. Findings included . Per the quarterly assessment dated [DATE], Resident #34 had diagnoses which included heart failure and depression. The assessment showed the resident required extensive, one-person assistance with bed mobility (repositioning in bed, including turning side-to-side). Per the most recent assessment dated [DATE], the resident required extensive, two-person assistance with bed mobility. This represented an increase in the need for assistance with bed mobility, from the previous (06/08/19) assessment. In an interview and observation on 10/22/19 at 3:25 PM, the resident stated she had a requested a bed rail so she could help herself sit up and turn in bed, and had been told the facility didn't allow them. On 10/29/19 at 9:41 AM, Staff E, Unit Manager, stated that bed rails were not allowed in the facility. In an interview on 10/29/19 at 9:52 AM, Staff V, Director of Therapy, stated that bed rails were against facility policy. A review of the facility policy titled Bed Rails - Safe and Effective Use of Bed Rails, showed the facility allowed the use of bed rails when indicated. The policy also showed the resident would be assessed for safety, and required to sign a consent form, which included education on the risks versus benefits of using bed rails. In a follow-up interview on 10/29/19 at 10:00 AM, Staff B, Director of Nursing, confirmed the facility allowed bed rails, with safety precautions and assessments in place. She further stated that a physician order should have been requested for Resident #34, to be evaluated for bed rail use, after she requested them. 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 advance directive care-planning documentation was thorough and complete, for one of one sample residents (#30), reviewed for advance directives. Failure to ensure the Physician's Orders for Life-Sustaining Treatment (POLST) was thoroughly completed, signed and dated, and failure to ensure legal documents were in the resident's record which designated her Power of Attorney (POA), placed the resident at risk of losing her right to have her preferences/decisions regarding end-of-life care followed. Findings included . Federal regulations define POLST as . a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the person wants in the event of a medical emergency, taking the patient's current medical condition into consideration. Per the admission assessment dated [DATE], Resident #30 admitted to the facility on [DATE], and had diagnoses which included dementia. The assessment also showed the resident was severely cognitively impaired, and unable to make decisions regarding her daily care. A review of the resident's record showed a family member was designated as her POA for decisions regarding her health. Per review of the record, any documentation showing the family mamber had a legal right to make health decisions on behalf of the resident, was not present. The resident's POLST form, was undated and incomplete. The front side of the form did not include the resident's date of birth or medical conditions/patient goals, and was not signed or dated by the patient/legal surrogate. The backside of the form (non-emergency preferences) was not signed or dated by the patient/legal surrogate or the physician, and had no indicated preferences for antibiotic use, or medically assisted nutrition by tube. In an interview on 10/28/19 at 10:13 AM, Staff F, Social Services Director, confirmed the POLST was incomplete, and the POA paperwork was not present in the resident's record. Reference: (WAC) 388-97-0300(3)(b-c)

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure allegations of potential abuse and neglect were timely reported to the administration and the State Survey Agency as required, for one of three sample residents (#20), reviewed for abuse. This failure placed the resident at risk for additional abuse and neglect. Findings included . An 08/23/19 admission assessment showed Resident #20 was cognitively intact, and required extensive assistance of one to two staff for most activities of daily living, including transfers and toileting. According to a 10/12/19 progress note, Resident #20's sister reported to Staff BB, Licensed Practical Nurse, that staff were being mean to the resident. Per the note, Staff BB spoke with the resident, who reported that she was not assisted to bed when she asked, was left to sit in soiled briefs for prolonged periods of time, and was told by staff that they did not have time for her. The note also showed Staff BB educated the resident to facility routines, assured her staff would help as soon as they were able, and encouraged the resident to allow staff to assist her to the bathroom every two hours. Review of the facility's incident log and grievance log on 10/28/19 showed no entries related to Resident #20's allegation. In an interview on 10/28/19 at 1:34 PM, Staff B, Director of Nursing, stated that allegations of abuse/neglect were to be reported to either her or Staff A, Administrator, within two hours, as well as reported to the State Survey Agency. The 10/12/19 progress note was then reviewed with Staff B. Staff B confirmed the note described an allegation of abuse/neglect, and that she had not been made aware of it. Staff B added that Staff BB had only worked at the facility a few weeks, and might need more education. Reference: WAC 388-97-0640 (5)(a), (6)(a)(c)

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to timely investigate an allegation of abuse/neglect for one of three sample residents (#20), reviewed for abuse. This failure placed the resident at risk for additional episodes of abuse/neglect. Findings included . An 08/23/19 admission assessment showed Resident #20 was cognitively intact, and required extensive assistance of one to two staff for most activities of daily living, including transfers and toileting. According to a 10/12/19 progress note, Resident #20's sister reported to Staff BB, Licensed Practical Nurse, that staff were being mean to the resident. Per the note, Staff BB spoke with the resident, who reported that she was not assisted to bed when she asked, was left to sit in soiled briefs for prolonged periods of time, and was told by staff that they did not have time for her. The note also showed Staff BB educated the resident to facility routines, assured her staff would assist her as soon as they were able, and encouraged the resident to allow staff to assist her to the bathroom every two hours. Per review of the record, Staff BB did not start and investigation to rule out abuse or neglect. Review of the facility's incident and grievance logs on 10/28/19 showed no entries related to the 10/12/19 allegation. In an interview on 10/28/19 at 1:34 PM, Staff B, Director of Nursing, reviewed the progress note, and confirmed the note represented an allegation of abuse/neglect. Staff B stated all allegations should be reported to administration within two hours, so an investigation could be initiated, which included taking immediate measures to protect the resident, interviewing staff and residents, and revising care plans. Staff B added the allegation involving Resident #20 should have been investigated, but she had not previously been made aware of it. Reference: WAC 388-97-0640 (a)(b)

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a written summary of the baseline care plan with all required elements was provided, for three of seven sample residents (#20, 32, 47), reviewed for baseline care plans. This failure placed the residents at risk of not being informed of the medications, services, and treatments they were receiving, as well as the initial care goals. Findings included: 1. According to an 08/23/19 admission assessment, Resident #20 was cognitively intact, and admitted to the facility on [DATE]. Per review of admission orders, the resident was on a specialized diabetic diet, and receiving multiple medications including insulin, several medications for breathing difficulties, thyroid medication, a blood thinner, an antidepressant, and narcotic pain medication. According to care conference attendance documentation, a baseline care plan was developed and shared with the resident, with a copy provided, on 08/16/19 (the day the resident admitted ). Review of the care plan showed it did not include dietary orders. In addition, documentation that a copy of ordered medications was provided to the resident, as required, was not found in the electronic or paper chart. In an interview on 10/22/19 at 10:38 AM, Resident #20 stated that she had not received a copy of her baseline care plan (despite the facility documentation) or a medication list. 2. According to a 09/06/19 admission assessment, Resident #32 was cognitively intact, and admitted to the facility on [DATE]. Per review of admission orders, the resident was on a specialized diabetic diet, and was receiving multiple medications including an antidepressant, a diuretic (medication to remove excess fluid from the body), several diabetes medications including insulin, an injectable blood thinner, and several medications to treat her heart and breathing issues. According to care conference attendance documentation, a baseline care plan was developed and shared with the resident, with a copy provided, on 10/04/19 (over a month after the resident admitted ). Review of the care plan showed it did not include dietary orders. In addition, documentation that a copy of ordered medications was provided to the resident, as required, was not found in the electronic or paper chart. In an interview on 10/22/19 at 11:10 AM, Resident #32 stated she did not get a copy of her baseline care plan (despite facility documentation), or a list of her medications. 3. Review of a 09/18/19 admission assessment showed Resident #47 admitted to the facility on [DATE], and was cognitively intact. According to care conference attendance documentation, a baseline care plan was developed on 09/11/19, and shared with the resident on 09/19/19. Review of the care plan showed it did not include dietary orders. Additionally, documentation that a copy of ordered medications was provided to the resident, as required, was not found in the electronic or paper chart. In an interview on 10/25/19 at 12:27 PM, Staff F, Social Services Director, stated that she provided residents a copy of their baseline care plan, within the first three days after admission. Staff F confirmed that she did not provide a list of ordered medications as part of that care plan, but thought that nursing staff did. In an interview on 10/29/19 at 12:34 PM, the missing dietary orders and medication lists were reviewed with Staff B, Director of Nursing. Staff B stated that the facility had recently switched electronic documentation systems, and baseline care plan summaries were still a work in progress. Reference: WAC 388-97-1020 (3)

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Per the quarterly assessment dated [DATE], Resident #36 had diagnoses which included dementia and depression. The assessment also showed the resident was interested in activities, and required extensive physical assistance with activities of daily living. A review of the resident's comprehensive care plan, initiated on 09/14/19, showed no focus, goals, or planned interventions/tasks, related to activities for the resident. The quartely assessment (see above) listed pet visits, outdoor activities, religious services, and reading materials as activities of interest. During an interview on 10/29/19 at 12:58 PM, Staff G, Activities Director, was unable to locate a care plan related to activities for the resident, either in the activity department's files, or the resident's record. Staff G confirmed there should have been a comprehensive care plan in place for the resident, related to activities. Reference: (WAC) 388-97-1020(1), 2(a)(b) Based on interview and record review, the facility failed to develop comprehensive, resident-centered care plans that addressed infection control concerns, use of psychotropic medications (medications that affect a person's mental state), and activity preferences, for three of 26 sample residents (#42, 20, 36), whose care plans were reviewed. Failure to establish specific, individualized care plans, that accurately reflected care needs, established goals, and provided direction to staff, placed the residents at risk for unmet care needs. Findings included . 1. According to a 09/07/19 admission assessment, Resident #42 had an infection that required special isolation precautions. A care plan related to the resident's infection, last revised 10/21/19, directed staff to encourage adequate nutrition and hydration, give medications as ordered, and notify the physician with any concerns. No interventions directing staff with regard to extra isolation precautions the resident required were found. A goal related to the infection (i.e., a date by which it was to resolve) was also not included. In an interview on 10/29/19 at 1:08 PM, Staff B, Director of Nursing, confirmed the resident's infection care plan was not complete, and should have included a resident-centered goal and interventions. 2. According to Resident #20's October 2019 Medication Administration Record, the resident was receiving an antidepressant daily, as well as antianxiety medication twice a day. Review of the resident's care plan showed no care plan in place for the antianxiety medication. A care plan related to the antidepressant directed staff to administer the medication, and observe for any adverse side effects. No target behaviors or non-medication interventions specific to the resident were included. In an interview on 10/29/19 at 12:34 PM, Staff B, Director of Nursing, confirmed that the resident did not have a care plan in place related to her antianxiety medication, but should. Staff B also stated that the care plan related to the antidepressant the resident was receiving was not complete.

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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Based on interview and record review, the facility failed to revise care plans to accurately reflect resident conditions and needs, for one of two sample residents (#49), reviewed for care plan revisions, related to urinary tract infections. This failure placed the resident at risk for not receiving appropriate and necessary care and services. Findings included . Review of the record showed the resident was admitted in October 2018, with diagnoses including dementia and chronic urinary tract infections (UTI's). According to the annual September 2019 assessment, the resident had moderate cognitive impairment, required assistance with activities of daily living, and was frequently incontinent of bowel and bladder. No behaviors were reported during the seven day look-back period for the assessment. Review of nursing progress notes showed in August 2019, the resident was treated for three urinary tract infections, and had one which involved a short hospital stay for urinary sepsis (a blood infection). Review of nursing progress notes showed in September 2019, the resident was treated for a UTI with an antibiotic and intravenous (a small needle inserted into a vein) hydration. In an confidential interview on 10/28/19 at 8:46 AM, an interested party stated Resident #49 had chronic UTI's, and the signs and symptoms were very subtle. She stated the resident did not typically develop fevers, had behaviors, mood changes, and needed reminded to increase her water intake. A 10/16/19 care plan addressed the relation of urinary incontinence to skin integrity, and directed staff to report physical signs and symptoms of UTI's. The care plan showed no revisions related to the resident's chronic UTI's, with measurable goals or interventions specific to the resident (i.e., behavioral changes), or prevention strategies to decrease the frequency of UTI's (such as fluid monitoring). In an interview on 10/29/19 at 1:35 PM, Staff M, Licensed Practical Nurse, stated Resident #49 only exhibited behaviors when she had symptoms of a UTI. She stated the resident would have agitation, kick out, and call people names. Reference WAC 388-97--1020 (5)(b)

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely assistance with personal hygiene for two of six sample residents (#30, 52), reviewed for assistance with activities of daily living. Failure to remove long facial hair, placed two female residents at risk for a loss of dignity. Findings included . 1. Per the admission assessment dated [DATE], Resident #30 had diagnoses which included dementia, depression, and anxiety disorder. The assessment also showed the resident required extensive, physical assistance to complete personal hygiene tasks, which included hair removal. In an observation on 10/22/19 at 10:18 AM, the resident was in her room in bed, and had several long hairs (approximately two inches in length) on her chin, that were curling under. The resident was pleasant, but confused, and unable to answer questions related to her daily care. During subsequent intermittent observations on 10/23/19, 10/24/19, 10/25/19, and 10/28/19, between the hours of 8:00 AM- 4:00 PM, the resident continued to have long facial hair that had not been removed. 2. Per the quarterly assessment dated [DATE], Resident #52 had diagnoses which included dementia and depression. The assessment showed the resident had impaired mobility of her upper extremities and required extensive, physical assistance to complete personal hygiene tasks. In an observation and interview on 10/22/19 at 9:52 AM, the resident had thick, gray, facial hair on her chin and neck. The resident stated that she hated it, and that staff hadn't been good about helping her remove it. During subsequent intermittent observations on 10/23/19, 10/24/19, 10/25/19, and 10/28/19, between the hours of 8:00 AM- 4:00 PM, the resident continued to have facial hair that had not been removed. In an interview on 10/29/19 at 2:20 PM, Staff T, Nursing Assistant, stated that in general the shower aide was responsible for shaving and removing facial hair for residents, but any of the nursing assistants could do it. In a follow-up interview on 10/29/19 at 2:30 PM, Staff FF, Nursing Assistant, confirmed both residents had long facial hair, and acknowledged any of the nursing assistants were able to assist with personal hygiene tasks, but had not done so. Reference: (WAC) 388-97-1060 (2)(c)

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 provide an ongoing program of meaningful activities for one of one sample residents (#36), reviewed for activities. This failure placed Resident #36 at risk for boredom and a diminished quality of life. Findings included . Per the quarterly assessment dated [DATE], Resident #36 had diagnoses which included dementia and depression. The assessment also showed the resident was interested in activities, and required total assistance from staff to get to and from them. The assessment also showed the resident liked books, magazines, newspapers, religious activities, pet visits, being outdoors, current events, and some group activities. In an interview on 10/23/19 at 9:51 AM, the resident's family member stated that in her opinion, the resident was not getting enough activities. A review of the resident's current care plan, dated 09/14/19, showed no care plan in place for an ongoing activity program for the resident. (Refer to F-656 for additional information). A review of the activity tracking logs for the resident showed the resident previously had 1:1 in-room visits with activities staff, but this stopped in August 2019. The tracking logs did not show consistent, meaningful, personalized activities for the resident since that time. Intermittent observations were made of the resident on 10/22/19,10/23/19,10/24/19,10/25/19, and 10/28/19, between the hours of 8:15 AM - 4:00 PM. During these observations, the resident was in her room with the television on. No other independent activities were available for her in her room. Additionally, the resident did not have any visitors, apart from staff providing care, during any of the observations. In an interview on 10/29/19 at 12:58 PM, Staff G, Activities Director, acknowledged the lack of documented activities for the resident. She stated that the resident was more likely to participate in an activity if she was up and dressed, and in the dining room already. Staff G confirmed that hadn't happened very often. Staff G looked at the resident's activity tracking log, and confirmed that the in-room staff visits with the resident had not occurred since August 2019. She was unable to say why the individual visits had stopped, and what was being done to keep the resident engaged, and free from boredom and feelings of isolation. Reference: (WAC) 388-97-0940 (1)

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 one of two sample residents (#22), reviewed for urinary tract infections (UTI's), received appropriate services to prevent additional UTI's. This failure increased the resident's risk for urinary tract infections and its associated complications. Findings included . Per the admission assessment dated [DATE], Resident #22 admitted to the facility on [DATE] from an acute hospital stay, related to a UTI. The assessment also showed the resident required extensive assistance with all activities of daily living. During an interview and observation on 10/23/19 at 10:01 AM, the resident stated that she had a long history of urinary tract infections. She stated that she had to be hospitalized for the last infection. The resident's family member, who was present during the interview, stated that she had been taking care of the resident for a very long time, and knew all the signs and symptoms she presented with, when she was coming down with a urinary tract infection. The family member stated that several weeks ago, the resident became very confused for several days, and this was one of the symptoms the resident had when she had an infection. She stated she had requested a urine sample be collected and tested. The family member stated the sample was never collected, and this was very concerning to her, because of the resident's history. As of the date of the interview, the resident was no longer symptomatic. Per record review, a physician's order dated 09/11/19 showed nursing staff were to collect and test a urine sample, related to the resident's increased confusion. Upon further review of the record, no laboratory results were located, and no progress notes were found, that showed the urine sample was ever collected. In an interview on 10/29/19 at 2:01 PM, Staff E, Unit Manager, was unable to find the lab results in the resident's record, and stated that she would contact the laboratory for a copy of the results. In a follow-up interview on 10/29/19 at 2:45 PM, Staff E stated that the urine sample was never collected, and that the physician's order had not been followed up on. Reference: (WAC) 388-97-1060 (3)(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 observation, interview, and record review, the facility failed to ensure one of four sample residents (#36), reviewed for nutrition, received physical assistance with eating. This failure placed the resident at risk for weight loss, and inadequate nutritional intake. Findings included . Per the 06/09/19 quarterly assessment, Resident #36 had diagnoses which included dementia, adult failure to thrive, and abnormal weight loss. The assessment showed the resident had no swallowing issues, no behaviors related to rejection of care, and required supervision, with set-up assistance only, for eating. According to the most recent quarterly assessment dated [DATE], the resident again had no behaviors related to rejection of care. The assessment showed the resident now required supervision, and one-person physical assistance with eating. Per the care plan, which was revised on 09/10/19, the resident had a high potential for weight loss, liked to eat meals in her room, and liked to lay in bed with her food on her chest or stomach, while eating. The care plan had not been updated, to include the resident's need for physical assistance with eating, as determined in the most recent assessment. A review of the facility's weight log on 10/23/19, showed the resident had a weight loss of 3 pounds (lbs.) during the previous seven days, going from 103 lbs., to 100 lbs. On 10/22/19 at 12:21 PM, the resident was seated in the assisted dining room; no physical assistance was given during the meal, and she ate very little of it. During an observation of breakfast on 10/25/19, from 7:37 AM until 8:30 AM, the resident was seated in the assisted dining room, at a table by herself. Staff Q, Nursing Assistant, was in the dining room, but did not provide physical assistance with eating to the resident. The resident intermittently fell asleep during the meal. During the observation, the resident attempted to pick up bacon with her spoon, and attempted to eat a bowl of thin, hot cereal with her fork. The cereal continuously ran through the fork. Additionally, the resident picked at her eggs with the spoon, but never scooped up a bite to eat. During the entire observation, Staff Q only spoke to the resident once, to ask her if she was finished with her meal. In an interview on 10/25/19 at 8:45 AM, Staff Q stated that she was unaware Resident #36 was assessed to need physical assistance with eating. She acknowledged the resident had eaten very little breakfast. In a follow-up interview on 10/29/19 at 12:48 PM, Staff N, Licensed Practical Nurse, stated that to her knowledge, the resident only required set-up assistance for meals. She stated no cueing, encouragement, or physical assistance was needed. Staff N acknowledged the resident had a history of poor nutritional intake. Additionally, Staff N stated that she felt the resident's intake was a little better when she ate in her room. Reference: (WAC) 388-97-1060 (3)(h)

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to comprehensively assess pain, develop non-medication interventions, and provide pain medication timely for one of three sample residents (#20), reviewed for pain. These failures placed the resident at risk for inadequate pain control and a diminished quality of life. Findings included . According to an 08/23/19 admission assessment, Resident #20 was cognitively intact, and had diagnoses including arthritis and chronic pain. Per the assessment, the resident reported occasional, moderate pain that affected her sleep, and limited her activities. A care plan related to pain was initiated on 08/27/19. Interventions included anticipating the resident's need for pain relief, responding immediately to any complaint of pain, observing and reporting any signs of non-verbal pain, and administering pain medications as ordered. No non-medication interventions for staff to try were found. The resident's October 2019 Medication Administration Record (MAR) included an entry for staff to assess the resident's pain every shift. Pain levels of zero to eight were recorded using a pain scale (with zero representing no pain, and 10 being the worst possible pain). A section listing the resident's acceptable level of pain was blank, as was a section for non-medication interventions to attempt, prior to administering pain medication. Further review of the MAR from 10/01/19 through 10/27/19 showed the resident had orders for one to two tablets of oxycodone (narcotic pain medication), to be given every four hours as needed for pain. Per review of the MAR, the resident received two tablets, two to four times a day, nearly every day for pain, with a pain rating ranging from three to eight. In addition, there were nine occasions in which the resident received one tablet. In an interview on 10/22/19, Resident #20 stated she had pain in her back and shoulders that she rated as 10 out of 10, and pretty constant. The resident added that the pain medicine she was receiving was not effective, the facility did not attempt any non-medication interventions to assist with pain control, and that the facility did not have enough staff, so she had to wait too long for care. On 10/24/19 at 2:24 PM, the resident was observed to tell Staff S, Nursing Assistant, and Staff HH, Nursing Assistant, that she needed pain medication. Staff S informed Staff BB, Licensed Practical Nurse, who was standing at a medication cart down the hallway, of the resident's request. At 2:29 PM, Staff HH returned to the resident's room to deliver a snack. The resident reminded Staff HH that she was waiting for pain medication. Staff BB did not bring the resident her pain medication until 3:01 PM, over thirty minutes after it was requested. Per review of the resident's MAR, the resident rated her pain at eight. In an interview on 10/25/19 at 11:27 AM, Staff L, Registered Nurse, stated she generally medicated the resident for pain at least once during her eight hour shift, and felt the resident's pain control regimen was adequate and effective. When asked if she attempted any non-medication interventions when the resident was experiencing pain, Staff L stated that repositioning sometimes worked. In a follow-up interview on 10/25/19 at 12:16 PM, the observations from 10/24/19 were discussed with the resident. She stated she usually had to wait too long for her pain medication to be given. In an interview on 10/29/19 at 12:34 PM, the lack of a complete pain assessment (meaning no non-medication interventions, or identification of an acceptable pain level, as written on the resident's MAR and care plan) were reviewed with Staff B, Director of Nursing. Staff B stated that pain assessments and care plans were a work in progress, adding that the facility was in the process of educating staff. The observations of the resident waiting for pain medication on 10/24/19 were shared with Staff B. Staff B stated that staff should have at least communicated with the resident as to the reason and length of any delay. Reference: WAC 388-97-1060 (1)

CONCERN (D)

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

Deficiency F0744 (Tag F0744)

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 attain or maintain the highest practicable well-being, for two of three sample residents (#11, 52), reviewed for dementia care. The failure to provide emotional comfort during times of distress, develop and implement individualized interventions, and ensure staff had sufficient dementia care training, placed the residents at risk for unmet care needs, and a reduced quality of life. Findings included . 1. The annual assessment dated [DATE], showed Resident #11 had diagnoses which included Alzheimer's disease, anxiety, depression, and suffered from hallucinations (a sensory experience in which a person can see, hear, smell, taste, or feel something that is not there). The assessment also showed the resident required extensive physical assistance with her activities of daily living. Per the resident's care plan, with a revision date of 08/20/19, the resident had a history of calling out mommy when she was in need of ice water, Kleenex, or assistance to use the bathroom. Interventions included: administer medications as ordered, explain all procedures to the resident before starting, allow the resident to adjust to changes, observe for behavioral changes, and attempt to establish underlying causes. The care plan did not show interventions or directions to staff related to the resident's hallucinations, nor was the care plan fully developed to include person-centered, individualized strategies, to ease the resident's distress, when present. On 10/22/19 at 10:19 AM, Resident #11 was crying out help me, as multiple staff passed the room, but did not go in. The resident's roommate was overheard comforting the resident, and assuring her someone would be in soon to help her. On 10/22/19 at 11:31 AM, the resident was calling out help, help! Staff T, Nursing Assistant, told her he would get help, and left the room without addressing the resident's needs. At 11:37 AM, the resident continued to call out for help. A medical records staff person told the resident someone would be there to help soon. During an observation on 10/22/19 at 11:53 AM, lunch was served to the resident in her room. The resident refused lunch, and was offered a soda and ice water instead. The resident's lunch tray was removed, without any additional interventions being attempted. On 10/24/19 at 7:54 AM, the resident was in bed sleeping, and was still wearing the same clothing she had on the day before. On 10/24/19 at 10:51 AM, the resident's call light was on. The resident called out continuously and told Staff T, I have to go to the bathroom. Staff T stated you're going to have to wait. Staff T proceeded to go into another room, where the call light was not on, and assisted that resident in getting ready for lunch. At 11:03 AM, the shower aide went in Resident #11's room, and assisted her with toileting. On 10/24/19 at 1:33 PM, the resident was in bed, with a toothbrush in her hand, saying help. In an observation on 10/25/19 at 5:16 AM, the resident was still wearing the same clothing she had been wearing the previous two days in a row. At 12:12 PM, her clothing still had not been changed. A look into the resident's closet showed she had a good selection of clothing to choose from. During an observation of care on 10/29/19 at 2:17 PM, Staff T, and Staff FF, Nursing Assistants, changed the resident's brief. They picked the resident up very quickly, didn't tell her what they were doing prior to turning her, and the resident screamed out, oh I hate you guys! The resident continued to cry for a few minutes. The brief change was completed quickly, without telling the resident step-by-step what they were going to do prior to doing it, and without giving her a chance to adjust to the care being given, as directed on the care plan. At 2:20 PM, the resident stated that Staff T and FF scared her, because they had gone too fast. 2. Per the quarterly assessment dated [DATE], Resident #52 had diagnoses which included dementia, depression, and anxiety. The assessment showed the resident required extensive physical assistance to complete activities of daily living. A review of the resident's most recent care plan showed the resident had the behavior of calling out help me, along with episodes of crying, related to her dementia. Planned interventions included: administer medications as ordered, anticipate and meet the resident's needs, observe for behavioral episodes, and attempt to determine an underlying cause. The care plan wasn't developed to include person-centered, individualized strategies, to ease the resident's distress, when present. During intermittent observations on 10/22/19, 10/23/19, 10/24/19, and 10/25/19, between the hours of 8:30 AM - 4:00 PM, the resident cried out help me in a soft, shaky voice. Multiple staff passed the room without going into the room to provide comfort, or assess the resident for the cause of her distress. In an interview on 10/24/19 at 11:15 AM, Staff T, Nursing Assistant, stated he had not received dementia care training since he first became a nursing assistant, and hadn't received any in-facility dementia training at all. (See F- 947 for additional information). On 10/24/19 2:13 PM, Staff Y, Nursing Assistant, stated that no specific care approaches for residents with dementia had been given to nursing staff, during in-facility training sessions. In a follow-up interview on 10/25/19 at 5:21 AM, Staff OO, Licensed Practical Nurse, stated that the facility hadn't provided dementia care training to staff in quite a while. Reference: (WAC) 388-97-1060 (1)

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to monitor one of three sample residents (#164), reviewed for abuse, for symptoms of psychosocial harm after an allegation of abuse. This failure placed the resident at risk for anxiety and distress. Findings included . According to a 10/17/19 admission assessment, Resident #164 was cognitively intact. In an interview on 10/22/19 at 9:53 AM, the resident made an allegation of abuse, related to rough treatment by staff during care. The allegation was immediately reported by the surveyor to Staff A, Administrator, and Staff B, Director of Nursing. The facility started an investigation the same day, and eventually ruled out abuse. Per the investigation, the resident was to be placed on alert charting, to monitor for signs or symptoms of psychosocial harm, related to the allegation. Review of the resident's progress notes, from 10/22/19 through 10/29/19, showed no documentation of monitoring for psychosocial harm, or any follow up with the resident, by staff. In an interview on 10/29/19 at 1:02 PM, Staff B stated that after an allegation of abuse, residents were to be placed on alert charting, and monitored for psychosocial harm for 72 hours. Per Staff B, staff were expected to chart on the resident's psychological condition every shift, during that time period. After reviewing Resident #164's record, Staff B confirmed that had not been done. Reference: WAC 388-97-0960 (1)

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 identify and monitor specific target behaviors related to psychotropic medications (medication that affect mental processes and behavior), for one of five sample residents (#20), reviewed for unnecessary medications. Failure to adequately monitor the resident, to determine if her medication regimen was effective, placed her at risk for adverse side effects, related to unnecessary medications. Findings included . According to an 08/23/19 admission assessment, Resident #20 was cognitively intact, and had diagnoses including depression and anxiety. Review of the resident's Medication Administration Record (MAR) showed the resident had been taking Ambien (a sedative used to treat insomnia), since 08/20/19. A care plan related to the use of Ambien was initiated on 08/27/19, but did not include any monitoring for effectiveness, such as hours of sleep. Review of the resident's MAR and Treatment Administration Record (TAR) for October 2019 showed no documentation related to the resident's sleep. In an interview on 10/29/19 at 12:34 PM, Staff B, Director of Nursing, was asked how the effectiveness of Ambien was monitored. Staff B stated the number of hours the resident slept should be recorded on the MAR/TAR, and confirmed that was not being done for Resident #20. Reference: WAC 388-97-1060 (3)(k)

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of two medication rooms (east), was clean and organized. The narcotic box in the east medication room refrigerator was not affixed, as required. In addition, the medication room temperatures in two of two medication rooms exceeded safe storage control. These failures placed residents at risk for receiving compromised or ineffective medication, and for unintended access by others to drugs and biologicals (a medicinal preparation made from living organisms and their products, such as a serum or vaccine), because they were not locked up and/or unmovable. Findings included . In an observation on 10/22/19 at 3:08 PM, Staff K, Licensed Practical Nurse, provided access to the medication room on the east unit. There was a large, gray plastic bin, with multiple doses of antibiotic medications and one brown, cardboard box, that contained various multiple, unidentified medications, on the floor. Wound care supplies were scattered across the entire counter, on shelves, and on top of boxes, which were not organized and therefore, did not allow staff to have easy access to the needed supply. The small medication refrigerator was unlocked, and the locked narcotic box, inside the refrigerator, which contained Ativan (a schedule II medication used to treat anxiety and end-of-life air hunger), was not permanently affixed, as to prevent potential drug diversion. The wall thermometer in the east medication room showed 80 degrees. The west medication room thermometer read 82 degrees. Those temperatures placed medications and biologicals at risk for becoming ineffective, due to the higher temperature. Staff K stated that she knew the medication rooms should be clean and organized, but no one took time to do it, as they were busy. She further stated she was aware that medications should not be on the floor, but they were waiting to send them back to the pharmacy, and they had not been picked up. As for the temperature in the medication rooms, Staff K stated the medication rooms got hot, and sometimes they get very hot. Staff K stated she had told maintenance, who had tried to adjust the temperature, but it still got really, really hot. In an interview with Staff A, Administrator, on 10/22/19 at 3:30 PM, he stated that the facility heating and cooling system did not adjust well. He stated that they checked and monitored the medication rooms to try and maintain a balance. He was asked if there was any documentation of monitoring of the medication rooms, but none was provided. On 10/23/19 at 10:28 AM, Staff J, Maintenance Assistant, stated that he was notified of the medication room issues the previous day (10/22/19), and acknowledged that there had not been any documentation of monitoring, but they were doing so now. Reference: WAC 388-97-1300 (2) & -2340

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide the needed dental services for one of three sample residents (#40), reviewed for dental care and services. This failed practice placed Resident #40 at risk for decreased quality of life, and a potential decline in nutritional status. Findings included . According to the record, Resident #40 was admitted to the facility in July 2019 with diagnoses including major depressive disorder, anxiety, and chronic pain. The resident was able to make her needs known, and had no cognitive deficits. The 08/16/19 quarterly Minimum Data Set (MDS), an assessment tool, showed the resident had no natural teeth, and broken or loosely fitting dentures. During an interview and observation on 10/22/19 at 2:28 PM, Resident #40 stated she had upper dentures and no lower dentures. The resident showed the surveyor her lower gums, and stated she had talked to the facility about obtaining lower dentures, indicating her insurance would cover the expense. She stated she had not heard back from anyone in the facility, as to when she would get fitted for lower dentures, and said she could still eat and chew her food without any difficulties. Review of the resident's current care plan (with a revision dated 08/25/19), showed the focus of obtaining dentures, related to resident's loose upper denture, and a requested need for lower dentures. The care plan showed no goals or interventions were in place, in order to meet the identified need for dental services. Review of the resident's electronic and paper records, from 08/25/19 through 10/29/19, showed no documentation the need for dental services was discussed with Resident #40. In an interview on 10/29/19 at 1:00 PM, Staff F, Social Services, stated when a resident required dental services, she would make the appointments. She stated the concerns were shared on daily rounds, and staff would leave her notes. She acknowledged she had not been made aware of Resident #40's request for dental services. Reference (WAC) 388-97--1060 (2)(c), (3)(j)(vii)

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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Based on observation, interview, and record review, the facility failed to ensure resident food preferences were honored for two of six sample residents (#32, 47), reviewed for food preferences. In addition, the facility failed to provide an alternate meal of similar nutritive value to one of six sample residents (#20). These failures placed the residents at risk for weight loss and diminished quality of life. Findings included . 1. In an interview on 10/22/19 at 11:14 AM, Resident #32 was asked if her preferences with regard to meals were honored. The resident stated the facility told her she could ask for an alternate meal, but when she did that, the request was not always honored. The resident added that she did not want juice with meals, as it raised her blood sugars, but she still got it, despite writing no juice on her weekly menu. At 12:14 AM the same day, the resident was observed eating lunch in her room. She showed the surveyor a copy of the weekly menu she had filled out. For lunch that day, the resident had requested a cheeseburger with onions and grapes. The resident stated she did not get an onion or grapes. In an interview on 10/24/19 at 8:33 AM, the resident stated the facility had talked to her about her food preferences when she admitted , but no one had followed up with her since. She pointed to her menu card from that day which showed no bread, but stated that she always got it. The menu card also listed carrots under dislikes, but the resident added they are forever sending me carrots. On 10/25/19 at 7:28 AM, the resident was observed eating breakfast in her room, which consisted of scrambled eggs, bacon, cream of wheat, cheerios, orange juice, coffee, and milk. The resident showed the surveyor the menu she had filled out. It showed she had crossed off the orange juice that was listed, as well as writing no juice next to it. The western omelet that was listed was also crossed off with no eggs handwritten in. The resident had also written in strawberries, but no fruit was on the plate. 2. In an interview on 10/22/19 at 8:43 AM, Resident #47 stated that she always got cream of wheat for breakfast, instead of the oatmeal that she ordered. On 10/25/19 at 7:42 AM, the resident was observed eating breakfast in her room. She stated she got scrambled eggs, white toast, and cream of wheat, instead of the western omelet, wheat toast, and oatmeal that was on the menu. At 11:43 AM that same day, the resident was observed in her room eating lunch. She stated her hamburger had been delivered with an onion, despite her writing no onion in on her menu. In an interview on 10/28/19 at 3:33 PM, Staff H, Food Services Manager, stated that residents filled out their menus weekly, by circling what they wanted, crossing off what they didn't want, or writing in a choice from the a la carte menu. Per Staff H, dietary staff would then use the weekly menu to fill out a meal ticket for each meal. The surveyor's observations and interviews regarding Resident #32 and Resident #47's meals were reviewed with Staff H. Staff H stated a new process and equipment had recently been implemented in the kitchen. He added staff might need more education. 3. On 10/22/19 at 9:09 AM, Resident #20 was observed in bed with two small cups of jello on the tray table in front of her. The resident stated she had been nibbling on her breakfast while she was getting a breathing treatment. Per the resident, staff then came in and took the breakfast away against her wishes, and provided her with the jello instead. In an interview on 10/28/19 at 10:28 AM, Staff JJ, Nursing Assistant, stated that the resident had been falling asleep and ignoring her breakfast, on the morning of 10/22/19. She added that after an hour she had to take the breakfast away, as it was cold and no longer safe to eat, and gave the resident jello instead. When asked if there was a way to get a resident another hot breakfast, Staff JJ stated there was not, as the kitchen threw all the breakfast food away after an hour. In an interview on 10/29/19 at 10:25 AM, Staff H, Food Services Manager, stated staff could call down to the kitchen and request a fresh, hot breakfast as a replacement, anytime. Reference: WAC 388-97-1100 (1), -1120 (3)(a), -1140(6)

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to consistently implement infection control policies, related to transmission-based precautions (enhanced strategies to prevent spread of infectious diseases) for one of two sample residents (#42), reviewed for infections. This failure placed residents at risk for exposure to an infectious disease. Findings included . According to the facility's Transmission-based Precautions and Isolation Procedures policy, dated 07/25/19, when a resident was placed on transmission-based precautions, signage that clearly identified the type of precautions and appropriate PPE (personal protective equipment) to be used, should be posted in a conspicuous place outside the resident's room. Per the policy, contact precautions (a type of transmission-based precautions) required the use of PPE, including gown and gloves, upon entering the resident's room, and removal of the PPE, and performance of hand hygiene, prior to leaving the room. Review of Resident #42's 09/13/19 admission assessment showed the resident had diagnoses including MRSA (methicillin-resistant Staphylococcus aureus; a bacterium that is resistant to antibiotics). Observations on 10/22/19 at 8:55 AM - 9:04 AM showed there was a small cart with disposable gowns and gloves, outside the resident's room. There was no sign, indicating whether any transmission-based precautions were in place for the resident. Staff II, Housekeeping, was observed in the resident's room emptying trash cans, wiping down the resident's sink, as well as cleaning the bathroom. Staff II wore gloves, but no gown. Staff II did not perform hand hygiene after removing her gloves, leaving the room, and proceeding down the hallway to the soiled utility room. At 11:39 AM that same day, Staff JJ, Nursing Assistant, was observed entering the resident's room to deliver his lunch. Staff JJ did not put on a gown or gloves, but was observed to perform hand hygiene before leaving the room. In an interview on 10/22/19 at 2:46 PM, Staff K, Licensed Practical Nurse, stated the resident had MRSA, and anyone entering the room needed to put on a gown and gloves first. On 10/24/19 at 11:28 AM, Staff P, Nursing Assistant, was observed delivering the resident's lunch in his room, without wearing a gown or gloves. In an interview on 10/25/19 at 7:55 AM, Staff AA, Nursing Assistant, stated she wore a gown and gloves when moving or turning the resident, but only gloves if she was delivering or picking up a meal tray. In an interview on 10/25/19 at 8:22 AM, Staff LL, Nursing Assistant, stated Resident #42 was on contact precautions, so a gown and gloves needed to be worn when staff were providing care to the resident. Staff LL added if staff were just delivering a meal tray, they did not need to wear any PPE. When asked how staff knew which residents were on transmission-based precautions, and what specific precautions were required, Staff LL stated the resident would have a cart outside the room, and a stop sign on the door, with the precautions listed on the back. In an interview on 10/28/19 at 10:11 AM, Staff D, Infection Control Preventionist, stated any resident on transmission based precautions should have a cart with supplies and a sign outside their door. Staff D confirmed Resident #42 was on contact precautions, due to a MRSA infection in his wound. When asked what PPE would be required for the resident, Staff D stated staff should be wearing gowns and gloves when providing care for the resident, but did not require PPE for tasks such as dropping off meal trays. Staff D stated she was unsure if housekeeping staff should wear PPE while cleaning the resident's room. After observing the resident's room with the surveyor, Staff D confirmed a sign instructing staff as to the resident's precaution status and PPE requirements was not present. In an interview on 10/29/19 at 1:08 PM, Staff B, Director of Nursing, stated she had personally put a precaution sign up, when the resident first admitted , but was uncertain when it had been taken down. Staff B added that transmission-based precautions were an area the facility was working on, and there had been some recent changes. She confirmed the policy provided to the surveyor was the most current one, and that per the policy, staff should be wearing gowns and gloves at all times, when in the resident's room. Reference: WAC 388-97-1320

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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4. Resident #6 was admitted with diagnoses which included traumatic brain injury, esophageal reflux disease (a chronic digestive disease where the liquid contents of the stomach rises into the esophagus), and intellectual disability. He was unable to make his needs known, was non-verbal, and required assistance from staff for all activities of daily living and nutritional needs. According to the current comprehensive care plan dated 07/26/19, the resident received a puree diet with nectar thick liquids (about the same consistency of eggnog or fruit nectar), and required assistance with meals. The 09/26/19 intellectual disability care plan showed the resident should have social interaction and stimulation, and to visit with him one on one. An observation in the assisted dining room on 10/25/19 at 11:52 AM showed Resident #6 had food falling out of his mouth, onto his chin and shirt. Staff Q, Nursing Assistant, was feeding the resident at the time. During the meal, Staff Q was watching TV, and did not interact with the resident. The staff member continued to feed the resident several large bites of mashed potatoes, and gave him drinks of juice, which continued to fall out of his mouth. This went on for several minutes before she wiped his face. Staff Q did not explain to the resident what he was eating or drinking, and continued to turn her head away from him to watch TV. In an interview on 10/25/19 at 12:19 PM, Staff E, Unit Manager, stated she expected her staff to engage with the residents during meals. Reference (WAC) 388-97-0180 (1-4) Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for four of five sample residents (#55,16, 8, 6), reviewed for dignity. This failed practice placed the residents at risk for diminished self-worth, humiliation, embarrassment, and a decreased quality of life. Findings included . 1. Per the 09/29/19 quarterly assessment, Resident #55 was severely impaired in cognition and required extensive assistance with activities of daily living. In an initial observation on 10/22/19 at 11:12 AM, Resident #55 was seated in his wheelchair. The wheelchair had his full name, in black magic marker, on a tag that was hanging loosely at the bottom of the seat back, on the outside of his wheelchair. His name was visible to everyone in the hallway. In addition, his socks had his name on them, which was visible from beneath his pant leg (when seated in a wheelchair). On 10/22/19 at 11:24 AM, Resident #55 was being pushed in his wheelchair down the hallway, by Staff W, Speech Therapist. Staff W stated out loud, Let's go find you a trip to the potty. The hallway had other residents and staff who could have overheard the conversation. On 10/28/19 at 8:59 AM, Resident #55 was in his room, seated in his wheelchair. His face was shaven on the left side, and unshaven on the right side. In an interview on 10/28/19 at 9:28 AM, Staff N, Licensed Practical Nurse, was asked if she was aware the resident had only half of his face shaved that morning, and stated no. Staff N further stated that the resident had an electric razor in his room, and probably tried to do it himself. She was asked if she was aware that his name, both on his socks and wheelchair, were visible when he was outside of his room. She stated she was not aware, however, acknowledged that would not be very dignified. 2. During a medication pass observation on 10/24/19 at 7:49 AM, Staff O, Registered Nurse, entered Resident #16's room to administer medications via a gastrostomy tube (G-tube - a tube inserted into the abdomen to provide food and medications, without having to swallow). She pulled back the resident's gown from her left side, to expose the tube insertion site, and proceeded to administer the medications. She did not shut the room door, or pull the curtain to provide the resident with dignity and privacy from other staff, residents, or visitors, in the hallway. In an interview on 10/24/19 at 8:01 AM, Staff O was asked what she could have done differently during the medication administration to maintain the resident's dignity. She stated she should have pulled the curtain. 3. Per the record, Resident #8 was first admitted in June 2016, with diagnoses including dementia, obesity, kidney disease, and urinary tract infections. The July 2019 quarterly Minimum Data Set (MDS), an assessment tool, showed the resident was frequently incontinent, and required assistance for personal hygiene. The resident was not interviewable regarding care and services. In an initial observation on 10/23/19 at 8:36 AM, Resident #8 was seated in her wheelchair; the resident had a strong urine odor. Immediately following the observation, the resident's room was inspected. Her room was clean and personalized; there was a strong urine smell throughout the living space. On 10/29/19 at 1:30 PM, Resident #8 was observed resting in her bed. A strong urine odor was present in the hallway, several feet away from the resident's room. In an interview following the observation, Staff M, Licensed Practical Nurse (LPN), stated the resident always had a urine odor, she did not know the cause, and the physician was aware of the problem. She stated there were times other residents and visitors complained about Resident #8's odor, but the facility had not recived any recent complaints. In an interview on 10/29/19 at 2:29 PM, Staff E, Unit Manager, stated the facility had tried to figure out the cause of Resident #8's odor, put her in a private room, improved personal hygiene, and changed her mattress and wheelchair cushion. When asked if the physician had been involved in finding the cause of the strong urine smell she stated, no, quite honestly no.

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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Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, three of three staff members (Staff L, M, O) made medication errors. There were five errors out of 27 medication opportunities, resulting in an 18.52% error rate. These failures placed residents at risk to not receive the full benefit of their medication therapy. Findings included . 1. On 10/23/19 at 8:21 AM, Staff L, Registered Nurse, prepared medications for Resident #47 which included Hydroxchloroquine (a medication used to treat auto-immune diseases), in addition to other medications. After Staff L had obtained all of the medications needed for Resident #47, she turned to go towards the resident's room. Before leaving the cart, Staff L was asked to count how many pills she had in the medication cup. She counted nine. Review of the physician orders for Hydroxchloroquine indicated that the resident was to receive two tablets every day, which would have made the pill count a total of 10. Staff L stated she had only punched out one pill and not two, per the order, and did not realize it until she was asked to count them. This constituted a medication error. 2. On 10/23/19 at 8:39 AM, Staff M, Licensed Practical Nurse, prepared medications for Resident #29. The medications included Vitamin C, a health supplement. Review of the current physician's order read, Vitamin C 500 mg. (milligrams). Staff M obtained the medication from a bottle that contained 1000 mg. tablets, and administered the whole pill. Staff M was asked if she had given the resident the whole pill instead of 1/2 of a pill (or 500 mg.), per the order. She stated that staff had not been cutting them in half, but had been giving her the whole pill. This constituted a medication error. 3. On 10/24/19 at 7:49 AM, Staff O, Registered Nurse, prepared medications for Resident #16, to be given per a gastrostomy tube (G-tube - a tube inserted through the abdomen, to provide food and medication, due to swallowing difficulty). Staff O crushed three medications, and placed them together into the medication cup, and after adding water, she instilled the medications through the tube. A 04/04/19 facility policy titled, Medication Administration through an Enteral Tube, showed that the facility should administer each medication separately. In an interview on 10/24/19 at 8:30 AM, Staff B, Director of Nursing, stated that medications given through a G-tube should be administered separately, with approximately 10-20 ml. (milliliters) of water, between medications. This constituted three medication errors. Reference: (WAC) 388-97-1060(3)(k)(ii)

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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MAIN DINING ROOM In an observation on 10/22/19 at 11:43 AM, Staff K, Licensed Practical Nurse, did not perform hand hygiene prior to serving meal trays. She was further observed touching multiple surfaces, then left the dining area to answer the phone, and did not perform hand hygiene upon return. She was observed assisting an unidentified resident with buttering her dinner roll. She took the dinner roll out of the plastic bag, tore the roll in half with her bare hands, buttered it, and handed it to the resident to eat. In an observation on 10/24/19 at 12:04 PM, Staff Y, Nursing Assistant, did not perform hand hygiene, prior to assisting Resident #3 with her meal. She removed the resident's bread from the bag with her bare hands, buttered it, then proceeded to feed it to the resident. Resident #3 required total assistance with meals. In an interview on 10/28/19 at 1:54 PM Staff B, Director of Nursing, was notified of the bare hand contact with food. Reference: (WAC) 388-97-1100(3) Based on observation and interview, the facility failed to ensure staff used proper food-handling techniques when serving or assisting residents with meals, in two of two three dining areas. Failure to use hand hygiene and proper glove use, when indicated, created the risk of cross-contamination of food. Findings included . ACTIVITY ROOM: On 10/25/19 at 7:31 AM, Staff G, Activity Director, had a special breakfast activity for the Men's Club, which met for breakfast every Friday. At the time of the observation, there were three residents in the activity room, being served by Staff G. Staff G put gloves on to serve a pan of sausages to the residents. On her right wrist was a plastic key ring, in which a key was seen dangling from it. Every time Staff G reached into the pan of sausages, her key went inside the pan and touched the sausages (potentially contaminating them). At 7:36 AM, Staff G was asked how she monitored food service, to prevent cross-contamination when serving the residents, as the key on her wrist went into the pan of sausages. She stated she did not realize the key on her wristband was a problem, as she usually had it higher on her arm.

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure sufficient, qualified staff were available, to meet resident needs. Failure to provide adequate staff to ensure resident care needs were attended to timely, placed the residents at risk for potential health risks, unmet care needs, and a diminished quality of life. Findings included FACILITY ASSESSMENT: The facility assessment was reviewed on 10/23/19. The assessment showed an update to it was done on 06/25/19. The assessment showed under Resident Profile the facility was licensed for 75 beds, and the average daily census was 60 residents. The facility assessment had a staffing plan, which was based on resident population and their needs for care and support, which showed: -Licensed nurses providing direct care: 8-10 nurses in a 24-hour period were needed, and; -Nurse aides: 22-24 aides in a 24-hour period. STAFFING PATTERN: On 10/23/19, the staffing coordinator provided the surveyor with the 30-day actual staffing pattern, from 09/22/19 through 10/22/19. The document showed: On Sunday 09/22/19, the facility had a total of 11.5 nursing assistants in a 24-hour period, for a census of 62. On Tuesday 09/24/19, the facility had a total of 13 nursing assistants in a 24-hour period, for a census of 65. The night shift had two nursing assistants for the entire facility, as there were two call-off's (staff that did not come into work), that were not replaced. On Wednesday 09/25/19, the facility had a total of 12 nursing assistants in a 24-hour period, for a census of 65 residents. The night shift had two nursing assistants for the entire facility. On Thursday 09/26/19, the census was 67 residents. According to the actual schedule, 14 nursing assistants worked in the 24-hours period. The schedule showed that three open positions were not filled. On Saturday 09/28/19, the facility census was shown to be 67 residents. The schedule showed 14 nursing assistants were on duty for the 24-hour period. The night shift schedule showed two staff worked from 10:00 PM to 6:00 AM, and one nursing assistant worked from 10:00 PM to 2:00 AM. On Sunday 10/13/19, the facility census was 68 residents. According to the actual schedule, there was a total of 14 nursing assistants. The night shift had a call-off, which left two nursing assistants caring for all 68 residents. In review of all of the days during the 30-day staffing pattern, the facility did not show that there were 22-24 nurse aides on duty, per 24 hours. RESIDENT COUNCIL MEETING: On 10/25/19 at 12:50 PM, a meeting was held with the resident council members. The seven alert and oriented residents were asked if they got the help and care they needed, without having to wait a long time. Resident #41 stated there were not enough nurse aides on staff, and call lights could take up to a half hour to be answered. Resident #34 stated it could be longer on some days to have her call light answered. Resident #41 stated that shift change was the worst, because at around 8:00 PM, staff tried to get everyone to bed, and if they were in a resident's room, they couldn't get to the call lights. RESIDENT INTERVIEWS: On 10/22/19 at 9:13 AM, Resident #20 was asked if there was enough staff to meet her needs. She stated, No, there's not enough staff, I have to wait for everything. When asked if there was a specific time of day, she stated no. On 10/22/19 at 10:02 AM, Resident #164 stated that sometimes they were short-staffed, so the aides had to work fast, and were not always gentle, because of being rushed. The resident stated the facility was more short-staffed on the weekends. On 10/22/19 at 10:49 AM, Resident #47 stated the previous night, she went to the bathroom by herself, as the aide was on break. She stated she pushed the button in the bathroom when she was done, and after 5-10 minutes, she got up by herself. She stated she was supposed to have help, but last night there were only three aides for the whole hallway. Resident #47 stated on some weekends there was usually just one. On 10/22/19 at 3:01 PM, Resident #34 stated that there were not enough staff, because other staff called off, and they were not replaced. She stated that the weekend call-offs were the worst. STAFF INTERVIEWS: On 10/25/19 at 7:55 AM, Staff AA, Nursing Assistant, was asked about staffing issues. She stated she had worked at the facility for about a year, and worked Friday through Monday, 12-hours shifts. She stated she was usually on-call (i.e., working as needed), however, lately she had been working pretty regularly, over the last couple of months. Staff AA further stated there was not enough staff, and said the shower aide frequently got pulled to work on the floor on the west unit, so the other nurse aides had to give bed baths in addition to taking care of residents. She stated she thought there should be three nurse aides for the east side, but lately it had only been two aides (and no shower aides). In addition, Staff AA stated that it was impossible to do showers and everything else the residents needed. On 10/28/19 at 2:06 PM, Staff Z, Licensed Practical Nurse, was asked about staffing issues. He stated there were not enough nurses or nurse aides. He further stated that he did not know his residents as well as he should. Staff Z was asked how many nurse aides were usually working the day shift; he stated usually two. Staff Z stated they count the shower aide, but she is giving showers, so is unable to help on the floor. Staff Z was asked how many nurse aides were needed on the east unit (short-term rehab), and stated at least three. For example, Staff Z stated, he had needed a nurse aide that day, to help him during a dressing change, so that left one nurse aide for the whole unit, and there were a lot of residents who required two-person cares. In an interview on 10/29/19 at 10:15 AM, Staff A, Administrator, Staff B, Director of Nursing, and Staff C, Regional Nurse Consultant, attended the interview. Staff A was asked how did he determine there was sufficient staff to meet the resident needs. He stated staffing was based on acuity (a scale in which nursing assignments were made, based on residents who needed more care), through the coding on the Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents). Staff A was asked about the facility assessment, and the documented need for 22-24 nurse aides in a 24 hour period, for a census of 60. The surveyor shared the 30-day staffing pattern with Staff A, informing him that he did not achieve that level for the entire 30-day period. Staff A stated that he would like to see one nurse aide for every 10 residents on the day and evening shifts, and a total of four nurse aides on the night shift. Staff A stated that replacing nurse aides for the open shifts was difficult, and agreed that having two nurse aides at night was not ideal. Staff A stated that was, not where he wanted to be. Staff A was asked how he determined staffing based on acuity, as the facility assessment did not show how the facility would handle the increased staffing needs, based on the multiple residents who required two-person assistance, or full body lifts, who currently resided in the facility. He stated he was trying to hire more staff, and currently had three people who were being sponsored by the facility, in a nurse aide program. In addition, he was offering a sign-on bonus, and felt that he was making progress. Reference: (WAC) 388-97-1080 (1), 1090 (1)

CONCERN (F)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure licensed nurses had the appropriate competencies, skill sets, and proficiencies, to provide nursing and related services for resident care, for three of three sample licensed nurses (Staff L,M,O). This failure placed residents at risk for health complications and a diminished quality of life. Findings included . Review of the employee files on 10/28/19, showed no documentation of staff competencies for Staff L, Registered Nurse, Staff O, Registered Nurse, and Staff M, Licensed Practical Nurse. On 10/28/19 at 10:23 AM, Staff D, Staff Development Coordinator, stated she had only been in the position for a few months. She confirmed that she did not have any trainings or skill competencies for the nurses in their personnel records. (See F-759: Medication Administration for additional information). Reference: (WAC ) 388-97-1080 (1), 1090 (1) .

CONCERN (F)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure a system which provided for annual nurse aide proficiency reviews and training, per the requirement, for five of five employees (Staff P,Q,R,S,T), whose records were reviewed. Failure to fully complete performance reviews, and provide regular in-service education based on those outcomes, placed residents at risk for unmet care needs related to unqualified care staff. Findings included . 1. Staff P, Nursing Assistant, had a hire date of 10/28/15. A review of her employee training records did not show an annual performance review. The only training Staff P had was from a skills fair, dated 07/26/19. The evaluation did not show complete documentation of skills, related to the performance of her job. 2. Staff Q, Nursing Assistant, had a hire date of 10/31/16. A competency and performance review, dated 12/24/18, showed an incomplete performance review summary. The evaluation did not show areas needed for improvement, or any goals/objectives to improve her performance. 3. Staff R, Nursing Assistant, had a hire date of 11/08/16. A competency and performance review, dated 12/21/18, showed an incomplete performance review summary. The evaluation did not show areas needed for improvement, or any goal/objectives to improve his performance. 4. Staff S, Nursing Assistant, had a hire date of 10/24/17. A review of the employee file showed a performance review, dated 01/29/18. There was no documentation of a review for 2019. 5. Staff T, Nursing Assistant, had a hire date of 02/12/14. The evaluation of competency and performance, dated 01/10/19, showed an incomplete evaluation. The summary did not show areas needed for improvement, or any goals/objectives to improve her performance. In an interview on 10/25/19 at 11:44 AM, Staff B, Director of Nursing, stated that there had not been a staff development person in place for two and half years. She confirmed that the performance reviews were incomplete. Reference: (WAC) 388-97-1680 (1),(2)(a-c)

CONCERN (F)

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

Staffing Information (Tag F0732)

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 accurately post nursing hours, and failed to maintain the daily nurse staffing data for 18 months, as required. This failed practice had the potential of preventing residents, family members, and/or visitors from knowing the facility's actual hours of nurse staff, and number of staff working during a particular shift. Findings included . On 10/22/19 at 10:05 AM, the daily nurse staff posting was observed hanging on the wall in the front reception area. The posting had a column that indicated the shifts - Day, Eve (evening), and NOC (nights); Registered Nurse (RN) hours; Licensed Practical Nurse (LPN) hours; and Nursing Assistant Certified (NAC) hours. The posting showed only number of hours, and not how many staff were on duty for each shift. The information was confusing and inaccurate (see below). A record review of the last 30 days (09/22/19 to 10/22/19) showed that there were three days (09/22/19, 09/28/19, and 10/13/19) when there was no posting at all. The staffing data, on the remainder of the days, did not reflect the actual schedules, and therefore, was inaccurate. On 10/22/19, Staff KK, Central Supply Director, was asked for the last 18 months of staff postings for review. She provided 12 months, and stated that she did not have 18 months, as she was unaware that she needed to keep them for that long. On 10/29/19 at 10:15 AM, the nurse staff posting was reviewed with Staff A, Administrator, and Staff B, Director of Nursing. The missing days and the inaccurate posting of hours were brought to their attention. Staff B stated that the nurse staff posting was done on the night shift, by the nurse. Staff A and Staff B confirmed that there were inconsistencies regarding the nurse posting, and felt that this was something that could be tightened up easily. No associated WAC

CONCERN (F)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to develop a thorough facility-wide assessment, to determine resources needed to care for residents. Failure to include accurate and complete components resulted in an assessment which lacked accurate staffing projections to meet residents overall day-to-day needs. This failure placed all 67 residents, identified by the current facility census, at risk for unmet care needs and a diminished quality of life. Findings included . A review of the facility assessment showed it was updated on 06/25/19, and reviewed with the Quality Assurance Committee on 07/25/19. The assessment showed the facility was licensed for 75 beds, and had an average daily census of 60. The Staffing Plan in the assessment, showed that the facility needed an average of 22-24 nurse aides in a 24-hour period. The 30-day staffing plan from 09/22/19 to 10/22/19, showed that for 30 out of 30 days, the facility did not meet this number. The Resident Support/Care Needs section of the assessment, showed the facility was able to care for residents through comprehensive wound care and wound prevention. According to the matrix (a document filled out by facility staff at the beginning of the survey), there were two residents in the facility who currently had Wound V.A.C (vacuum-assisted closure of a wound to assist with healing) treatments. The assessment did not include Wound V.A.C treatments, as well as the required educational component involved, in caring for this complex wound treatment. The Infection Prevention and Control Section of the facility assessment, showed there was an on-going antibiotic stewardship program. There was no documentation that the facility currently had an antibiotic stewardship program. The Staff Training/Education and Competencies section did not show staff training and competencies, required to meet resident care needs in the facility. The facility did not provide documentation of the Hand-in-Hand dementia training, as outlined in the facility assessment. In addition, the facility was unable to show the required 12-hours of nurse aide training annually, including abuse/neglect, reporting of allegations of abuse, or any dementia training. Observations of the facility environment, throughout the survey, revealed a non-audible call light system. On 10/25/19 at 12:45 PM, Staff B, Director of Nursing, confirmed there was no formal dementia and abuse training for staff, and verified they have not had the required 12-hours of training. On 10/28/19 at 10:56 AM, Staff C, Regional Nurse Consultant, stated the facility had no antibiotic stewardship program in place at this time. In an interview on 10/29/19 at 10:15 AM, Staff A, Administrator, was asked about the lack of nurse aide staffing as compared to the 30-day staffing pattern, and what was documented on the facility assessment. He stated he felt the facility needed only one nurse aide for every 10 residents on the day and evening shifts, and a total of four nurse aides on the night shift. Staff A stated that he was aware that staffing had not achieved the level he wanted, and this was something they had been working on. Staff A was asked if they cared for residents with Wound V.A C.s in the facility, and he stated yes. He was unaware that the facility assessment did not include this component. Staff A was asked if he was aware of the non-audible call light system. He stated yes, that it had been out for almost a year. Staff A further stated that all the paperwork was in order, and they were currently awaiting the go-ahead for the repairs to begin. Refer to: F-609: Reporting of alleged violations; F-610: Investigate/prevent/correct alleged violations; F-677: Activities of daily living care for dependent residents; F-725: Sufficient staffing; F-726: Competent nurse staffing; F-730: 12-hour nurse aide training and performance reviews; F-744: Dementia care; and F-759: Medication error rate greater than 5%. Reference: (WAC) 388-97-1000(1)(a)(b)(c)(d)

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to implement an effective Quality Assessment and Assurance (QAA) program, that identified and/or corrected system deficiencies. In addition, the QAA program failed to ensure sustainability from previous system deficiencies, which resulted in additional citations in resident care and services, related to: Sufficient staffing, competent nurse staffing, nurse aide proficiency and training, and antibiotic stewardship. These failures resulted in residents having unmet care needs, delays in services, and care from potentially inadequately trained staff, which placed residents at risk for a decreased quality of life and potential health complications. Findings included . On 10/29/19 at 10:15 AM, the surveyor conducted an interview with Staff A, Administrator, regarding the facility's quality assurance activities. Staff A stated that he had only been at the facility for six months, and had reviewed the facility's QAA activities. Staff A stated that when he came, he started first with those care issues that might cause harm to a resident, and was now getting to identified QAA trends and deficiencies. The following areas of repeated deficiency were identified by the survey team, and reviewed with Staff A at the date and time listed above: -ADL Care for Dependent Residents: Based on observation, interview, and record review, the facility failed to provide timely assistance with personal hygiene. (See F-677 for additional information). Similar deficiencies were cited during the annual recertification surveys dated 07/17/17, and 08/10/18. -Sufficient Staffing: Based on interview and record review, the facility failed to ensure sufficient qualified staff were available to meet resident needs. (See F-725 for additional information). Similar deficiencies were cited during the annual recertification survey dated 08/10/18 -Antibiotic Stewardship: Based on interview and record review, the facility failed to establish an antibitoic stewardship program to promote appropriate use of antibiotics. (See F-881 for additional information). Similar deficiencies were cited during the annual recertification survey dated 08/10/18 -Reporting of Alleged Violations: Based on interview and record review, the facility failed to ensure allegations of potential abuse and neglect were timely reported to administration and the State Survey Agency. (See F-609 for additional information). Similar deficiencies were cited during an abbreviated survey dated 02/15/19. -Investigate Alleged Violations: Based on interview and record review, the facility failed to timely investigate an allegation of potential abuse/neglect. (See F-610 for additional information). Similar deficiencies were cited during the annual recertification survey dated 08/10/18 Staff A was shown a part of the Quality Assurance Performance Improvement (QAPI) plan, which showed that all staff would be in-serviced on the QAPI plan at orientation. Staff A was informed that QAPI was not shown on the newly hired staff orientation checklist. Staff A stated he was unaware that it was not included on the checklist, and therefore, not discussed at orientation. Staff A was asked what action had been taken to correct the issues, especially with staffing. He stated the facility was continuing to work on this, and had made improvements. He stated he had tried to fix everything he could in a short amount of time. Staff A was asked if there was QAA committee monitoring, to ensure corrective actions had been implemented and sustained. He stated that staffing had improved, even though it was not yet optimal. He stated that he planned to continue to discuss staffing in QAA meetings, and to have developed performance plans for staff development. Staff A was asked how long he would continue to monitor issues, to know any correction was sustained. He stated that the committee planned to continue to monitor for a long-term solution. Reference WAC 388-97-1760(1)(2)

CONCERN (F)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to establish an antibiotic stewardship program, to promote appropriate use of antibiotics, and to reduce the risk of unnecessary antibiotic use, including development of antibiotic resistance. This failure placed all residents at risk for potential adverse outcomes, associated with the inappropriate and/or necessary use of antibiotics. Findings included . On 10/28/19 Staff D, Infection Control Preventionist, was asked to provide her antibiotic stewardship use protocols and system for review. On 10/28/19 at 10:56 AM, Staff C, Regional Nurse Consultant, stated the facility did not have an antibiotic stewardship program at this time. She stated that Staff D had recently started in the position and was currently receiving training, however, there was nothing currently in place. No associated WAC reference

CONCERN (F)

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

Deficiency F0943 (Tag F0943)

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 provide documented staff orientation and training on abuse and neglect, as well as dementia care training for seven of eight employees (Staff L,O, P, Q, R, U, T), reviewed for abuse and dementia training. This failed practice had the potential of not identifying and preventing abuse and/or neglect. In addition, this failed practice placed residents with dementia at risk of not receiving appropriate care. Findings included . 1. Staff L, Registered Nurse, had a hire date of 10/11/19. A review of her employee file and orientation record did not show any documented abuse/neglect or dementia training prior to her working independently. 2. Staff O, Registered Nurse, had a hire date of 02/19/19. A review of her employee file and orientation/training records did not show any documented abuse/neglect or dementia training. 3. Staff P, Nursing Assistant, had a hire date of 10/28/15. A review of her training records showed that an in-service on abuse/neglect was provided on 12/28/18, however, Staff P did not attend the in-service, and there was no follow-up training documented. In addition, there was no documentation in her record which showed she had dementia training. 4. Staff Q, Nursing Assistant, had a hire date of 10/31/16. A review of her training records showed that the 12/28/18 abuse in-service was offered, however, Staff Q did not attend. There was no documentation of follow-up education. In addition, there was no documented dementia training in her record. 5. Staff R, Nursing Assistant, had a hire date of 11/08/16. A review of his training record showed the 12/28/18 abuse training was offered, however, Staff R did not attend. There was no documentation of follow-up education. In addition, there was no documentation of dementia training in his record. 6. Staff U, Nursing Assistant, had a hire date of 02/12/14. There was no documentation of any abuse/neglect or dementia training in her record. 7. Staff T, Nursing Assistant, had a hire date of 12/18/18. There was no documentation of any abuse/neglect or dementia training in his record. In an interview on 10/25/19 at 12:45 PM, Staff B, Director of Nursing, confirmed that there had been no documentation of dementia or abuse/neglect training for staff. (See F-744: Treatment/Service for Dementia Care for additional information). Reference: (WAC) 388-97-0640 (2)

CONCERN (F)

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

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to provide no less than 12 hours of continuing competency training per year, for five of five nursing assistants (Staff P,Q,R,S,T), whose records were reviewed. This failure had the potential to affect all 67 residents identified by the current facility census, and placed residents cared for by the nursing assistants at risk of not receiving competent care. Findings included . During the review for Sufficient and Competent Nurse Staffing on 10/22/19, the training records for the nursing assistants was requested from Staff B, Director of Nursing. Staff B stated that Staff D, Staff Development Coordinator, was hired approximately two months ago, to fill the position for training, and was behind on getting all the training for the nursing assistants completed. The information that was provided included: 1. Staff P had a hire date of 10/28/15, and according to her file, had one training in the last year, on full body lifts. There was no other documentation of 12 hours of competency training. 2. Staff Q had a hire date of 10/31/16. Her file showed she had attended an in-service on infection control, vital signs, and full body lifts. She did not have any further training in the last 12 months. 3. Staff R had a hire date of 11/08/16. Her file showed she attended an in-service on vital signs and full body lifts. This was the only competency training documented for the last year. 4. Staff S had a hire date of 10/24/17. Her file showed she attended an in-service on abuse, vital signs, and full body lifts. There was no other competency training identified. 5. Staff T was hired on 12/28/18. His record showed he had an in-service on body mechanics, and how to care for a resident on 1:1 supervision. There was no further documentation of competency training. In a follow-up interview with Staff D, when asked if she had any documentation of staff training, she stated she had not done anything with skills and competencies. She stated that there had not been someone in the position for awhile, and she was having difficulty getting to everything. For more information, refer to: F-677: ADL Care for Dependent Residents; and F-692: Nutritional Status. Reference: (WAC) 388-97-1680 (2)(a-c)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 harm violation(s), $32,214 in fines. Review inspection reports carefully.
• 86 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
• $32,214 in fines. Higher than 94% of Washington facilities, suggesting repeated compliance issues.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Alderwood Manor's CMS Rating?

CMS assigns ALDERWOOD MANOR an overall rating of 3 out of 5 stars, which is considered average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Alderwood Manor Staffed?

CMS rates ALDERWOOD MANOR's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Washington average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Alderwood Manor?

State health inspectors documented 86 deficiencies at ALDERWOOD MANOR during 2019 to 2025. These included: 3 that caused actual resident harm and 83 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Alderwood Manor?

ALDERWOOD MANOR is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LIFE CARE CENTERS OF AMERICA, a chain that manages multiple nursing homes. With 85 certified beds and approximately 60 residents (about 71% occupancy), it is a smaller facility located in SPOKANE, Washington.

How Does Alderwood Manor Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, ALDERWOOD MANOR's overall rating (3 stars) is below the state average of 3.2, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Alderwood Manor?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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 high staff turnover rate.

Is Alderwood Manor Safe?

Based on CMS inspection data, ALDERWOOD MANOR has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Alderwood Manor Stick Around?

Staff turnover at ALDERWOOD MANOR is high. At 57%, the facility is 11 percentage points above the Washington average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Alderwood Manor Ever Fined?

ALDERWOOD MANOR has been fined $32,214 across 1 penalty action. This is below the Washington average of $33,401. 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 Alderwood Manor on Any Federal Watch List?

ALDERWOOD MANOR 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: 85
Avg. Residents: 60
Occupancy: 71.1%
Ownership: For profit - Partnership
Chain: LIFE CARE CENTERS OF AMERICA
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
High Turnover: -5
3 Actual Harm citations: -15
86 Deficiencies: -10
Fines ($32,214): -5
Final Score: 35/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505257