Based on interview and record review, the facility failed to administer methadone consistent with the dosage prescribed by Opioid Treatment Program provider and as a part of medications for opioid use disorder (MOUD) for 1 of 8 residents (Resident 1) reviewed for medication administration. This failure placed the resident at risk for medical complications, unintended health consequences and diminished quality of life.Findings included .Per the Code of Federal Regulations Title 42 Section 8.12 (h)(1) opioid treatment programs (OTP; a specialized clinic that provides medication-assisted treatment for individuals with opioid use disorder) must ensure that medications for opioid use disorder (MOUD) are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (2) OTPs shall use only those MOUD that are approved by the Food and Drug Administration under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) for use in the treatment of OUD. In addition, OTPs who are fully compliant with the protocol of an investigational use of a drug and other conditions set forth in the application may administer a drug that has been authorized by the Food and Drug Administration under an investigational new drug application under section 505(i) of the Federal Food, Drug, and Cosmetic Act for investigational use in the treatment of OUD. Currently the following MOUD will be considered to be approved by the Food and Drug Administration for use in the treatment of OUD: (i) Methadone; (ii) Buprenorphine and buprenorphine combination products that have been approved for use in the treatment of OUD; and (iii) Naltrexone.Review of Washington State Department of Health (DOH) Opioid Treatment Program Approved by Substance Abuse and Mental Health Services Administration (SAMHSA), dated October 9, 2024, documented in Page 53 under Procedures for Dosing CFR 8.12 (h) (3) (i) (ii), The program provider is the only practitioner authorized to order and/or change a patient's dosage of methadone (long-acting opioid medication used to reduce withdrawal symptoms in people addicted to narcotic drugs that may sometimes be used as a pain reliever) or buprenorphine. The provider must make an individualized decision informed by up-to- date product labeling and clinical judgment.Review of the 02/28/20205 care plan showed Resident 1 used methadone for an opioid use disorder (OUD), and the dosage was managed at weekly outpatient appointments with a local OTP. The care plan included a diagnosis list which showed the resident had Hepatitis B and Hepatitis C (serious liver conditions that can be acute or chronic).Review of a hospital after-visit summary dated 03/28/2025 showed Resident 1 was treated for an opioid overdose and hospital staff coordinated with the OTP for the resident to receive 35mg (milligrams; unit of measurement) of methadone for the following two days (03/29/2025 and 03/30/2025), which was half of the resident's previous dose (70mg). The after-visit summary showed the resident was to go to the OTP on 03/31/2025 for further dosing.Review of the methadone chain of custody record started 03/31/2025 showed Resident 1 received 50mg of methadone at the OTP that day, and facility staff to administer 60mg on 04/01/2025, then 70mg daily starting 04/02/2025. Further review showed the actual dose of methadone given to Resident 1 was 50mg daily each day from 04/01/2025 to 04/07/2025. In an interview on 07/22/2025 at 2:10 PM, Staff A, Director of Nursing, stated after Resident 1's suspected overdose on 03/28/2025 the facility received orders from the OTP to taper the resident's methadone dose back up to 70mg daily, but the order was changed to 50mg daily by Staff B, Physician Assistant. Staff A stated Staff B gave a verbal order for the dose change due to recommendations by the resident's hepatology clinic (branch of medicine that focuses on diseases affecting the liver, gall bladder, bile ducts, and pancreas) to reduce or eliminate the methadone use on 04/02/2025.Review of Resident 1's April 2025 Medication Administration Record showed facility staff administered 50mg of methadone to the resident daily from 04/01/2025 to 04/12/2025, except for 04/08/2025 when the resident received their methadone during their appointment at the OTP. On 05/30/2025 at 2:55 PM Collateral Contact 1 (CC1) stated when Resident 1's methadone vials were returned to the OTP in April 2025 the vials should have been empty, but instead still had dose amounts remaining. Per CC1 the facility did not report giving the resident less methadone than ordered by the OTP until the OTP staff asked about the remaining dose amounts.In an interview on 07/22/2025 at 12:52 PM, Staff D, Administrator, stated the facility did not have a specific policy related to residents who utilized an OTP, but the facility followed the OTP provider's orders for methadone use. Staff D further stated that Resident 1's case was difficult due to medical providers at the hospital and other appointments expressing concerns with the resident's use of methadone with their other underlying medical conditions.Review of a provider progress note dated 04/02/2025 showed Resident 1 was to continue receiving 70mg of methadone daily and that Staff B would follow-up with the resident through the next several days regarding the hepatology team's recommendations. There was no documentation the OTP was consulted about the resident's methadone dose and/or attempts to coordinate care between the OTP medical provider(s) and the resident's hepatology provider(s).Staff B was not available for interview during the course of the survey.In an interview on 09/17/2025 at 3:53 PM, Staff C, Medical Director, stated which type of medical provider was responsible for managing methadone doses was dependent upon the resident's diagnosis. Per Staff C, if methadone was used for pain facility providers could adjust the dose, but if the methadone was used for OUD then the facility should send the resident to the OTP for dosing. Staff C stated if there were multiple types of providers involved in a resident's care who disagreed on treatment, they would coordinate with the various providers directly. Staff C clarified they were not the medical director during April 2025 and had no additional information related to Resident 1's methadone order changes.Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to coordination with the opioid treatment program provider to change dosage of medications for opioid use disorder (MOUD) for 1 of 1 sampled residents, (Resident 1), reviewed for MOUD. This failure placed the resident at risk for medical complications, unintended health consequences and diminished quality of life.Findings included .Per the Code of Federal Regulations Title 42 Section 8.12 (h)(1) opioid treatment programs (OTP; a specialized clinic that provides medication-assisted treatment for individuals with opioid use disorder) must ensure that medications for opioid use disorder (MOUD) are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (2) OTPs shall use only those MOUD that are approved by the Food and Drug Administration under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) for use in the treatment of OUD. In addition, OTPs who are fully compliant with the protocol of an investigational use of a drug and other conditions set forth in the application may administer a drug that has been authorized by the Food and Drug Administration under an investigational new drug application under section 505(i) of the Federal Food, Drug, and Cosmetic Act for investigational use in the treatment of OUD. Currently the following MOUD will be considered to be approved by the Food and Drug Administration for use in the treatment of OUD: (i) Methadone; (ii) Buprenorphine and buprenorphine combination products that have been approved for use in the treatment of OUD; and (iii) Naltrexone.Review of Washington State Department of Health (DOH) Opioid Treatment Program Approved by Substance Abuse and Mental Health Services Administration (SAMHSA), dated October 9, 2024, documented in Page 53 under Procedures for Dosing CFR 8.12 (h) (3) (i) (ii), The program provider is the only practitioner authorized to order and/or change a patient's dosage of methadone (long-acting opioid medication used to reduce withdrawal symptoms in people addicted to narcotic drugs that may sometimes be used as a pain reliever) or buprenorphine. The provider must make an individualized decision informed by up-to- date product labeling and clinical judgment.Review of the 02/28/20205 care plan showed Resident 1 used methadone for an opioid use disorder (OUD), and the dosage was managed at weekly outpatient appointments with a local OTP. The care plan included a diagnosis list which showed the resident had Hepatitis B and Hepatitis C (serious liver conditions that can be acute or chronic).Review of a hospital after-visit summary dated 03/28/2025 showed Resident 1 was treated for an opioid overdose and hospital staff coordinated with the OTP for the resident to receive 35mg (milligrams; unit of measurement) of methadone for the following two days (03/29/2025 and 03/30/2025), which was half of the resident's previous dose (70mg). The after-visit summary showed the resident was to go to the OTP on 03/31/2025 for further dosing.Review of the methadone chain of custody record started 03/31/2025 showed Resident 1 received 50mg of methadone at the OTP that day, and facility staff to administer 60mg on 04/01/2025, then 70mg daily starting 04/02/2025. In an interview on 07/22/2025 at 2:10 PM, Staff A, Director of Nursing, stated after Resident 1's suspected overdose on 03/28/2025 the facility received orders from the OTP to taper the resident's methadone dose back up to 70mg daily, but the order was changed to 50mg daily by Staff B, Physician Assistant. Staff A stated Staff B gave a verbal order for the dose change due to recommendations by the resident's hepatology clinic (branch of medicine that focuses on diseases affecting the liver, gall bladder, bile ducts, and pancreas) to reduce or eliminate the methadone use on 04/02/2025. Review of Resident 1's April 2025 Medication Administration Record showed facility staff administered 50mg of methadone to the resident daily from 04/01/2025 to 04/12/2025, except for 04/08/2025 when the resident received their methadone during their appointment at the OTP. Further review showed no record of coordination with the opioid treatment program provider to change dosage of MOUD. On 05/30/2025 at 2:55 PM Collateral Contact 1 (CC1) stated when Resident 1's methadone vials were returned to the OTP in April 2025 the vials should have been empty, but instead still had dose amounts remaining. Per CC1 the facility did not report giving the resident less methadone than ordered by the OTP until the OTP staff asked about the remaining dose amounts.In an interview on 07/22/2025 at 12:52 PM, Staff D, Administrator, stated the facility did not have a specific policy related to residents who utilized an OTP, but the facility followed the OTP provider's orders for methadone use. Staff D further stated that Resident 1's case was difficult due to medical providers at the hospital and other appointments expressing concerns with the resident's use of methadone with their other underlying medical conditions.Review of a provider progress note dated 04/02/2025 showed Resident 1 was to continue receiving 70mg of methadone daily and that Staff B would follow-up with the resident through the next several days regarding the hepatology team's recommendations. There was no documentation the OTP was consulted about the resident's methadone dose and/or attempts to coordinate care between the OTP medical provider(s) and the resident's hepatology provider(s).Staff B was not available for interview during the course of the survey.In an interview on 09/17/2025 at 3:53 PM, Staff C, Medical Director, stated which type of medical provider was responsible for managing methadone doses was dependent upon the resident's diagnosis. Per Staff C, if methadone was used for pain facility providers could adjust the dose, but if the methadone was used for OUD then the facility should send the resident to the OTP for dosing. Staff C stated if there were multiple types of providers involved in a resident's care who disagreed on treatment, they would coordinate with the various providers directly. Staff C clarified they were not the medical director during April 2025 and had no additional information related to Resident 1's methadone order changes.Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure a resident was evaluated to self-administer their medications for 1 of 5 sampled residents (Resident 74) reviewed for medication administration. This failure placed the resident at risk for missed medication doses or unintended health consequences. Findings included . The 11/04/2024 quarterly assessment documented Resident 74 had diagnoses that included bipolar disorder (episodes of manic highs and depressive lows), high blood pressure and cervical cancer. Resident 74 was cognitively intact and took antidepressant medication daily. On 01/29/2025 at 9:35 AM, Resident 74 was observed in their room seated on their bed with their overbed table in front of them. Several loose pills were on the table lying on a surgical mask. Included were four round white tablets, one pink round pill, one orange oblong tablet, one blue capsule, and one football shaped pill that was red on one side and white on the other. The pills were not in a medication cup. Additionally, there was a small medication cup on the table that contained applesauce. Resident 74 stated they were unsure what the pills were because they took many. They stated the nurse gave them applesauce so they could put their pills in the applesauce to help them go down easier. Resident 74 stated the reason nurses watched them take their pills was to make sure they did not choke on them or drop them on the floor and miss a dose, but nurses did not always stay and watch them. During an interview on 02/05/2025 at 1:10 PM, Staff F, Licensed Practical Nurse, acknowledged they gave medications to Resident 74 on 01/29/2025. They stated they did not remember leaving the resident's medications without watching the resident take them. Staff F stated they might have been called to another room. They stated it was important to watch the residents take their medications; this ensured the resident did not throw them away, drop them or that a different resident took them. During an interview on 02/06/2025 at 8:43 AM, Staff C, Resident Care Manager, stated nurses were expected to stay with the resident when they took their medications unless the resident had an assessment completed to self-administer their pills, and the provider signed off on it. The assessment did not include all medications, only certain ones, and the assessment was to be re-evaluated regularly and if there was a change in the resident's condition. Staff C stated Resident 74 had not been assessed for self-administration of their medications. Reference: WAC 388-97-0440

Based on observation and interview, the facility failed to ensure the weekly menus and/or alternative menus were provided for 3 of 9 sampled residents (Residents 23, 36 and 48), reviewed for food. This failure denied residents the right to choose their meal preference, had the potential to negatively affect their nutritional needs and create a diminished quality of life. Findings included . <Resident 23> The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care. On 01/31/2025 at 9:20 AM, Resident 23 was observed lying in bed watching television. When asked how breakfast was, Resident 23 stated it was good, had sausage, but one time the meal looked like scraps, like someone had eaten and they were served the left-over plate. When asked if the facility handed out menus, Resident 23 stated the menus were not handed out, you had to ask for them and it usually took a couple days to get it, so by then you had missed a couple days of being able to choose what you wanted for the meal. In an interview on 02/03/2025 at 12:08 PM, Staff O, Nursing Assistant, when asked if the weekly menus were passed out to the residents, Staff O stated a stack of the menus and always available menu (alternative menu) were always kept at the nurses station and they were handed out if the residents asked for them. In an interview on 02/05/2025 at 9:06 AM, Staff W, Dietary Manager, was asked what the process was for handing out the menus to the residents. Staff W stated they did not know what the policy was, the menus were printed out and given to the nursing staff to keep at the desk to hand out. Staff W stated a resident received the regular meal if a menu had not been filled out and currently for the week of 02/03/2025 through 02/09/2025, 14 residents had turned in menus. At the time of the interview, 96 residents lived at the facility. <Resident 36> The 12/16/2024 quarterly assessment documented Resident 36 was cognitively intact to make decisions regarding their care. During an interview on 01/28/2025 at 10:26 AM, Resident 36 stated the food was not good, the food was too salty and was not edible. In an interview on 02/05/2025 at 9:43 AM, Staff EE, Nursing Assistant, was asked if the menus were handed out to the resident. Staff EE stated the menus were not handed out, but a stack of them was kept at the nurses' station and would be given to the residents when they asked. When asked if Resident 36 had ever received a menu, Staff EE stated they had never asked for one that they were aware of. On 02/05/2025 at 11:43 AM, Resident 36 was observed lying in bed. When asked if the staff ever handed out the weekly menus, Resident 36 stated, They have menus? I did not know that. They never tell us things like that, I don't recall ever seeing a menu. <Resident 48> The 01/09/2025 comprehensive assessment documented Resident 48 had diagnoses which included gastroesophageal reflux disease (GERD, a chronic digestive disease that occurred when stomach acid or bile flowed into the food pipe and irritated the lining and created an esophageal ulcer, a sore that developed in the lining of the esophagus) with bleeding. The resident was cognitively intact to make decisions regarding their care. In an observation and interview on 02/03/2025 at 9:48 AM, Resident 48 was lying in bed resting. They stated the meals served all tasted the same. The resident stated that staff did not offer them alternative food choices. Resident 48 stated they had never ordered from or been offered a menu to select their food choices. In an interview on 02/04/2025 at 12:00 PM, Staff W stated the kitchen generally received only 10-20 menus from all the residents living at the facility. Staff W stated the facility had been unsuccessful in developing a solution in the past. Staff W stated that it was important for residents to make their own food choices so they were able to meet their nutritional needs by eating the foods they preferred. Reference (WAC): 388-97-0900(1-4)

Based on interview and record review, the facility failed to provide information on services and charges for those services not covered under the facility's per diem rate for 2 of 3 sampled residents (Resident 91 and 14), reviewed for advanced beneficiary notices. This failure placed residents at risk of incurring unknown debt, financial hardship and a decreased quality of life. Findings included . Record review showed a 12/31/2024 Notice of Medicare Non-coverage letter (NOMNC) had been given to Resident 91, which showed Medicare payment for physical therapy, occupational therapy, and skilled nursing care would end on 01/02/2025. Additional record review showed Resident 91 had received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), however, the written notice was incomplete and failed to inform Resident 91 of the costs for continuing to reside in the facility. A NOMNC dated 12/20/2024 was given to Resident 14, which showed Medicare payment for physical therapy, occupational therapy, and skilled nursing care would end on 12/23/2024. No documentation was found on the SNFABN or other written notification had been provided to the resident or POA, to inform them of the costs for continuing to reside in the facility after the Medicare payment stopped. In an interview on 02/07/2025 at 8:42 AM, Resident 14's power of attorney (POA, person who can make healthcare decisions when one is unable to) stated the facility called and informed them of the Medicare ending but did not discuss the daily cost for care. The POA further stated they had not received or signed any documents pertaining to this change. In a telephone interview on 02/07/2025 at 8:21 AM, Staff J, Business Office Manager, confirmed Resident 91 and Resident 14's SNF/ABN forms had no documentation of the facility's per diem rate, including the cost of daily services as required Reference (WAC) 388-97-0300(1)(e), (5), (6)

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 4 of 8 sampled residents (Residents 14, 39, 46 and 83), reviewed for environment. Specifically Resident 14 had a wheelchair that was not maintained in a sanitary manner, Resident 39 had a hole in their drywall in their room, and Residents 39, 46 and 83 had drywall that was in disrepair. This failure did not allow residents to enjoy a homelike environment. Findings included . <Drywall> Per the 10/13/2024 quarterly assessment, Resident 39 was severely cognitively impaired and unable to make their needs known. During an observation on 01/28/2025 at 2:38 PM, Resident 39 was sitting in their recliner. There were gauges out of the drywall behind their recliner and a hole that was approximately six inches long and an inch wide near the headboard toward the floor. Similar observations were made on 01/30/2025 at 9:24 AM, 01/31/2025 at 9:00 AM, 02/03/2025 at 10:21 AM and 02/04/2025 at 8:53 AM. Per the 12/04/2024 quarterly assessment, Resident 46 was cognitively intact and able to make their needs known. In an observation on 01/31/2025 at 9:07 AM, Resident 46 was lying in bed asleep. There were gauges out of their drywall on the wall to the right as you entered the room, on the wall the head of their bed was facing and to the left of their bed. Similar observations were made on 02/03/2025 at 9:34 AM, 02/04/2025 at 9:02 AM and 02/05/2025 at 11:00 AM. Per the 09/26/2024 quarterly assessment, Resident 83 had severe cognitive impairments and was not able to make their needs known. During an observation on 01/30/2025 at 1:28 PM, Resident 83 was lying in bed. There were gauges out of their drywall near the resident's window and headboard. Similar observations were made on 01/31/2025 at 9:05 AM and 02/04/2025 at 8:59 AM. In an interview on 02/07/2025 at 9:52 AM, with Staff K, Maintenance Director and Staff A, Administrator, Staff A stated a room with holes and drywall in disrepair was not a homelike environment. Staff K stated the staff needed to inform them when repairs were needed. <Unclean wheelchair> Per the 12/03/2024 admission assessment, Resident 14 was severely cognitively impaired and was not able to make their needs known. In an observation on 01/30/2025 at 11:34 AM, Resident 14 was sitting in their wheelchair in the hallway. The wheelchair was unclean with white debris on the wheelchair cushion and wheels and a brown substance on the legs of the wheelchair. Similar observations were made on 01/31/2025 at 10:39 AM and 2:06 PM, 02/03/2025 at 9:43 AM, 11:02 AM, and 11:49 AM, 02/04/2025 at 8:57 AM and 1:26 PM and 02/05/2024 at 1:40 PM. During an interview on 02/07/2025 at 12:31 PM, Staff A stated everyone was responsible for cleaning the wheelchairs and it was important for sanitation and dignity for the resident. Reference WAC 388-97-0880

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to thoroughly investigate potential allegations of abuse for 2 of 3 sampled residents (Residents 30 and 83), reviewed for abuse. The facility further failed to investigate falls for 2 of 6 sampled residents (Residents 4 and 14) reviewed for falls. Specifically, Resident 30 had a fall in which they alleged the call light had been removed by staff and the call light concern was not investigated and Resident 83 had a scabbed area on their arm allegedly caused by staff and the cause of the scab was not investigated to rule out abuse. This failure placed residents at risk of further potential abuse and diminished quality of life. Findings included . Review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation revised November 2017, showed staff would conduct a thorough investigation of allegations. <Resident 83> In an interview and observation on 01/28/2025 at 2:49 PM, Resident 83 stated a week or two ago a nursing assistant was rough when they repositioned them and bumped their arm on the tray table. The resident stated they did not think staff liked them because they had to call for things because they could not get out of the bed. The resident was lying in bed and had a scab similar in size to a sunflower seed on their right forearm. Per the 09/26/2024 quarterly assessment, Resident 83 had diagnoses of stroke with hemiplegia (paralysis that affected one side of the body) and anxiety. Resident 83 had severe cognitive impairments and was not able to make their needs known. The 06/20/2024 care plan stated the resident had an activity of daily living performance deficit and required substantial to maximal assistance with repositioning in bed. Review of the 01/28/2025 facility investigation showed Resident 83 had an older scab, a light purple/pink discoloration and a dark blue bruise to their right forearm. According to the investigation, Resident 83 was cognitively intact, and never stated someone was rough with them. The resident used their forearms to scoot and adjust themselves which would explain the bruising and scabbed areas. There were no staff interviews included in the investigation. It was determined that no abuse or neglect occurred. During an interview on 02/06/2025 at 1:01 PM, Staff L, Social Service Director, stated they asked Resident 83 how they got the scab, and the resident stated they got it from a girl. Staff L stated the resident was more cognizant since medications changes had been made. In an interview on 02/06/2025 at 3:46 PM, Staff B, Director of Nursing, was notified of the statement made by Resident 83 regarding the scab during the conversation with Staff L and was asked how they were able to rule out abuse. Staff B stated they were unaware of the comment about the scab. Staff B read the progress note that staff L had made regarding the allegation of abuse, and it did not include the part about the scab or the girl. During an interview on 02/06/2025 at 3:59 PM, Staff B was present, Resident 83 stated they were flipped in bed, and did not think it was an accident. Resident 83 stated the person had been rough in flipping them from left to right. Resident 83 gave Staff B a description of what the person looked like. In an interview on 02/06/2025 at 4:11 PM, Staff B stated the investigation needed to be continued and they were going to look at staffing to see if a staff member fit the description, they were given by Resident 83. During an interview on 02/07/2025 at 11:33 AM, Staff B stated it was important to do a thorough investigation to keep the resident safe and the expectation was for staff that did interviews related to the investigation needed to present complete information. <Resident 30> According to the 01/21/2025 admission assessment, Resident 30 had diagnoses including stroke with weakness and/or paralysis affecting one side of the body. Resident 30 was cognitively intact and able to clearly verbalize their needs. A 01/20/2025 nursing progress note documented Resident 30 was told they activated their call light too often and the call light was removed from their reach. Resident 30 stated they were looking for their call light and fell out of bed. The 01/20/2025 facility incident report documented Resident 30's family member reported Resident 30's call light was moved out of their reach and they fell on [DATE]. The investigation contained three resident and three staff interviews that asked three simple questions 1) who were falls reported to, 2) should residents always have access to a call light, and 3) were staff allowed to take away a resident's call light. The incident report did not include staff or witness statements about the specific nature of Resident 30's allegation that their call light had been taken away due to excessive use. A 01/24/2025 investigation conclusion showed abuse and/or neglect was ruled out through interviews and determined Resident 30's call light was placed in a way that it had most likely fallen off the bed and was not taken away from the resident. In an interview on 01/31/2025 at 4:06 PM, Resident 30 stated the nurse told them they pushed their call light too much and took the call light away. Resident 30 explained they fell out of bed recently because they were trying to reach their call light. In an interview on 02/07/2025 at 9:28 AM, Staff C, Resident Care Manager, stated when an allegation of abuse was received, resident safety was the first priority, then they would notify Staff A, Administrator, because they were the abuse coordinator. Staff C was unsure how an allegation of abuse was investigated. Staff C acknowledged reports of rough care and staff taking resident call lights away were potential allegations of abuse that needed to be investigated as such. In an interview on 02/07/2025 at 11:19 AM, Staff B stated when allegations of abuse were received, they were reported to the State Survey Agency and investigated. Staff B explained abuse and/or neglect was ruled out by conducting resident and staff interviews. Staff B acknowledged reports of rough care and staff taking resident call lights away were potential allegations of abuse that needed to be investigated as such. In an interview on 02/07/2025 at 12:03 PM, Staff A, Administrator, stated they expected staff to complete thorough investigations for allegations of abuse and/or neglect. <Resident 4> According to the 12/05/2024 quarterly assessment, Resident 4 had diagnoses including a right hip fracture, dementia and high blood pressure. The assessment further showed Resident 4 had not sustained a fall since the most recent admission but had undergone a surgery to repair the fracture. Resident 4 was cognitively intact and able to make their needs known. Review of the 12/02/2024 fall risk evaluation showed Resident 4 had a history of falls and was at risk for additional falls. Review of the 12/02/2024 risk for falls care plan showed Resident 4 was at risk for falls related to confusion, balance problems, and history of falls. An 11/10/2024 progress note documented the resident was found lying on their floor mat in their room. The resident was sent to the hospital for behaviors. On 02/05/2025 the investigation for the fall on 11/10/2024 was requested and Staff A sent an email stating there was no investigation as the resident was sent to the hospital. In an interview on 02/07/2025 at 9:36 AM, Staff B stated the fall on 11/10/2024 should have been logged on the required incident log and investigated. <Resident 14> According to the 12/03/2024 admission assessment, Resident 14 had diagnoses including atrial fibrillation (irregular heartbeat), dementia and repeated falls. The assessment further showed Resident 14 had a fall prior to admission. Resident 14 was cognitively impaired and was able to make their needs known. Review of the 11/27/2024 fall risk evaluation showed Resident 14 had a history of falls and was at risk for additional falls. Review of the 11/27/2024 risk for falls care plan, last updated 01/30/2025, showed Resident 14 was at risk for falls related to deconditioning, balance problems, incontinence, vision and hearing problems and medication use. A 01/16/2025 progress note documented Resident 14 was found in their room on the floor mat next to the bed. On 02/03/2025 at 12:30 PM the investigation for the fall on 01/16/2025 was requested and Staff A stated there was no investigation as they were not notified of the fall. In an interview on 02/07/2025 at 9:34 AM, Staff B stated the fall on 01/16/2025 should have been logged on the incident log and investigated and it was important to put interventions in place to help prevent falls and monitor the effectiveness of the interventions. Reference: WAC 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to ensure a resident's medical record contained documentation of a hospital transfer and/or that the receiving hospital had received information of the resident's condition, for 1 of 4 sampled residents (Resident 4), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs. Findings included . The 11/23/2024 discharge assessment documented Resident 4 had cognitive impairment and had diagnoses which included diabetes, depression and anxiety. A review of Resident 4's transfer form dated 11/23/2024 documented the resident needed a proxy to make decisions and was being transferred to the hospital to be evaluated for behaviors such as agitation and psychosis. The area on the form which asked if the report had been called in to the hospital and to whom was blank.There was no further documentation that described what, if any, information was relayed to the hospital at the time of the resident's transfer. During an interview on 02/07/2025 at 9:01 AM, Staff M, Licensed Practical Nurse, stated they were expected to call the hospital and give a report when a resident was transferred. In an interview on 02/07/2025 at 9:36 AM, Staff B, Director of Nursing, stated the receiving hospital should have been notified of Resident 4's condition and this was important because they needed to know the status of the resident as well as their history. Reference: WAC 388-97-0120(2)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions], was completed after an exempted hospital stay for 1 of 5 sampled residents (Resident 46), reviewed for PASARR services. This failure placed the resident at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Per the [DATE] quarterly assessment, Resident 64 admitted to the facility in [DATE] from the hospital and had diagnoses which included depression and anxiety. Review of Resident 46's record showed a level I PASARR was completed prior to admission on [DATE] by the hospital, which showed a level II PASARR (a more in-depth screening, to identify whether nursing home services were needed, and if specialized mental health services were required), was needed, due to meeting the guidelines for an exempted hospital stay (meaning the resident was admitted to the facility directly from a hospital after receiving acute inpatient care, and the expected stay at the facility was 30 days or less). Further record review showed Resident 46 did not discharge from the facility within 30 days or less as expected and was currently still a resident at the facility. A new PASARR was not completed until [DATE], 40 days after the exempted 30-day stay had expired. In an interview on [DATE] at 1:11 PM, Staff L, Social Service Director, stated the PASARR should have been completed timely and this was important so recommendations could be implemented to care for the resident's mental health. Reference: WAC 388-97-1915 (1)(2)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prepare a discharge summary that included all the required components, complete a final summary of the resident's status upon discharge, complete a discharge plan of care with all the required components, and convey discharge information to the provider continuing care for 2 of 6 sampled residents (Residents 90 and 110), reviewed for discharge. This failure placed residents at risk of unsafe discharges, unmet care needs and diminished quality of life. Findings included . <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Resident 90 had severe cognitive impairment. Review of the 01/24/2025 discharge summary showed Resident 90 discharged from the facility to the community. Review of the January 2025 nursing progress notes showed Resident 90 was scheduled to discharge on [DATE]. The last progress note in Resident 90's record was on 01/23/2025 at 11:34 PM and showed Resident 90 was in bed with their eyes closed with staff at their bedside. No documentation was found to show when Resident 90 discharged the facility, what condition they were in upon discharge, who Resident 90 left the facility with or what documentation was reviewed or whom it was reviewed with. Review of discharges from 11/05/2024 through 02/05/2025 showed Resident 90 discharged from the facility on 01/24/2025. In an interview on 02/05/2025 at 2:28 PM, Resident 90's power of attorney (POA- person who can make healthcare decisions when a person was unable to) stated the facility informed them Resident 90 was being administered medication to help with behavioral outbursts. Resident 90's POA further stated they felt Resident 90 was overmedicated. The POA explained Resident 90 admitted to the facility requiring one person transfer assist using a walker but upon discharge Resident 90 could barely hold their head up and it took three persons to stand pivot transfer Resident 90 out of the wheelchair. <Resident 110> According to the 01/26/2025 discharge assessment, Resident 110 admitted to the facility on [DATE] and discharged on 01/26/2025 with diagnoses including psychoactive (drug or substance that affected how the brain worked and caused changes in mood, awareness, thoughts, feelings, and behaviors) substance abuse, anxiety, and schizophrenia (mental illness that affected a person's thoughts, feelings, and actions). The assessment further showed Resident 110 was independent with making decisions regarding daily life, had fluctuating inattention and disorganized thinking. Review of the 01/24/2025 hospital transition of care orders showed Resident 110 used amphetamines (methamphetamine or meth, powerful addictive central nervous system stimulant) and discontinuation of use was recommended. Hospital progress notes were included that showed Resident 110 was recently hospitalized with osteomyelitis (bone infection) in both feet but left the hospital AGAINST MEDICAL ADVICE. The notes further showed concerns of underlying psychotic (mental health condition where a person loses touch with reality) illness contributed to Resident 110's recent AGAINST MEDICAL ADVICE discharge and possibly interfering with their medical decision-making capacity. Review of the January 2025 nursing progress notes showed Resident 110 admitted to the facility on [DATE] at approximately 3:30 PM. On 01/26/2025 at 8:00 PM, staff were unable to locate Resident 110 to administer their bedtime medication. At 8:15 PM, an elopement was called. At 8:20 PM, the building was searched inside and out, staff were unable to locate Resident 110. At 8:30 PM, law enforcement was notified of the missing resident. At 9:08 PM, a nursing assistant reported Resident 110 was upset about not having enough snacks earlier in the day and ate their lunch in their room. On 01/27/2025 at 7:11 AM, Resident 110 was located at a local hospital, the resident left the facility and was drinking alcohol and did not know how to get back to the facility. No documentation was found to show what occurred with Resident 110 after the facility located them at the local hospital. Review of discharges from 11/05/2024 through 02/05/2025 showed Resident 110 discharged from the facility on 01/26/2025. In an interview on 02/05/2025 at 4:03 PM, Staff Q, Licensed Practical Nurse, explained social services was responsible for discharge planning but the cart nurse reviewed the discharg packet with a resident. Staff Q further stated a progress note should be written that included the resident's status at time of discharge, who they discharged with, medications sent, what documentation was reviewed and sent upon discharge. In an interview on 02/06/2025 at 9:48 AM, Staff C, Resident Care Manager, explained when a resident discharged the nurse reviewed any discharge paperwork with the resident, gathered medications to send upon discharge, and documented a detailed progress note that included what time a resident discharged , who they left with, any education provided, medications/belongings taken, what condition the resident discharged in, and any concerns voiced, if any. Staff C reviewed Resident 110's medical record. Staff C acknowledged there was no facility follow up documented after Resident 110 was located at a local hospital the day after they eloped from the facility. In an interview on 02/06/2025 at 12:06 PM, Staff L, Social Service Director, explained the discharge process. Staff L stated a discharge summary needed to be completed when a resident discharged with copies of the care plan, medication list, consults, testing performed, therapy notes, and any other pertinent information sent to the receiving provider. Staff L stated they were unsure what discharge documentation was required by nursing upon discharge. In an interview on 02/06/2025 at 1:31 PM, Staff A, Administrator, stated Resident 110 was part of the facility's new bridge bed program. Staff A explained the bridge bed program were facility beds paid by a local hospital for persons with placement issues and part of the bridge bed program requirement was that the resident only visited the hospital who paid for the bed, or the resident would be disqualified from the bridge bed program. Staff A further stated after Resident 110 eloped from the facility they were located at the incorrect hospital, so they were disqualified from the bridge bed program. Staff A explained Resident 110's discharge was considered discontinuation of care which they have not had to deal with before. Staff A was informed no discharge documentation was found in Resident 110's medical record. Staff A reviewed Resident 110's medical record. Staff A acknowledged the bridge bed program was new and the program needed tweaking to work out the kinks. Reference WAC 388-97-0080 (7)(a)(b) Refer to F689 and F758 for additional information.

Based on interview and record review, the facility failed to ensure a staff member was available to provide assistance to a resident while they were at an appointment with a provider outside the facility and failed to provide bathing as care planned for 2 of 4 sampled residents (Resident 109 and 54) reviewed for activities of daily living. Findings included . <Resident 109> The 12/26/2024 admission assessment documented Resident 109 was severely cognitively impaired, was dependent on nursing staff for activities of daily living (ADLS) such as toileting and had diagnoses which included medically complex conditions. Review of the State Agency's reporting database showed a concern had been reported which documented Resident 109 was wheelchair bound and had conditions that required a caregiver to be with them while attending appointments with providers outside the facility. The report further documented on 01/06/2025, Resident 109 had been dropped off at an appointment without a caregiver and while at the appointment, the resident needed assistance to the bathroom. Review of the ADL care plan documented Resident 109 required two nursing staff to assist with using the bathroom, and the resident required the use of a mechanical lift for transferring (such as from the wheelchair to the toilet). A progress note on 01/06/2025 at 4:37 PM documented the facility's transportation driver had been sent to pick up Resident 109 from the appointment with the outside provider due to the resident exhibiting behaviors and screaming. In an interview on 02/03/2025 at 12:15 PM, Staff O, Nursing Assistant, stated the facility sometimes scheduled a nursing assistant to go to appointments with a resident and reached out to family also to see if they could attend with the resident. In an interview on 02/05/2025 at 1:37 PM, Staff B, Director of Nursing, confirmed Resident 109 should have had a staff member and/or family member with them at the appointment due to needing assistance for ADLS. <Resident 54> In an interview on 01/28/2025 at 10:53 AM, Resident 54's representative stated the resident was not getting bathed as care planned and was told they had no one to bathe them or the facility had not hired anyone to do bathing. According to the 10/22/2024 quarterly assessment, Resident 54 was cognitively intact and needed assistance from staff for activities of daily living, such as bathing. Per the 03/23/2022 care plan, Resident 54 was to be showered/bathed one to two times per week. The resident was to be offered a bed bath if they refused to be showered. Review of the task report bathing documentation from 09/2024 to 01/29/2025 showed the following: September 2024: September 25th was marked non applicable; no other bathing was documented. October 2024: October 8th and 18th documented activity did not occur, October 10th and 23rd documented resident refused, and October 30th was marked non applicable. November 2024: November 7th resident received a bed bath, November 14th and 19th documented resident refused, no other bathing was documented. December 2024: December 11th resident received a bed bath, November 18th documented resident refused, no other bathing was documented. January 2025: January 22nd and 29th resident received a bed bath, January 8th documented resident refused, no other bathing was documented. In an interview on 02/06/2025 at 1:49 PM, Staff N, Registered Nurse, stated showers were given twice weekly unless the resident had another preference. Staff N stated if residents continued to refuse their showers management would be notified to see what interventions could be implemented for the resident to receive bathing. During an interview on 02/06/2025 at 2:57 PM, Staff B, Director of Nursing, stated bathing was provided one to two times per week per the resident's preference. Staff B stated they were aware that Resident 54 had refused bathing and stated they preferred bed baths in the evening. Review of the care plan showed no preference for Resident 54's desire to have been given bed baths in the evening. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer and implement treatement timely for the development of a wound for 1 of 2 sampled residents (Resident 54), reviewed for pressure ulcers. This placed the resident at risk for unidentified wounds, worsening pressure ulcers and delayed wound healing. Findings included . Review of the facility policy titled, Quality of Care Skin Integrity dated 08/2018, showed the facility staff would monitor residents skin conditions and be alert to potential changes in the residents' skin condition and identified changes would be reported. The website nih.gov - in which nih refers to national institute of health- with regard to the revised National Pressure Ulcer Advisory Panel pressure injury staging system showed a pressure injury is localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion [flow of fluid or blood to cells and tissues], comorbid condition [medical conditions that coexist and affect health and treatment], and condition of the soft tissue Stage 1 pressure injury: intact skin with a localized area of non-blanching erythema [redness that does not disappear when pressure is applied to the area] . Stage 2 pressure injury: partial thickness [involving epidermis and/or dermis] loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister Stage 3 pressure injury: full thickness [wound that extends below the epidermis and dermis into the subcutaneous tissue or deeper] skin loss, in which adipose (fat) or granulation [new connective tissue] tissue is visible in the ulcer Stage 4 pressure injury: full thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue], muscle, tendon [strong cords of tissue that connect muscle to bones], ligament [bands that connect bones and joints], cartilage [tough, flexible connective tissue that protects bones and joints, and provides structure to the nose and ears], or bone in the ulcer . unstageable pressure injury: full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead skin or tissue that can appear in a wound] or eschar [dead tissue that forms over healthy skin and eventually falls off] . Deep Tissue Pressure Injury [DTPI]: intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood filled blister It is essential that the intended staging or classification system be used for each type of injury to ensure appropriate treatment. In an interview on 01/28/2025 at 10:53 AM, Resident 54 stated they had a sore on their left heel and had acquired it at the facility. During an interview on 01/28/2025 at 11:42 AM, Resident 54's representative stated the resident had a huge, rotting sore on their heel that appeared two weeks ago. The representative stated the resident had been dealing with the wound off and on for a year. The representative stated the area on the heel was black and the staff had been circling the area with a marker. The representative stated a wound consultation was requested and nobody followed up on it. Per the 10/22/2024 quarterly assessment, Resident 54 was admitted with diagnoses which included diabetes, Multiple Sclerosis (a disease in which the immune system breaks down the protective covering of the nerves, the resulting nerve damage disrupts communication between the brain and body) and depression. The resident was cognitively intact, able to make their needs known and was dependent for bed mobility. The assessment showed the resident was at risk for pressure ulcers and did not currently have a pressure ulcer. Review of the 03/23/2022 care plan showed Resident 54 had potential for skin impairment related to immobility. On 04/01/2022 the care plan was revised and showed Resident 54 had a pressure ulcer to their left heel related to immobility. The care plan was revised on 09/22/2023 to state the resident had a potential for pressure ulcer development/pressure ulcer to left heel related to immobility. The care plan was again revised on 01/28/2025 to state the resident had a pressure ulcer to their left heel related to immobility. The facility placed interventions which included: 03/23/2022 encourage good nutrition and hydration to promote healthier skin and keep skin clean and dry 02/06/2023 air mattress 04/01/2022 administer medications and treatments as ordered 09/22/2023 keep heels floated while in bed and staff to encourage resident to comply with repositioning 09/29/2023 left foot boot to keep the heel offloading 01/28/2025 betadine to left heel twice daily, United Wound Healing referral 02/03/2025 avoid exposure to temperature extremes: heating pads, hot water bottles, heat lamps, hot/cold solutions and soaks, sunburn, ice packs, avoid mechanical trauma, carefully dry between toes but do not apply lotion between toes, determine and treat cause: poor fitting shoes, poor blood sugar control, pressure area, infection, ensure appropriate protective devices are applied to affected areas, monitor blood sugar levels, monitor pressure areas for color, sensation, temperature, monitor/document wound size, document progress in wound healing on an ongoing basis, notify MD as indicated, monitor and report signs of infection, position resident off the affected area, change position every two hours and as needed, refer to foot care nurse/podiatrist, weekly treatment documentation to include measurements. A 07/19/2024 Skin and Nutrition Review documented the left heel wound was healed. A 10/09/2024 Skin and Nutrition Review stated to discontinue the nutritional drink as the heel wound was resolved. A 01/21/2025 Weekly Skin check documented there were no skin concerns. A 01/27/2025 Weekly Skin check documented Resident 54 had an unstageable pressure ulcer that measured five centimeters by three centimeters (cm) to their left heel. A 01/30/2025 Skin and Wound evaluation documented Resident 54 had a stage four pressure ulcer to their left heel that had been present for one to three months and was facility acquired. The wound measured 7.9 cm by 5 cm and had a depth of 2.1 cm. A 02/04/2025 progress note by United Wound Healing, stated the wound was a stage four pressure ulcer. In an interview on 02/06/2025 at 1:43 PM, Staff GG, Nursing Assistant, stated new skin issues were reported to the nurse. When asked if the resident had any wounds, Staff GG stated they had not been at the facility for two days but when last there the resident did not have any wounds. During an interview on 02/06/2025 at 1:49 PM, Staff N, Registered Nurse, stated skin checks were completed weekly by the nurse. Staff N stated when a wound was identified, the provider and resident representative were notified, a treatment order was obtained, alert charting, and measurements of the wound were taken. Staff N stated Resident 54 had a wound on their heel, and was unsure when it developed, they added they started working at the facility in September and thought it was acting up again but would have to check. In an interview on 02/06/2025 at 2:05 PM, Staff C, Resident Care Manager, stated Resident 54's representative brought the pressure ulcer to their attention on 01/27/2025 and they placed a referral that day to United Wound Healing. Staff C stated a treatment for the pressure ulcer was implemented on 01/28/2024. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure a physician ordered foot care referral for a podiatrist was followed for 1 of 2 sampled residents (Resident 54), reviewed for wound care. This failure placed the resident at risk for skin impairment, discomfort, and a diminished quality of life. Findings included . Per the 10/22/2024 quarterly assessment, Resident 54 had diagnoses which included diabetes, Multiple Sclerosis (a disease in which the immune system breaks down the protective covering of the nerves and the resulting nerve damage disrupts communication between the brain and the body), and depression. The resident was cognitively intact and able to make their needs known. In an interview on 01/28/2025 at 10:53 AM, Resident 54's representative stated the resident's toenails were extremely bad and had curled over their toes. The representative stated they were told the facility could not get a podiatrist to come into the facility. The representative stated the nurse practitioner did the resident's toenails on 01/27/2025. Review of a 09/30/2024 provider progress note showed Resident 54 had long/thick toenails and needed a podiatry referral to evaluate and treat the resident for hypertrophic toenails (thickened, overgrown toenails that can cause pain, discomfort, and difficulty with footwear). In an interview on 02/06/2025 at 1:49 PM, Staff N, Registered Nurse, stated nursing staff processed provider orders. Staff N stated if a resident had a podiatry referral, depending on their insurance, the resident would have an appointment arranged with an outside provider. During an interview on 02/07/2025 at 7:46 AM, Staff C, Resident Care Manager, was asked why the order in September for podiatry was not followed and they stated the facility was trying to get a podiatrist to come into the facility to see the residents and was unsure if residents could be sent out to see the podiatrist. In an interview on 02/07/2025 at 7:48 AM, Staff L, Social Service Director, stated the facility was getting a list of residents who needed podiatry because they were trying to get a podiatrist to come into the facility. Staff L stated they could send the residents out to see the podiatrist. During an interview on 02/07/2025 at 7:53 AM, Resident 54 stated they did not leave the facility for appointments because it was too hard for them to do so. In an interview on 02/07/2025 at 11:05 AM, Staff B, Director of Nursing, was asked if the resident's nail care could have occurred earlier than January and they stated staff could have asked the provider sooner to assist with nail care and nursing could have attempted nail care as well. Staff B stated nail care was important to prevent infections. At the time of the survey exit Resident 54 had still not been seen by a podiatrist. Reference WAC 388-97 -1060 (3)(j)(viii)

Based on observation, interview, and record review, the facility failed to ensure consistent, ongoing communication and collaboration with the dialysis facility for 1 of 2 sampled residents (Resident 23) reviewed for dialysis, a treatment that removed waste products and excess fluid from the bloodstream when the kidneys no longer functioned properly. In addition, the facility failed to ensure Resident 23's care plan included accurate goals and interventions related to the care and maintenance of the central venous catheter (CVC: a flexible tube that was inserted into a vein to provide an access site for dialysis). Findings included . The 11/21/2024 admission assessment documented Resident 23 was cognitively intact to make decisions regarding their care and had diagnoses which included diabetes and end stage kidney disease. In addition, the assessment documented the resident received dialysis via an intravenous access site. In an interview on 01/28/2025 at 3:27 PM, Resident 23 was observed lying in bed watching television. During the conversation, the resident stated they received dialysis treatments and had a CVC that was used as the access site. Resident 23 had the following active provider orders: - monitor the dialysis fistula (an access site for dialysis that was created by connecting an artery to a vein) every shift for potential complications and signs of infection - monitor the fistula for thrill (a vibration felt by feeling the fistula) and bruit (listening to the fistula for a swishing sound), and to notify the kidney physician if absent. - complete and print the Pre-Dialysis Assessment and Communication form, ensure the form was sent with the resident on Mondays and Fridays to their dialysis appointments, review and follow up as indicated upon return from the appointment, and to call the dialysis center if the form was not sent back with the resident. Review of Resident 23's record found Pre-Dialysis assessment and Communication forms for the dates of 12/30/2024, 01/03/2025, 01/13/2025, 01/24/2025, and 02/03/2025, which showed out of 19 appointments, the form had been returned five times. All of the returned forms documented Resident 23 had a CVC for the dialysis access site, and did not have a fistula. Review of the Dialysis care plan documented interventions were implemented on 11/18/2024 which instructed licensed nursing staff to monitor, document, and report any signs or symptoms of infection to the dialysis access site. On 11/27/2024, interventions were added that instructed the licensed nursing staff to monitor the dialysis fistula every shift for a thrill, and bruit, and to notify the kidney physician if absent. No goals or interventions were found regarding a CVC. Review of the January 2025 Medication and Treatment Administration Records showed the licensed staff had documented every shift that they had checked the dialysis fistula for a thrill and bruit and signs of infection every shift as ordered. Additional review of the Medication and Treatment Records from November 2024 through February 2025 found the licensed staff were documenting they had checked Resident 23's dialysis fistula for a thrill and bruit each shift. In a follow up interview on 01/31/2025 at 9:20 AM, Resident 23 was observed lying in bed watching television. When asked for clarification regarding the dialysis access site, Resident 23 stated they had never had a fistula, had a CVC, and pulled the collar of their shirt down to show the CVC on their right upper chest. Resident 23 stated they were avoiding getting a fistula as long as possible, they were ugly, had seen them burst open, they didn't last forever, had to be redone, and there was a man at dialysis whose arms looked like a snake was crawling down it because of the multiple fistula revisions they have had to had done. In an interview on 02/03/2025 at 9:42 AM, Staff R, Licensed Practical Nurse, stated the Pre-Dialysis Assessment and Communication forms were filled out and sent with the resident, the nurses made sure it was returned with the resident, and a call was placed to the dialysis center if it wasn't. Staff R stated Resident 23 had a fistula when asked what type of access site the resident had, then immediately corrected and stated, no, the resident had a CVC. When asked about the documentation of the thrill and bruit, Staff R stated it had to be an error. In an interview on 02/05/2025 at 1:29 PM, Staff B, Director of Nursing, stated the expectation was the Pre-Dialysis Assessment and Communication form was completed, returned with the resident and a call made if it was not. Staff B stated Resident 23 had a CVC for dialysis and stated the dialysis orders and care plan interventions should reflect that and acknowledged they did not. Reference (WAC) 388-97-1900 (1), (6)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility had 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 3 of 8 sampled residents (Resident 83, 90 and 110), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment updated December 2024, showed the facility was licensed for 119 beds with an average daily census of 88. The assessment further showed the facility provided care related to fall prevention, behavioral health needs, substance use disorders (SUD), nutrition services, pressure injury prevention and care, and infection prevention practices. The facility employed a staffing coordinator to assist with facility staffing needs. The assessment further showed the facility leadership utilized the facility assessment as a framework to ensure sufficient staff with the appropriate competencies and skill sets were available to care for residents' needs on each unit and shift (day, evening, night). The facility's budget was used as a staffing guide, but leadership may choose to adjust staffing based on resident needs. If the facility census increased or decreased the facility might add or reduce the number of staff on each shift. If the resident's acuity increased or decreased the facility might add or reduce additional staff on each unit. The facility's staffing contingency plan included use of on-call nurse managers and facility leadership to provide immediate coverage, overtime hours, incentives for staff to work, or use of agency staffing to maintain adequate staffing coverage. <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 had severe cognitive impairment and sustained two or more falls while in the facility. The assessment further showed Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. The 11/18/2024 provider order summary indicated Resident 90 did not receive antipsychotic medications (medication that affect the mind, emotions, and behaviors). The 11/18/2024 nursing progress note documented Resident 90 was transported to the facility for admission. During transport Resident 90 repeatedly attempted to get out of their wheelchair (WC) while the vehicle was in motion requiring the driver to pull over three times. Once at the facility, staff attempted to admit Resident 90, but the resident was too impulsive to participate in the admission process with several attempts to self-transfer out of the WC, bed, and off the toilet with redirection only successful for a short time. Resident 90 was unaware of their safety needs and required constant supervision as they would transfer in less than a minute and seemingly required one on one supervision as Resident 90's safety would be compromised if left alone at any time. Resident 90 was transported back to the hospital for more adequate and safer placement at a later time. Resident 90 returned to the facility for admission on [DATE]. The notes further showed Resident 90 sustained three falls prior to having one-on-one supervision initiated. The 11/18/2024 hospital progress notes showed Resident 90 was very pleasant, made eye contact, and did not show agitation. The hospital received report from the facility Resident 90 was agitated, impulsive, lacked judgement and behaved agressively. The resident had been sent to the care facility earlier in the day, but challenges had arisen due to the facility report of understaffing and inablity to provide Resident 90 with 1:1 supervision. The resident was started on a low dose antipsychotic medication, Seroquel. Review of the 11/20/2024 hospital discharge medication list showed Resident 90 was to be administered Seroquel 25 milligrams (mg) twice daily after discharge. Review of the 11/20/2024 care plan showed Resident 90 was at risk for falls and instructed staff to anticipate resident needs, ensure the call light was within reach, maintain a safe environment, ensure proper footwear was worn, and keep commonly used items within reach. The care plan further showed Resident 90 sustained 9 falls from 11/22/2024 through 01/22/2025. The 01/08/2025 provider progress note documented Resident 90 had increased behaviors, made inappropriate sexual gestures and was impulsive which caused an additional fall. The plan was to increase Seroquel to 100 mg three times daily. The provider also ordered for Resident 90 to receive Ativan (antianxiety medication) twice daily to reduce impulsiveness. In an interview on 02/05/2025 at 2:28 PM, Resident 90's power of attorney (POA, person who can make healthcare decisions on ones behalf if unable to do so) stated Resident 90 had numerous falls at home, including a fall that resulted in a neck fracture prior to facility placement. The POA stated Resident 90 sustained falls at the facility, 1:1 monitoring was implemented, yet the resident continued to fall. The POA stated they were informed Resident 90 was administered medications to help reduce behavioral outbursts. The POA stated it was their opinion the resident was overmedicated. The POA explained Resident 90 required one person for transfers using a walker on admission to the facility but could barely hold their head up and required three people to transfer out of their WC at discharge. <Resident 110> The 01/26/2025 discharge assessment documented Resident 110 was admitted on [DATE], discharged on 01/26/2025, and had diagnoses which included psychoactive substance abuse (drug or substance that affected how the brain worked and caused changes in mood, awareness, thoughts, feelings, and behaviors), and schizophrenia (mental illness that affected a person's thoughts, feelings, and actions). Resident 110 was independent with making decisions regarding daily life, had fluctuating inattention and disorganized thinking. The 01/24/2025 hospital transition of care orders documented Resident 110 used amphetamines (powerful addictive central nervous system stimulant) and discontinuation of its use was recommended. The resident had been hospitalized with a bone infection in both feet but left the hospital against medical advice. The note documented underlying psychotic illness (mental health condition where a person loses touch with reality) contributed to the resident leaving against medical advice and interfered with their medical decision-making capacity. The 01/25/2025 wander risk assessment showed Resident 110 could move without assistance, did not have a history of wandering, had no diagnosis of cognitive impairment, and had no reported episodes of wandering in the past six months. The assessment identified Resident 110 as low risk for wandering or elopement. The 01/26/2025 care plan documented Resident 110 required partial assistance to complete most of their activities of daily living and used a wheelchair for mobility. There was no documenation that Resident 110 had a substance use disorder (SUD), and no goals or interventions were developed regarding potential risks associated with a SUD such as leaving the facility without staff knowledge. The January 2025 nursing progress notes documented Resident 110 arrived at the facility on Saturday 01/25/2025 at approximately 3:30 PM. On 01/26/2025 at 8:00 PM, staff were unable to locate Resident 110 to administer their bedtime medication. At 8:15 PM, an elopement was called. At 8:20 PM, the building was searched inside and out, staff were unable to locate Resident 110. At 8:30 PM, law enforcement was notified of the missing resident. On 01/27/2025 at 7:11 AM, Resident 110 was located at a local hospital, had been drinking and was unable to find their way back to the facility. No documentation was found that showed what occurred with Resident 110 after the facility located them at the local hospital. In an interview on 02/05/2025 at 4:08 PM, Staff C, Resident Care Manager, acknowledged Resident 110 had psychoactive substance abuse listed as a diagnoses but did not have a care plan or interventions implemented. Staff C further stated Resident 110 eloped from the facility, drank alcohol, was unable to get back to the facility, and ended up in the hospital. In an interview on 02/06/2025 at 1:17 PM, Staff B, Director of Nursing, stated the facility maintained resident safety by monitoring resident behaviors and implementing care plan interventions. Staff B reviewed Resident 110's medical record. Staff B stated Resident 110 admitted on the weekend and eloped prior to assessments being completed. In an interview on 02/06/2025 at 1:31 PM, Staff A, Administrator, was asked if the facility had guidelines such as not admitting after a certain time of day or on the weekends because the facility team was not available to complete needed assessments to ensure adequate resident safety. Staff A acknowledged the process was being reviewed. <Resident 83> According to the 12/27/2024 quarterly assessment, Resident 83 was dependent on staff assistance to perform most activities of daily living. Resident 83 was cognitively intact and able to clearly verbalize their needs. In an interview on 01/28/2025 at 2:49 PM, Resident 83 stated they had excessively long call light wait times. Resident 83 explained they had a clock on their bedside table and had waited up to one hour and 40 minutes to have their call light answered. During an interview on 02/04/2025 at 2:32 PM, the Ombudsman (a person who acted as an advocate for residents living in long-term care) stated residents expressed concerns about the facility's lack of staff. In an interview on 02/05/2025 at 9:37 AM, Staff EE, Nursing Assistant, stated the facility did not have enough staff on the [NAME] unit because every resident required two staff assistance for cares. In a confidential interview on 02/05/2025 at 10:07 AM, Confidential Staff 1, feared retaliation and wanted to remain anonymous. Confidential Staff 1 acknowledged the facility did not have enough staff, especially in the evenings and on weekends. In a confidential interview on 02/06/2025 at 11:35 AM, Confidential Staff 2, feared retaliation and wanted to remain anonymous. Confidential Staff 2 acknowledged the facility did not have enough staff and some nights only one nurse worked. In a confidential interview on 02/06/2025 at 2:07 PM, Confidential Staff 3, feared retaliation and wanted to remain anonymous. Confidential Staff 3 explained the nursing assistant section assignments were set and did not change based on resident acuity. Confidential Staff 3 was asked what occurred if staff did not have good teamwork. Confidential Staff 3 stated the section assignments were not adjusted. In an interview on 02/06/2025 at 2:27 PM, Staff Y, Staffing Coordinator, explained the [NAME] unit residents required more staff assistance and the nursing assistant to resident ratio was about 1:10 on that hall. In an interview on 02/07/2025 at 9:03 AM, Staff A, Administrator, stated Staff Y wore 4 different hats and explained Staff Y was the staffing coordinator, health unit coordinator, driver, and appointment scheduler. Staff A further stated some staff worked multiple double shifts and/or extra shifts. Staffing was reviewed with Staff A. Staff A acknowledged the facility utilized fewer nursing assistants when the facility census was decreased. In an interview on 02/07/2025 at 9:06 AM, Staff B, Director of Nursing, stated staff had voiced the need for more staff but the staff scheduled was adequate and enough to meet resident needs. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F552, F689, F692 and F758 for additional information.

Based on interview and record review, the facility failed to ensure monitoring of potential adverse effects from a blood thinning medication was done consistently for 1 of 5 sampled residents (Resident 22) reviewed for unnecessary medications. This failure placed the resident at risk for medical complications, unmet care needs and adverse side effects. Findings included . <Resident 22> The 01/06/2025 quarterly assessment documented Resident 22 was able to make decisions regarding their care and had diagnoses which included heart failure and high blood pressure. In addition, the assessment documented the resident was taking a blood thinning medication. The provider orders documented Resident 22 was prescribed a blood thinning medication (Xarelto). Additional orders included instruction to the licensed staff to monitor for adverse reactions such as bleeding, severe bruising, difficulty breathing or chest pain. Review of the January 2025 Medication Treatment Record on 01/31/2025 found on the following dates and shifts, the monitoring documentation for adverse side effects of the blood thinning medication were blank and had not been completed: - day shift from 01/02/2025 through 02/05/2025, and 02/08/2025 through 02/11/2025 - evening shift on 01/11/2025, - night shift on 01/03/2025, 01/05/2025, 01/09/2025, 01/17/2025, 01/24/2025, and 01/25/2025. In an interview on 02/05/2025 at 11:03 AM, Staff N, Registered Nurse, stated the expectation was that all charting/documentation was completed each shift as ordered and a progress note made if there were any issues or concerns. After review of the resident record, Staff N confirmed the documentation was blank as stated above. In an interview on 02/05/2025 at 1:21 PM, Staff B, Director of Nursing, stated the expectation was that medication monitoring and any documentation was completed before the end of the shift. After review of Resident 22's record, Staff B confirmed the blood thinning medication had not been consistently monitored. Reference: WAC 388-97-1060 (3)(k)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident beds were in safe operating condition for 4 of 26 beds in use on the [NAME] nursing unit observed. Specifically, bed controls had wires exposed and old electrical tape that had peeled off for 4 resident beds. This failure put residents at risk of injury and of being deprived of a home-like environment. Findings included . On 01/29/2025 at 9:35 AM, Resident 74 was observed in room [ROOM NUMBER]-1 seated on their bed. The bed control was observed to have wiring exposed where the wiring entered the portion that had buttons for adjusting the position of the head or foot of the bed. The resident stated they were unsure when the wiring became exposed. There were no frayed wires present. On 01/29/2025 at 10:18 AM, Staff K, Maintenance Director had replaced the bed in room [ROOM NUMBER]-1 and was observed pushing the bed with the exposed wiring down the hall. On 01/29/2025 at 10:25 AM, further resident bed observations identified the following: -The bed in room [ROOM NUMBER]-2 had two areas on the cord of the bed control that had old peeled electrical tape that had begun to come off. Under, there were exposed bed control wires. -The bed in room [ROOM NUMBER]-1 had electrical tape that had begun to peel off near the portion that was connected to the controller and wires were exposed. -The bed in room [ROOM NUMBER]-2 had old electrical tape that had begun to peel off and wiring was exposed. The same beds were observed in the same condition on 01/30/2025 at 2:09 PM and 02/03/2025 at 9:28 AM. During an interview on 02/06/2025 at 12:57 PM, Staff K stated if they did not receive a work order, they did not know if beds were in disrepair. Staff K stated they did not do regular walk around preventive inspections or audits of the equipment on the nursing units. They stated if they received a work order for a bed it was fixed. See also citation K0921. Reference: WAC 388-97-2100

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the call bells were in working condition for 2 of 50 residents observed (Residents 4 and 74) housed on the [NAME] nursing unit. This failure placed residents at a safety risk of having their urgent needs unanswered and unintended health consequences. Findings included . <Resident 74, room [ROOM NUMBER]-1> On 01/29/2025 at 9:35 AM, Resident 74 was observed in their room seated on their bed. The call light cord was observed pulled out of the wall, coiled up in a cardboard toilet paper roll and was placed on top of the chest of drawers. The call light system at the wall over the resident's head of their bed had green painter's-type tape over the button that turned off the light if it had been activated. Resident 74 stated their call light had not functioned for a couple of weeks. Resident 74 stated previously the light did not shut off and they had removed the cord the previous day. Resident 74 stated they had notified Staff S, Recreation Therapy at that time. Resident 74 stated if they needed staff they went in the hall to get someone. They were unsure how they would get help if, for example, they had fallen in their room. During an interview on 01/29/2025 at 9:41 AM, Staff F, Licensed Practical Nurse (LPN), stated they were not aware that Resident 74's call bell did not work. They stated they had not noticed the cord was pulled out when they had given Resident 74 their medications earlier. Staff F observed the call light and after they attempted to reinsert the cord into the wall identified that the cord did not work. On 01/29/2025 at 10:01 AM, Staff K, Maintenance Director, replaced the call light cord and the call system again functioned. Staff K confirmed they had received a work order from Staff S on 01/28/2025 at 1:28 PM but they had not seen the work order until 01/29/2025, that morning. Staff K stated they were the only maintenance worker for the entire building and attempted to address work orders timely. <Resident 4, room [ROOM NUMBER]> On 02/04/2025 at 4:20 PM, Resident 4 was observed lying in their bed and stated they did not feel well. Resident 4 stated they had not eaten and stated they were hungry. When Resident 4 attempted to activate their call light to request food, it was observed that it did not work. On 02/04/2025 at 4:24 PM, Staff Q, LPN, was notified the call light in room [ROOM NUMBER] did not work. Staff Q stated Resident 4 had problems with their call light in the past and used to pull the cord out of the wall and the cord had been replaced several times. Staff Q retrieved a desk-style manual call bell for Resident 4 and notified Staff K. On 02/04/2025 at 4:48 PM, Staff K had repaired the call light in room [ROOM NUMBER] and the call bell functioned. In a follow up interview on 02/06/2025 at 12:57 PM, Staff K stated they did not do routine regular observations or audits of the equipment on the nursing units. They stated if they did not get a work order, they did not know if call bells did not function. Reference: WAC 388-97-2280(1)(a)

Based on observation, interview and record review, the facility failed to ensure resident personal refrigerators were maintained in a clean manner, without expired foods and at the appropriate temperatures for 2 of 5 sampled residents (Residents 74 and 51) reviewed for a homelike environment. This failure placed the residents at risk of eating spoiled foods and having an unclean environment. Findings included . <Resident 74> During an interview on 01/29/2025 at 9:35 AM, Resident 74 was observed seated on the edge of their bed. A small dormitory-style refrigerator was on the floor next to the head of the bed. Inside the refrigerator, a brown liquid had been spilled on the bottom. A can of soft drink rested in the liquid, and a supplement drink was on the shelf. Resident 74 stated they were given the refrigerator when another resident got a new one. They stated they kept drinks and snacks in it, but were unsure who kept track of refrigerator temperatures.They stated there was no temperature log in their room. On 01/31/2025 at 9:40 AM, Resident 74's refrigerator no longer had a brown liquid in the bottom. There were empty coffee mugs and half full fruit cups on top of the refrigerator. There was no temperature log. <Resident 51> During an observation on 01/08/2025 at 2:31 PM, Resident 51 was lying in bed. They had a personal refrigerator that contained vanilla yogurt that had expired on 08/01/2024 and butterscotch pudding that had expired on 07/24/2024. The refrigerator was unclean with spilled brown liquid on the bottom shelf and there was no temperature log. Subsequent observations of the refrigerator being unclean with expired yogurt and butterscotch pudding were made on 01/30/2025 at 1:25 PM, 01/31/2025 at 9:02 AM, 02/03/2025 at 9:20 AM, and 02/04/2025 at 8:54 AM. In an interview on 02/07/2025 at 9:24 AM, Staff X, Nursing Assistant, stated they were unsure of who was responsible for monitoring the resident's personal refrigerator. During an interview on 02/07/2025 at 9:26 AM, Staff C, Resident Care Manager, stated temperature logs were kept in the resident rooms and the expired food should have been discarded. Staff C stated the temperature of the refrigerator should have been monitored to prevent illness. In an interview on 02/07/2025 at 9:28 AM, Staff B, Director of Nursing, stated the nurses were responsible for monitoring the personal refrigerators. Staff B stated they should have monitored the temperatures, discarded expired food and kept the refrigerators clean to prevent illness. Reference: WAC 388-97-3220 (1)

Based on interview and record review the facility failed to ensure the resident and/or the resident's representative was informed of and consented to a new medication for 2 of 3 sampled residents (Residents 54 and 90), reviewed for care planning. This failure disallowed the resident and/or the resident representative to make an informed decision regarding treatment and placed the resident at risk of diminished quality of life. Findings included Review of the facility policy titled, Resident Rights Notification of Changes of Condition dated July 2018, showed the facility would keep the resident and/or the resident representative informed of changes in health status. <Resident 90> According to the 11/26/2024 admission assessment Resident 90 had diagnoses including dementia, traumatic brain injury (TBI- brain damage caused by an external force), anxiety, and depression. Resident 90 had severe cognitive impairment with fluctuating inattention, disorganized thinking and no altered level of consciousness. Review of the 11/20/2024 hospital discharge medication list showed Resident 90 was to be administered Seroquel (antipsychotic, medication that affected the mind, emotions, and behaviors) 25 milligrams (mg) twice daily after discharge. Review of the 11/21/2024 facility order summary showed Resident 90 was to be administered Seroquel 25 mg twice daily for psychophysical visual disturbances, violent behavior, restlessness and agitation. Review of the 11/21/2024 provider progress note showed Resident 90 was started on low dose Seroquel due to dementia with behavioral disturbances. The provider's treatment plan included continued use of Seroquel at 25 mg twice daily. The provider's note also included the following general recommendations for environmental treatment of agitation: frequent orientation with cues, staffing consistency, communicate with short clear statements and requests, maintain day/night structure especially with lighting, minimize noise/stimuli especially at night, ensure the resident had freedom of mobility within confines of medical treatment and plan, ensure pain was addressed related to resident may not be able to vocalize which may lead to agitation, and correct any sensory deficits by ensuring the resident wore hearing aides and/or glasses as needed. Review of the 11/20/2024 self-care performance deficit care plan showed Resident 90 required partial staff assistance to perform most activities of daily living including bed mobility and transfers. The 11/21/2024 psychotropic medication use care plan instructed staff to administer medications as ordered, monitor for adverse side effects, orient to reality and clarify mistaken beliefs. The 11/27/2024 delirium (sudden and severe state of confusion) care plan instructed staff to call Resident 90 by their preferred name, encourage resident family, friends, and care givers to be at bedside during episodes of confusion. The 11/30/2024 impaired cognitive function care plan instructed staff to administer medications as ordered, monitor for potential side effects and medication effectiveness. Review of the 11/25/2024 provider progress note showed Resident 90 sustained a fall, was transferred to the hospital for evaluation and returned with multiple recommendations for behaviors. The provider's note further showed the hospital increased Resident 90's Seroquel from 25mg to 50mg twice daily and advised continued increase by 25 mg twice daily to reduce hyperactivity and agitation until symptoms were controlled or max dose of 750 mg/ 24 hours was reached. The provider noted Resident 90 was currently on Seroquel 75mg daily with reported increased fatigue and Resident 90 was more sedated today. The hospital also recommended starting use of Ativan (antianxiety medication) orally for anxiety and in an injectable form for severe agitation and combativeness. Review of the 12/10/2024 provider progress note showed Resident 90 reported intermittent sleep issues. The provider's plan was to increase Seroquel to 100mg twice daily and continue the as needed Ativan. The provider note did not document any behaviors Resident 90 experienced, if any. Review of the 01/08/2025 provider progress note showed Resident 90 had increased behaviors and impulsiveness. Resident 90 had been making more sexual inappropriate gestures, comments and just inappropriateness. Resident 90 had another fall due to impulsiveness. The provider's plan was to increase the Seroquel to 100 mg three times daily due to impulsiveness which leads to falls, inappropriate behaviors, and sexual inappropriateness. The note further showed the as needed Ativan was not effective at managing impulsiveness, Resident 90 continued to be a fall risk, and the provider scheduled Ativan 1 mg twice daily routinely. Review of the 01/22/2025 provider discharge summary showed Resident 90 sustained repeated falls secondary to impulsiveness. Resident 90 discharged the facility with provider orders to administer Seroquel 100 mg three times daily, Ativan 1 mg routinely twice daily and Ativan 1 mg every four hours as needed for agitation. Review of November 2024 through January 2025 nursing progress notes showed Resident 90 was alert to self, not redirectable, was short with staff, cursed at times, self-transferred often, unsteady gait, experienced frequent falls, was confused, and anxious at times. The notes further showed Resident 90 was administered as needed Ativan for restlessness and anxiousness, minimal vague documentation was found to show what non-medication interventions were attempted prior to medicating, intervention effectiveness and/or specific details of the behaviors Resident 90 experienced. No documentation was found to show Resident 90's resident representative was informed of the numerous Seroquel dose increases or Ativan medication changes. In an interview on 02/05/2025 at 2:28 PM, Resident 90's POA stated the facility informed them Resident 90 was being administered medication to help with behavioral outbursts, the facility did not ask for medication consent. Resident 90's POA further stated they felt Resident 90 was overmedicated. The POA explained Resident 90 admitted to the facility requiring one person transfer assist using a walker but upon discharge Resident 90 could barely hold their head up and it took three persons to stand pivot transfer Resident 90 out of the wheelchair. The POA further stated they were not informed of Resident 90's psychotropic medication changes and were not aware Resident 90 had as needed medication ordered for an injectable medication. The POA stated the facility had a major communication issue. In an interview on 02/06/2025 at 12:38 PM, Staff L, Social Service Director, explained psychotropic medication use required consent prior to administering medication. Staff L explained consent was obtained from the resident if they were cognitively intact and the resident representative if the resident had cognitive impairment. Staff L acknowledged Resident 90's POA should have been notified of all the medication changes. In an interview on 02/26/2025 at 3:58 PM, Staff N, Registered Nurse, explained when medication changes occurred, the resident and/or their resident representative would be notified, a progress note documented, and the resident placed on alert charting to monitor the resident's tolerance to the medication changes, potential adverse side effects or complications. In an interview on 02/07/2025 at 8:47 AM, Staff C, Resident Care Manager, explained the nurse was expected to inform a resident or the resident representative when medication changes occurred and document a progress note. Staff C acknowledged Resident 90's POA should have been notified of all of Resident 90's medication changes because a POA could not fully participate in a resident's care if they were not being informed. In an interview on 02/07/2025 at 9:11 AM, Staff B, Director of Nursing, explained a self-responsible resident would be informed of medication changes, a POA was notified of changes if a resident had cognitive impairment, and a progress note was to be documented. Staff B stated they expected staff to notify a resident and/or resident representative each time a medication was changed. Staff B acknowledged a resident and/or resident representative could not fully participate in their care if they were not informed of changes made. <Resident 54> Review of the 10/22/2024 quarterly assessment showed Resident 54 had diagnoses which included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves and causes pain), chronic pancreatitis (a progressive disease when the pancreas is permanently damaged by inflammation and causes abdominal pain), and depression. The resident was cognitively intact and able to make their needs known. In an interview on 01/28/2025 at 11:42 AM, Resident 54's representative stated the resident had times of confusion and that's why they became the power of attorney (POA- a person that assists with making health care decisions for a person with cognitive impairments). The representative stated the resident's pain medication had been decreased and they were unaware. Review of the December 2024 Medication Administration Record (MAR) showed an order for Xtampa (a medication used to treat pain) to be decreased from 18 mg to 13.5 mg was entered on 12/06/2024. Review of the December 2024 nursing progress notes showed no notes the resident or their representative had been notified of the decrease of the Xtampa. In an interview on 02/05/2025 at 2:26 PM, Resident 54 stated they were not aware changes had been made to the Xtampa. During an interview on 02/06/2025 at 2:05 PM, Staff C, RCM, stated when a medication was changed, the resident was placed on alert charting and the resident, or their representative was notified, and a progress note was made. In an interview on 02/06/2025 at 2:57 PM, Staff B, DNS, stated the resident or their representative should have been notified of the change in medication and a progress note should have been made to reflect this. Staff B stated this was important because they may not have wanted the medication changed. Reference WAC 388-97-0300 (3)(a), -0260, -1020(4)(a-b) Refer to F758 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Office of the State Long-Term Care Ombudsman (a person who acted as an advocate for residents that lived in long-term care) received written notification of a hospital transfer and/or discharges, as required for 5 of 6 sampled residents (Resident 4, 30, 46, 71 and 90), reviewed for hospitalization and discharge. This failure placed residents at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman, unmet needs, and diminished quality of life. Findings included . Review of the facility policy titled, Admission, Transfer and Discharge dated July 2018, showed the notifications to the Ombudsman office would occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. The policy further showed emergency transfer notifications would be sent to the Ombudsman at least on a monthly basis. <Resident 4> The 12/05/2025 discharge assessment documented Resident 4 was cognitively impaired and unable to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and depression. An 11/23/2024 progress note showed the resident had increased behaviors and was sent to the hospital. 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. <Resident 46> The 11/23/2024 discharge assessment documented Resident 46 was cognitively intact and able to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breathe). Review of Resident 46's record showed an 11/23/2024 nursing progress note which documented the resident had a fall and was unable to recall what happened and was sent to the hospital. 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 02/06/2025 at 11:09 AM, Staff A, Administrator, stated they were unaware the Ombudsman needed to be notified for hospital discharges and stated that was not a practice they were currently doing. <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Resident 90 had severe cognitive impairment. Review of nursing progress notes showed Resident 90 was transferred to the hospital on the evening of 11/22/2024 for evaluation after a fall occurred, returning to the facility the same day, and again on the evening of 11/23/2024 returning to the facility the following day. No documentation was found to show the Ombudsman was notified of the hospital transfers, as required. <Resident 30> According to the 01/21/2025 admission assessment, Resident 30 admitted to the facility on [DATE] with diagnoses including stroke with weakness and/or paralysis affecting one side of the body. Resident 30 was cognitively intact and able to clearly verbalize their needs. Review of the 01/18/2025 provider progress note showed Resident 30 sustained a fall around 1:00 AM with redness and swelling noted to the right side of the head. Resident 30 reported 5 out of 10 pain (on a scale of 0-10, 0 being no pain and 10 being worst pain experienced). Resident 30 was transferred to the hospital for additional testing. Review of the January 2025 nursing progress notes showed Resident 30 was found on the floor on 01/18/2025 at 1:15 AM. The provider was notified of Resident 30's fall that morning, the provider assessed Resident 30, and Resident 30 was transported to the hospital for further evaluation. No documentation was found to show the Ombudsman was notified of the hospital transfers, as required. In an interview on 02/04/2025 at 2:32 PM, the Ombudsman stated the facility was not notifying them of hospital transfers or discharges, as required. The Ombudsman further stated the facility had only notified them when they presented a resident with a 30-day notice of eviction. In an interview on 02/05/2025 at 4:03 PM, Staff Q, Licensed Practical Nurse, stated they were unsure how the Ombudsman was notified of hospital transfers and/or discharges. In an interview on 02/06/2025 at 9:48 AM, Staff C, Resident Care Manager, stated they were unsure how the Ombudsman was notified of hospital transfers and/or discharges. In an interview on 02/06/2025 at 12:06 PM, Staff L, Social Service Director, stated the facility only informed the Ombudsman if and/or when the facility gave a resident a 30-day eviction notice. Staff L further stated Ombudsman transfer and/or discharge notifications were new to the facility and it was rarely done. In an interview on 02/06/2025 at 1:50 PM, Staff A, Administrator, acknowledged the facility had only been notifying the Ombudsman when a facility-initiated discharge occurred. Reference WAC 388-97-0120 (2)(a-d) -0140 (1)(a)(b)(c)(i-iii) Refer to F625 for additional information. <Resident 71> Per the 12/11/2024 admission assessment, Resident 71 had diagnoses which included renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids) and diabetes (a group of diseases that result in too much sugar in the blood). The resident was cognitively intact to make decisions regarding their care. Review of Resident 71's record showed a 12/27/2024 progress note documented the resident had experienced vomiting, fever and high blood sugar and was sent to the hospital. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 were hospitalized , to the resident and/or their representative at the time of discharge or within 24 hours of transfer to the hospital for 5 of 5 sampled residents (Resident 4, 30, 46, 71 and 90), reviewed for hospitalization. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included <Resident 4> The 12/05/2025 discharge assessment documented Resident 24 was cognitively impaired and unable to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and depression. An 11/23/2024 progress note showed the resident had increased behaviors and was sent to the hospital. Additional record review found no documentation that showed the resident or their representative had been provided a bed-hold notice. <Resident 46> The 11/23/2024 discharge assessment documented Resident 46 was cognitively intact and able to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breathe). Review of Resident 46's record showed an 11/23/2024 nursing progress note which documented the resident had a fall and was unable to recall what happened and was sent to the hospital. An 11/25/2024 progress note showed Resident 46 was called about a bed hold, two days after their discharge. In an interview on 02/06/2025 at 11:09 AM, Staff A, Administrator, stated bed holds were offered when residents discharged to the hospital. Staff A stated admission staff notified the resident or their representative within the 24-hour time frame. Staff A stated it was important to offer the bed hold because the resident had a right to return to their room. <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Resident 90 had severe cognitive impairment. Review of nursing progress notes showed Resident 90 was transferred to the hospital on the evening of 11/22/2024 for evaluation after a fall occurred, returning to the facility the same day, and again on the evening of 11/23/2024 returning the following day. No documentation was found to show a bed hold was explained or offered to the resident's representative, as required. <Resident 30> According to the 01/21/2025 admission assessment, Resident 30 admitted to the facility on [DATE] with diagnoses including stroke with weakness and/or paralysis affecting one side of the body. Resident 30 was cognitively intact and able to clearly verbalize their needs. Review of the January 2025 nursing progress notes showed Resident 30 was found on the floor on 01/18/2025 at 1:15 AM. The resident was sent to the hospital for further evaluation. No documentation was found to show a bed hold was explained or offered, as required. <Resident 71> Per the 12/11/2024 admission assessment, Resident 71 had diagnoses which included renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids) and diabetes (a group of diseases that result in too much sugar in the blood). The resident was cognitively intact to make decisions regarding their care. Review of Resident 71's record showed a 12/27/2024 progress note documented the resident had experienced vomiting, fever and high blood sugar. Resident 71 was assessed and sent to the hospital for evaluation. No documentation was found to show a bed hold was explained or offered, as required. In an interview on 02/07/2025 at 9:49 AM, Staff U, Resident Care Manager, reviewed Resident 71's medical record. Staff U confirmed there was no documentation a bed-hold was offered, as required. Staff U further stated a bed-hold should have been offered and this was important because residents had a choice if they wanted to keep their bed once they were discharged to a hospital. Reference WAC 388-97-0120(4) Refer to F623 for additional information.

Based on interview and record review the facility failed to routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 4 of 11 sampled residents (Residents 7, 12, 86 and 90), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11 revised October 2024, showed the RAI consisted of three basic components: the MDS, the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yielded information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. Nursing homes were required to submit Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. For submission, the MDS data must be in record and file formats that conform to standard record layouts and data dictionaries, and pass standardized edits defined by CMS and the State. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. When the transmission file was received by iQIES, the system performed a series of validation edits to evaluate whether or not the data submitted met the required standards. MDS records were verified to ensure clinical responses were within valid ranges and were consistent, dates were reasonable, and records were in the proper order with regard to records that were previously accepted by iQIES for the same resident. The provider was notified of the results of this evaluation by error and warning messages on a Final Validation Report. <Resident 86> According to the 08/25/2024 discharge assessment, Resident 86 discharged from the facility on 08/25/2024 with a return not anticipated. The assessment further showed it was signed as completed on 08/29/2024. <Resident 7> According to the 10/25/2024 discharge assessment, Resident 7 discharged from the facility on 10/25/2024 with a return not anticipated. The assessment further showed it was signed as completed on 10/29/2024. <Resident 12> According to the 12/19/2024 quarterly assessment, Resident 12 was able to perform most activities of daily living independently. The assessment further showed the assessment observation end date was 12/19/2024 and was signed as completed on 02/04/2025. Review of the 12/20/2024 discharge assessment showed Resident 12 discharged from the facility on 12/20/2024 with a return not anticipated. <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate assistance of staff to complete most activities of daily living. The assessment further showed the observation end date was 01/14/2025 and was signed as completed on 02/01/2025. Review of the 02/04/2025 MDS validation report showed 79 files were submitted with 49 error messages, 23 out of 79 accepted filed were submitted late, 14 days beyond the assessment completion date. The report included Resident 86's 08/25/2024, Resident 7's 10/25/2024, and Resident 12's 12/20/2024 discharge assessments and Resident 12's 12/19/2024 and Resident 90's 01/14/2025 quarterly assessments as accepted late submissions. In an interview on 02/05/2025 at 12:09 PM, Staff E, MDS Director, explained MDSs needed to be submitted to CMS and/or the health insurance providers within 14 days of the assessment reference or observation end date. Staff E acknowledged the facility was late on submitting MDS assessments as required. In an interview on 02/05/2025 at 12:29 PM, Staff B, Director of Nursing, acknowledged the facility had submitted MDS assessments late but they should be submitted per the required RAI timelines. In an interview on 02/05/2025 at 12:37 PM, Staff A, Administrator, stated they expected staff to submit MDS's per the required RAI timelines. Reference WAC 388-97-1000 (4)(b), (5)(b) Refer to F641 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 14> According to the 12/03/2024 admission MDS assessment, section B showed Resident 14 was able to make themselves understood and understood others, however this conflicted with the information under section C which documented Resident 14 was not interviewed due to being severely cognitively impaired and rarely or never understood. The assessment further documented Resident 14 had diagnoses which included non-Alzheimer's dementia. Review of the nursing progress notes from 11/27/2024 through 02/04/2025 showed Resident 14 was cognitively impaired, had dementia, was alert to self only, but able to make needs known at times. <Resident 109> According to the 12/26/2024 admission MDS assessment, section B showed Resident 109 was sometimes able to make themselves understood and usually understood others, however this conflicted with the information under section C which documented Resident 109 was not interviewed due to being severely cognitively impaired and rarely or never understood. <Resident 90> According to the 11/26/2024 admission assessment, Resident 90 had diagnoses including dementia. Section B of the assessment documented Resident 90 was able to make themselves understood and understood others, however this conflicted with the information under section C which documented Resident 90 was not interviewed due to being severely cognitively impaired and rarely or never understood. The assessment further showed the observation end date was 11/26/2024 and was signed as completed on 12/04/2024. Review of Resident 90's quarterly assessment showed the observation end date was 01/14/2025 and was signed as completed on 02/01/2025. Review of Resident 90's 01/24/2025 discharge assessment showed Resident 90 discharged from the facility on 01/24/2025 with a return not anticipated. The assessment further showed it was not signed as completed as of 02/03/2025. In an interview on 02/04/2025 at 3:18 PM, Staff B, Director of Nursing, was asked about the conflicting information in sections B and C of Resident 14, 109, and 90's MDS assessments. Staff B stated a resident was marked as being able to make themselves understood and understanding others when they have the ability to make their needs known whether in a verbal or non-verbal manner and staff understood them. Staff B explained to be marked rarely or never understood meant the resident could not respond verbally, in writing or by using any other method. Staff B acknowledged Resident 14, 109 and 90's assessments did not accurately reflect the resident's status as of the ARD and should have. In a follow-up interview on 02/05/2025 at 12:29 PM, Staff B acknowledged the facility was behind on completing MDS assessments, as required. In an interview on 02/05/2025 at 12:37 PM, Staff A, Administrator, acknowledged the facility was behind on completing MDS assessments, as required. Staff A stated they expected staff to complete MDS assessments per the required time frames. Reference (WAC) 388-97-1000(b)(d) Refer to F640 for additional information. Based on interview and record review the facility failed to routinely timely and accurately complete Minimum Data Sets (MDS - an assessment tool) for 9 of 11 sampled residents (Residents 3, 12, 14, 39, 82, 83, 90, 109, and 510), reviewed for timely MDS assessment completion. This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11 revised October 2024, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. The MDS contained data elements that reflect the acuity level of the resident, including diagnoses, treatments, and an evaluation of the resident's functional status. A RAI (MDS, CAA process, and utilization guidelines) assessment must be completed initially and periodically for any resident residing in the facility. The assessment reference date (ARD) was the end of the resident observation period and served as the reference point for determining the care and services captured on the MDS assessment. <Resident 3> According to the 09/28/2024 quarterly assessment, Resident 3 required supervision up to partial assistance to complete most activities of daily living (ADL). Review of Resident 3's 12/29/2024 quarterly assessment showed the assessment observation end date was 12/29/2024. The assessment further showed it was not signed as completed as of 02/05/2025. <Resident 12> According to the 12/19/2024 quarterly assessment, Resident 12 was able to perform most ADLs independently. The assessment further showed the observation end date was 12/19/2024 and was signed as completed on 02/04/2025. Review of the 12/20/2024 discharge assessment showed Resident 12's discharge date was 12/20/2024. The assessment further showed it was signed as completed on 02/04/2025. <Resident 39> According to the 10/13/2024 quarterly assessment, Resident 39 required substantial up to dependent staff assistance to perform most ADLs. The assessment further showed the observation end date was 10/13/2024 and was signed as completed on 10/25/2024. Review of Resident 39's 01/01/2025 annual assessment showed the observation end date was 01/01/2025 and the assessment was not signed as completed as of 02/06/2025. <Resident 82> According to the 09/26/2024 quarterly assessment, Resident 82 required supervision up to partial assistance to complete most ADLs. The assessment further showed the observation end date was 09/26/2024 and was signed as completed on 10/14/2024. Review of Resident 82's 12/27/2024 quarterly assessment showed the observation end date was 12/27/2024 and the assessment was signed as completed on 02/05/2025. Review of Resident 82's discharge assessment showed Resident 82 discharged from the facility on 01/24/2025 with a return not anticipated. The assessment further showed it was signed as completed on 02/05/2025. <Resident 83> According to the 09/26/2024 quarterly assessment, Resident 83 was dependent on staff assistance to perform most ADLs. The assessment further showed the observation end date was 09/26/2024 and was signed as completed on 10/14/2024. Review of Resident 83's 12/27/2024 quarterly assessment showed the observation end date was 12/27/2024 and was signed as completed on 02/05/2025. <Resident 510> According to the 01/09/2025 admission assessment, Resident 510 admitted to the facility on [DATE] and discharged on 01/09/2025 with a return not anticipated. The assessment further showed it was not signed as completed as of 02/06/2025. Review of an against medical advice (AMA) release form showed Resident 510 discharged from the facility AMA on 01/09/2025. During an interview and record review on 02/05/2025 at 12:09 PM, Staff E, MDS Director, explained the process for completing MDS assessments included reviewing data in resident records to complete the MDS by the ARD. Staff E acknowledged the facility was behind on completing MDS assessments, as required. Staff E provided a list of MDS assessments that were currently late. Review of the MDS in progress list from 11/01/2024 through 02/04/2025 showed 76 MDS's were still in progress beyond the ARD.

Based on observation, interview and record review, the facility failed to consistently monitor and provide bowel care timely for 7 of 7 sampled residents (Residents 23, 36, 54, 62, 4, 39, and 46) reviewed for constipation. This failure placed the residents at risk for medical complications and unmet care needs. Findings included . <Resident 23> The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for activities of daily living (ADLS) such as toileting. On 01/28/2025 at 3:51 PM, Resident 23 was observed lying in bed watching television. During the conversation with the resident, they stated they took pain medications and had trouble with constipation at times. Review of the Order Summary Report from 11/15/2024 through 02/04/2025 documented on 11/15/2024, the physician had ordered a laxative (Senna tablets) to be given on an as needed basis if the resident had not had a bowel movement (BM) in 48 hours, and if the resident still had not had a BM 24 hours after receiving the Senna, an additional laxative (Miralax) was to be given. Review of the bowel records from 01/04/2025 through 02/01/2025 documented Resident 23 had not had a BM on the following dates as follows: - 01/06/2026 through 01/12/2025, a period of seven days - 01/16/2025 through 01/20/2025, a period of five days, and - 01/28/2025 through 01/31/2025, a period of four days. Review of the January 2025 Medication Administration Record (MAR) showed the Senna and Miralax had not been administered as ordered during the above time frames, and no documentation was found in Resident 23's record that stated the reason for the omissions. In an interview on 02/03/2025 at 9:33 AM, Staff R, Licensed Practical Nurse, stated bowel medication was usually given if a resident had not had a BM in 72 hours, unless the physician had ordered something different. After discussion and review of Resident 23's record, Staff R confirmed that bowel medication should have been administered on the dates identified, and if the medication had been offered and refused it should have been documented. <Resident 36> The 12/16/2024 quarterly assessment documented Resident 36 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for ADLS such as toileting Review of the Order Summary Report from 01/01/2025 through 02/06/2025 documented on 11/06/2023, the physician had prescribed both Senna tablets and Miralax to be administered on an as needed basis for constipation (no time frame was specified). Review of the bowel records from 01/05/2025 through 02/03/2025 documented Resident 36 had not had a BM from 01/18/2025 through 01/22/2025, a period of five days. Review of the January 2025 MAR showed neither the as needed Senna or Miralax had been administered or offered to Resident 36 during the above time frame, and no documentation was found in the resident's record that stated the reason for the omission. In an interview on 02/04/2025 at 11:03 AM, Staff N, Registered Nurse, stated the facility process was to give bowel medication after 72 hours unless the physician had ordered something different for the resident. In an interview on 02/05/2025 at 1:10 PM, Staff B, Director of Nursing (DNS), stated the expectation was residents would be offered bowel care medication after 48 hours of not having a BM unless the resident's provider had ordered differently. After review of Resident 23 and Resident 36's records, Staff B confirmed bowel care medication should have been offered. <Resident 4> The 12/05/2024 quarterly assessment documented Resident 4 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for ADLS such as toileting. Review of the 10/11/2022 care plan documented the resident was at risk for constipation and had interventions which instructed nursing to monitor BMs and implement interventions as ordered. Review of the January 2025 MAR documented on 12/02/2024, the physician had ordered laxatives (Miralax and Senna) to be given as needed. Review of the bowel records from 01/05/2025 through 02/02/2025, documented Resident 4 had not had a BM on the following dates: - 01/22/2025 through 01/26/2025, except for a small BM on 01/26/2025, a period of five days - 01/28/2025 through 01/30/2025, a period of three days Additional review of the MARS for January 2025 and February 2025, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 48's record that stated the reason for the omissions. <Resident 54> Per the 10/22/2024 quarterly assessment, Resident 54 was cognitively intact, able to make decisions regarding their cares, and needed assistance from staff for ADLS, such as toileting. Review of the 03/23/2022 care plan documented the resident was at risk for constipation secondary to reduced mobility and use of pain medication and had interventions which instructed nursing staff to monitor BMs and implement interventions as ordered. Review of the January 2025 MAR documented on 11/06/2023 the physician had ordered laxatives Miralax and Senna to be given as needed. On 01/18/2024, the physician had ordered the following laxatives: Lactulose every two hours as needed times three and if no BM give Milk of Magnesia daily as needed and if no BM give a Bisacodyl suppository. Review of the bowel records from 01/01/2025 through 01/31/2025 documented Resident 54 had not had a BM on the following dates: -01/01/2025 through 01/08/2025, a period of eight days -01/20/2025 through 01/24/2025, except a small BM on 01/21/2025 a period of five days -01/25/2025 through 01/28/2025, except for a small BM on 01/27/2025 and 01/28/2025, a period of four days Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 54's record that stated the reason for the omissions. <Resident 39> Per the 10/13/2024 quarterly assessment, Resident 39 was cognitively impaired, unable to make decisions regarding their cares, and needed assistance from staff for ADLS, such as toileting. Review of the 10/12/2018 care plan documented the resident was at risk for constipation and had interventions which instructed nursing staff to monitor BMs and implement interventions as ordered. Review of the January 2025 MAR documented on 09/29/2023 the physician had ordered the following laxatives: Lactulose every two hours times three doses and if no BM give Milk of Magnesia as needed and if no BM after six hours, give a Bisacodyl suppository. On 11/06/2023 the physician had ordered Miralax and Senna as needed. Review of the bowel records from 12/29/2024 through 01/29/2025 documented Resident 39 had not had a BM on the following dates: -12/31/2024 through 01/05/2025, except for a small BM on 01/01/2025 and 01/03/2025, a period of six days -01/08/2025 through 01/11/2025, except a small BM on 01/08/2025 and 01/09/2025, a period of three days -01/27/2025 through 01/29/2025, a period of three days Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 54's record that stated the reason for the omissions. <Resident 46> Per the 12/04/2024 quarterly assessment, Resident 46 was cognitively impaired, able to make decisions regarding their cares, and needed assistance from staff for ADLS, such as toileting. Review of Resident 46's record showed no care plan for constipation. Review of the January 2025 MAR documented on 11/17/2024 the physician had ordered the following laxatives: Senna as needed for no BM after 48 hours and Miralax for no BM after the Senna was administered. Review of the bowel records from 01/01/2025 through 01/30/2025 documented Resident 46 had not had a BM on the following dates: -01/04/2025 through 01/08/2025, a period of five days -01/11/2025 through 01/13/2025, a period of three days -01/15/2025 through 01/17/2025, a period of three days -01/22/2025 through 01/24/2025, a period of three days Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 54's record that stated the reason for the omissions. In an interview on 02/06/2025 at 10:16 AM, Staff N, Registered Nurse, stated the bowel protocol was initiated on day three of no BM. Staff N stated the bowel protocol should have been initiated for the above time frames. At 1:49 PM that same day, Staff N stated a small bowel movement did not count. During an interview on 02/07/2025 at 9:36 AM, Staff B, DNS, stated bowel medications should have been administered as ordered and this was important to prevent a bowel obstruction. <Resident 62> Per the 12/15/2024 quarterly assessment, Resident 62 had diagnoses including kidney disease (damage to the kidneys in which they lose function) and diabetes. The resident was cognitively intact to make decisions regarding their care. The resident was always incontinent of bowels and had an indwelling catheter. Review of the December 2024 MAR documented on 12/09/2024, the physician ordered a laxative, Senna, to be offered as needed for constipation and given for no BM after 48 hours. An additional laxative, Miralax, was to be offered as needed for constipation and given for no BM 24 hours after Senna. In an observation and interview on 01/28/2025 at 3:18 PM, Resident 62 was laying in bed, eating snacks, and watching television. The resident stated that they have had issues with constipation and the medications were variable in relief. Review of the bowel records from 01/01/2025 through 01/30/2025, showed Resident 62 had no BM's from 01/01/2025 through 01/05/2025 (5 days), 01/08/2025 through 01/10/2025 (3 days) and 01/26/2025 through 01/28/2025 (3 days). Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 62's record that stated the reason for the omissions. In an interview on 02/06/2025 at 3:06 PM, Staff T, Licensed Practical Nurse, confirmed Resident 62 did not have a BM on the above dates and the bowel protocol should have been followed. Reference (WAC): 388-97-1060(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure falls were investigated, safety interventions implemented, and residents monitored after falls were sustained for 4 of 6 sampled residents (Residents 4, 14, 30,and 90), reviewed for falls. In addition, the facility failed to assess residents for risks associated with a substance use disorder (SUD) and their ability to safely smoke for 2 of 3 sampled resident (Resident 46 and 110), reviewed. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Fall Prevention Program dated February 2020, showed residents would be evaluated for fall risk upon admission, quarterly, and as needed. The policy showed all residents would be considered at risk for falls upon admission and general precautions implemented. A fall risk decision tree would be utilized to identify potential interventions specific for each resident with identified interventions implemented and added to the resident's person-centered care plan. The policy further showed each fall would be thoroughly investigated and implementation of interventions monitored by nursing staff on a routine basis. Review of the facility policy titled, Behavioral Health Services revised September 2018, showed the facility provided necessary behavioral health care and services to attain or maintain a resident's highest practicable physical, mental, and psychosocial well-being. The facility utilized assessment, care planning, implementation and plan revision to meet the individual resident's behavioral health needs. The policy further showed non-pharmacological interventions were to be used as clinically indicated and if a resident required more intensive behavioral health services, the facility would document reasonable attempts to provide for and/or arrange for such services. Review of the facility policy titled, Physical Environment Smoke Free Facility revised March 2019, showed the facility was designated smoke free within the building with the smoke-free area extending outward from the building the distance designated by State and local laws. The policy included the utilization of electronic cigarettes, pipes, cigars, tobacco products and/or vaping equipment as smoking materials. Residents, visitors, contractors, and staff were not permitted to smoke on the property at any time. <SUBSTANCE USE DISORDER> <Resident 110> According to the 01/26/2025 discharge assessment, Resident 110 admitted to the facility on [DATE] and discharged on 01/26/2025 with diagnoses including psychoactive (drug or substance that affected how the brain worked and caused changes in mood, awareness, thoughts, feelings, and behaviors) substance abuse, anxiety, and schizophrenia (mental illness that affects a person's thoughts, feelings, and actions). The assessment further showed Resident 110 was independent with making decisions regarding daily life, had fluctuating inattention and disorganized thinking. Review of the 01/20/2025 hospital social worker mental health assessment showed Resident 110 previously eloped from the hospital and returned with progression of their bone infection. Resident 110 reported methamphetamine (meth/amphetamine, powerful addictive central nervous system stimulant) and alcohol usage, for over 15 years. Resident 110 disclosed their substances of choice were meth and beer, consuming 1 ball and two cans of beer per day. Resident 110 explained they used drugs and/or alcohol to calm down when they were mad or angry. Review of the 01/24/2025 hospital transition of care orders showed Resident 110 used amphetamines and discontinuation of use was recommended. Hospital progress notes were included that showed Resident 110 was recently hospitalized with osteomyelitis (bone infection) in both feet but left the hospital AGAINST MEDICAL ADVICE. The notes further showed concerns of underlying psychotic illness contributed to Resident 110's recent AGAINST MEDICAL ADVICE discharge and possibly interfering with their medical decision-making capacity. Review of the 01/25/2025 nursing admission assessment showed Resident 110 drank one beer per day and smoked meth, 1 ball per day sometimes. Review of the 01/25/2025 wander risk assessment showed Resident 110 could move without assistance, did not have a history of wandering, had no diagnoses of cognitive impairment, and had no reported episodes of wandering in the past six months. The assessment identified Resident 110 as low risk for wandering or elopement, contrary to the hospital information. Review of the 01/26/2025 care plan showed Resident 110 required partial assistance to complete most of their activities of daily living and used a wheelchair for mobility. The care plan showed no documentation Resident 110 had a substance use disorder, no interventions were found to address potential risks associated with a SUD. Review of January 2025 nursing progress notes showed Resident 110 admitted to the facility on [DATE] at approximately 3:30 PM. On 01/26/2025 at 8:00 PM, staff were unable to locate Resident 110 to administer their bedtime medication. At 8:15 PM, an elopement was called. At 8:20 PM, the building was searched inside and out, staff were unable to locate Resident 110. At 8:30 PM, law enforcement was notified of the missing resident. On 01/27/2025 at 7:11 AM, Resident 110 was located at a local hospital, the resident left the facility and was drinking alcohol and did not know how to get back to the facility. No documentation was found to show what occurred with Resident 110 after the facility located them at the local hospital. In an interview on 02/05/2025 at 3:30 PM, Staff P, Nursing Assistant, was unsure what staff were trained to recognize signs and/or symptoms of substance use, how the facility dealt with potential emergencies related to substance use or how the facility assessed for potential risks associated with substance use such as a resident leaving the facility without staff knowledge. Staff P further stated the facility cared for residents with SUDs but had not seen it care planned. In an interview on 02/05/2025 at 3:44 PM, Staff Q, Licensed Practical Nurse (LPN), stated the facility used a wander risk assessment to assess for elopement risk. Staff Q further stated the facility monitored resident behaviors for potential signs and/or symptoms of substance use. Staff Q reviewed Resident 110's medical record. Staff Q acknowledged Resident 110 had a SUD with a history of smoking a ball of meth a day but no care plan was implemented. In an interview on 02/05/2025 at 4:08 PM, Staff C, Resident Care Manager (RCM), stated the facility determined if a resident had a SUD history by reviewing the medical records. Staff C was unsure how residents with SUD were assessed for potential risks associated with substance use. Staff C acknowledged the facility cared for residents with history of SUDs. Staff C reviewed Resident 110's medical record. Staff C acknowledged Resident 110 had psychoactive substance abuse listed as a diagnoses but did not have a care plan or interventions implemented. Staff C further stated Resident 110 eloped from the facility, drank alcohol, was unable to get back to the facility, and ended up in the hospital. In an interview on 02/06/2025 at 11:29 AM, Staff L, Social Service Director (SSD), explained a SUD disorder could be use of alcohol, marijuana, or an illicit substance that alters a person's life. Staff L explained resident records were reviewed to attempt to determine if a resident had a history of SUD and a social service psychosocial evaluation with questions on SUD was to be completed. Staff L reviewed Resident 110's medical record. Staff L acknowledged Resident 110 had a SUD diagnoses but a social service psychosocial evaluation with questions on SUD was not completed and Resident 110 did not have a SUD care plan with interventions implemented. In an interview on 02/26/2025 at 1:17 PM, Staff B, Director of Nursing, was unsure if the facility had an assessment to assess for risks associated with SUD. Staff B further stated the facility maintained resident safety by monitoring resident behaviors and implementing care plan interventions. Staff B reviewed Resident 110's medical record. Staff B stated Resident 110 admitted on the weekend and social services did not have time to complete their assessment because Resident 110 eloped prior. In an interview on 02/06/2025 at 1:31 PM, Staff A, Administrator, stated a SUD would fall under the facility's behavioral health program policy, the facility did not have a policy specifically for dealing or managing SUDs. <Resident 46> The 12/04/2024 quarterly assessment showed Resident 46 had diagnoses including anxiety and depression, was cognitively intact and able to make their needs known. Review of the 08/20/2024 hospital history and physical showed the resident had an alcohol level of less than ten and a urine toxicology which was positive for cannabinoids. The intake stated the resident used marijuana seven days per week. Review of the 08/25/2024 nursing admission assessment showed Resident 46 used marijuana. Review of the 08/28/2024 care plan showed showed no documentation Resident 46 had a SUD, no interventions were found to address potential risks associated with a SUD. In an interview on 02/05/2025 at 3:44 PM, Staff Q reviewed Resident 46's medical record. Staff Q acknowledged Resident 46 had a history of SUD, but no care plan was implemented. In an interview on 02/05/2025 at 4:08 PM, Staff C reviewed Resident 46's medical record. Staff C stated Resident 46 did not have a SUD listed as a diagnosis. In an interview on 02/06/2025 at 10:32 AM, Staff C stated Resident 46 was asked on 01/18/2025 if they had smoked marijuana and they stated yes. Staff C stated when asked on 01/19/2025 if they had smoked marijuana because they had glossed eyes and slurred speech, the resident stated they were not going to smoke it earlier but was shaking their head yes and that they would hide it outside. Staff C stated there was no assessment to assess for marijuana use, the nurses used their clinical judgment, notified providers and placed the resident on alert charting for continued monitoring. When asked if counseling was offered for drug use, Staff C stated they were unsure, but they had meetings for those dealing with alcohol abuse. In an interview on 02/06/2025 at 11:29 AM, Staff L acknowledged Resident 46 voiced marijuana use but when asked Resident 46 would deny a SUD. Staff L reviewed Resident 46's medical record. Staff L acknowledged Resident 46 did not have a SUD care plan or interventions implemented. <SMOKING> During the entrance conference meeting on 01/28/2025 at 8:42 AM, with Staff A, when asked if the facility had residents who smoked, Staff A stated the facility was a non-smoking facility but they had smokers and residents who smoked and they had to be 25 feet away from the building and there were no designated smoking times, since residents had to be independent to smoke. The 12/04/2024 quarterly assessment showed Resident 46 had diagnoses including stroke, respiratory failure and high blood pressure, was cognitively intact and able to make their needs known. They required assistance for transfers and wheelchair mobility. An 08/28/2024 care plan documented Resident 46 was a smoker or used an electronic cigarette/vape device and would not smoke without supervision. An 08/28/2024 smoking screen documented the resident smoked one to two times per day, had visual deficits, was unable to demonstrate a safe technique for extinguishing matches/lighter and dispose of ashes safely, unable to retrieve a cigarette if it were dropped, unable to use a fire extinguisher to extinguish a fire as a result of smoking and used medications that could cause drowsiness. The resident stated they stopped smoking one month prior. A 11/23/2024 hospital note documented the resident had reported smoking cigarettes and that they had never used smokeless tobacco. A 01/22/2025 provider note documented the resident was seen related to their falls and their smoking regimen was discussed as they were going outside to smoke. The resident informed the provider they had vaped. The provider advised cessation; however, the resident was not going to quit smoking. Resident 46 was not observed smoking during the survey. In an interview on 02/06/2025 at 10:16 AM, Staff N, Registered Nurse, stated smoking supplies were kept in the nurse's carts and they thought smoking assessments were completed quarterly and with a significant change in condition. During an interview on 02/06/2025 at 10:32 AM, Staff C when asked who smoked on the unit, stated Resident 46 did, but had not seen them go outside to smoke since they had moved to the unit. Staff C stated the resident smoked on 01/28/2025 when they were on the east side of the facility. Staff C stated the resident should have had another smoking assessment when they found out they were smoking again. Staff C stated it was brought up in a progress note on 01/18/2025 that the resident had smoked. Staff C added the smoking assessment was important to ensure the resident was capable of smoking without injuring themselves, capable of disposing the cigarette in a safe area and that they could hold the cigarette safely. Staff C stated the facility was non-smoking, but the residents had a right to smoke. Staff C stated the smoking area was on the facility grounds, in the corner to the right of the parking lot when you exited the front door. Staff C stated they should have a fire blanket and there were fire extinguishers on all hallways. Staff C stated they have not provided supervision for any of the smokers because they have never had anyone that needed it. When Staff C was asked to look at Resident 46's smoking assessment from 08/28/2024, they stated the resident needed supervision and was unsafe to smoke independently. In an interview on 02/06/2025 at 11:09 AM, Staff A stated the facility did not have a fire blanket because they were a non-smoking facility and to get a blanket would say they were a smoking facility. Staff A stated they did not have a designated smoking area, and the residents went 25 feet away from the front entrance of the building. Staff A stated when Resident 46 arrived at the facility they smoked cigarettes, and they educated them on doing so. Staff A stated the resident was unsafe to smoke independently. Staff A stated the facility did not provide supervision for smokers and they could not stop them from going outside to smoke. Staff A stated they offered cessation and needed to make sure the residents were safe. Staff A stated if the resident could not get themselves outside to smoke, they were not allowed to smoke. Staff A stated Resident 46 should have had a new smoking assessment after they returned from the hospital in November. During an interview on 02/06/2025 at 12:36 AM, the Fire Marshall stated the facility needed to define their policy that they were a non-smoking facility and that smoking was not allowed on the property or if they allowed smoking on the property the area that the residents were allowed to smoke had to be defined and must be 25 feet away from entrances, exits, windows, and ventilation intakes. The facility also needed to have things ready such as a fire blanket, fire extinguisher and a place to dispose of cigarettes. <FALLS> <Resident 4> According to the 12/05/2024 quarterly assessment, Resident 4 had diagnoses including a right hip fracture, dementia and high blood pressure. The assessment further showed Resident 4 had not sustained a fall since the most recent admission but had undergone a surgery to repair the fracture. Resident 4 was cognitively intact and able to make their needs known. The 11/23/2024 discharge assessment showed Resident 4 had two or more non injury falls, two or more falls with minor injury and one fall with major injury. Review of the 12/02/2024 fall risk evaluation showed Resident 4 had a history of falls and was at risk for additional falls. Review of the 12/02/2024 risk for falls care plan showed Resident 4 slid from their wheelchair on 05/07/2024, slid in the bathroom on 05/28/2024, rolled out of bed on 06/28/2024, slid from edge of bed onto floor on 09/09/2024, found on floor on 10/23/2024, had an unwitnessed fall on 11/07/2024, res found on floor on 11/08/2024 and had three unwitnessed falls on 11/23/2024. The care plan had multiple fall interventions in place to include placing a fall mat on the floor which was initiated on 10/10/2022. Per the 10/23/2024 incident investigation, Resident 4 had a fall when they had attempted to transfer from their bed to their wheelchair without assistance. The intervention was to place an impact mat at bedside to reduce injury with falls. Resident 4 hit their head and received a hematoma (a localized collection of blood that pools in an area). The resident was supposed to have a fall mat in place as care planned on 10/10/2022, but that had not occurred. In an interview on 02/07/2025 at 9:36 AM, Staff B stated the impact mat was probably the same as the floor mat, same concept. Staff B stated Resident 4 should have had a fall mat in place prior to the fall on 10/23/2024 to help prevent injury. <Resident 14> According to the 12/03/2024 admission assessment, Resident 14 had diagnoses including atrial fibrillation (irregular heartbeat), dementia and repeated falls. The assessment further showed Resident 46 had a fall prior to admission. Resident 14 was cognitively impaired and was able to make their needs known. Review of the 11/27/2024 fall risk evaluation showed Resident 14 had a history of falls and was at risk for additional falls. Review of the 11/27/2024 risk for falls care plan, last updated 01/30/2025, showed Resident 14 had unwitnessed falls on 12/08/2024, 12/09/2024, 12/10/2024, 01/04/2025 and 01/07/2025. The care plan had multiple fall interventions in place which included the bed against the wall, a floor mat in front of the bed, and for the resident not to be left alone in their room in their wheelchair. In an observation on 01/30/2025 at 1:53 PM, Resident 14 was lying in bed asleep. There was a fall mat on the resident's right side of the bed. The bed was not up against the wall and there was no fall mat on the left side of the bed. During an observation on 02/03/2025 at 09:43 AM, Resident 14 was sitting in their wheelchair in their room alone. In an observation at 11:29 AM, that same day, the resident was brought to their room by a nursing assistant and was alone in their wheelchair in their room. At 11:49 AM, the resident was lying in bed with a fall mat on their right side, the bed was not up against the wall and there was no fall mat on the left side of the bed. In an observation on 02/03/2025 at 2:05 PM, the resident was lying in bed and there was no fall mat on the floor. At 2:11 PM, Resident 14 was sitting on the side of the bed yelling they needed to go to the bathroom. At 2:14 PM, the resident attempted to stand and sat back down on the bed. At 2:17 PM, the resident sat up and then laid back down. During an observation on 02/04/2025 at 8:57 AM, Resident 14 was lying in bed and had no fall mat on the floor. At 1:26 PM, the resident was sitting in their wheelchair in their room alone. In an observation on 02/07/2025 at 8:08 AM, the resident was sitting in their wheelchair in their room alone. During an interview on 02/07/2025 at 12:09 PM, Staff GG, Nursing Assistant, stated fall risk interventions were found on the care plan. Staff GG stated Resident 14 was a fall risk and had fall mats and interventions needed to be implemented to minimize the risk of injury. In an interview on 02/07/2025 at 12:12 PM, Staff B stated the expectation was for nursing staff to follow the care planned interventions and it was important to prevent future falls and to keep the resident safe. <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 had severe cognitive impairment and sustained two or more falls while in the facility. The assessment further showed Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Review of 11/15/2024 hospital notes showed Resident 90 had progressive dementia with frequent falls including a recent ground level fall that resulted in a neck fracture. Review of the 11/20/2024 fall risk evaluation showed Resident 90 had a history of multiple falls in the past 3 months. Review of the 11/20/2024 care plan showed Resident 90 was at risk for falls and instructed staff to anticipate resident needs, ensure the call light was within reach, maintain a safe environment, ensure proper footwear was worn, and keep commonly used items within reach. The care plan further showed Resident 90 sustained 9 falls, two falls on 11/22/2024, and additional falls on 11/23/2024, 11/25/2024, 12/26/2024, 01/07/2025, 01/11/2025, 01/15/2025, and on 01/22/2025. Review of November 2024 nursing progress notes showed on 11/18/2024 the facility transported Resident 90 from the hospital to the facility for admission. During transport Resident 90 repeatedly attempted to get out of their wheelchair (WC) while the vehicle was in motion requiring the driver to pull over three times. Once at the facility, staff attempted to admit Resident 90, but the resident was too impulsive to participate in the admission process with several attempts to self-transfer out of the WC, bed, and off the toilet with redirection only successful for a short time. Resident 90 was unaware of their safety needs and required constant supervision as they would transfer in less than a minute and seemingly required one on one supervision as Resident 90's safety would be compromised if left alone at any time. Resident 90 was transported back to the hospital for more adequate and safer placement at a later time. Resident 90 returned to the facility for admission on [DATE]. The notes further showed Resident 90 sustained three falls prior to having one-on-one supervision initiated. Review of the Resident 90's fall incident reports showed the following: -11/22/2025 unwitnessed fall near the nurses' station. A 12/15/2024 summary showed a new intervention to provide activities that promote exercise and strength building when possible. Review of the care plan showed this intervention was initiated on 11/20/2024, four days prior to the fall. -11/23/2024 unwitnessed fall self-transferring out of bed. A 12/15/2025 summary showed a new intervention of physical therapy consult for strengthening was added. Review of provider orders showed physical therapy was ordered on 11/20/2024, three days prior to the fall. -11/23/2024 (second fall that day) staff overheard resident having an unwitnessed fall. A 12/15/2024 summary showed a new intervention of 1:1 care. -11/24/2024 fall during staff assist. A 12/15/2024 summary showed a new intervention of safety reminders to resident. Review of the care plan showed this intervention was initated 01/31/2025, seven days after Resident 90 discharged the facility. -11/25/2025 fall while working with therapy. A 12/15/2024 summary showed a new intervention of medication review. Review of the record showed no documentation Resident 90's record was reviewed for high-risk medications. -12/07/2024 no incident report provided. Nursing progress notes showed Resident 90 had a near miss fall in the bathroom. -12/26/2024 fall during staff assisted toileting. A 01/26/2025 summary showed a new intervention of using a mechanical lift for transfers as needed was initiated. -01/07/2025 witnessed fall near bed. A 01/30/2025 summary showed a new intervention of activities that minimize falls while providing diversion and distraction was implemented. -01/11/2025 fall during staff assist. A 01/31/2025 summary showed an intervention of reviewing past falls to determine root cause and removing potential fall causes was implemented. No specific intervention was identified. -01/15/2025 fall during staff assist. A 01/31/2025 summary showed a new intervention of right side of bed placed against the wall with fall mat on floor in front of bed. -01/22/2025 witnessed fall during resident transport to the bathroom. A 01/31/2025 summary showed an intervention of reminding resident to lock wheelchair brakes was implemented. In an interview on 02/05/2025 at 2:28 PM, Resident 90's power of attorney (POA, person who can make healthcare decisions) stated Resident 90 had numerous falls at home, including a fall that resulted in a neck fracture prior to facility placement. The POA further stated Resident 90 sustained a few falls prior to the facility implementing 1:1 monitoring. The POA was concerned Resident 90 continued to fall even after 1:1 monitoring was implemented and wondered how that was possible. <Resident 30> According to the 01/21/2025 admission assessment, Resident 30 admitted to the facility on [DATE] with diagnoses including stroke with weakness and/or paralysis affecting one side of the body. The assessment further showed Resident 30 sustained a fall in the month prior to admission and a fracture related to a fall in the past six months. Resident 30 was cognitively intact and able to clearly verbalize their needs. Review of the 01/06/2025 history and physical showed Resident 30 had an unwitnessed fall on 12/22/2024 with head injury and loss of consciousness. On 12/23/2024 Resident 30 had a craniotomy (surgical procedure where part of the skull was removed to access the brain) performed to remove a hematoma (collection of blood that pools outside of a blood vessel). Review of the 01/15/2025 fall risk evaluation showed Resident 30 had a history of falls and was at risk for additional falls. Review of the 01/15/2024 risk for falls care plan showed Resident 30 had an unwitnessed fall on 01/18/2025 and instructed staff to anticipate resident needs, clip the call light to the bed within reach, ensure commonly used items were within reach and resident wore appropriate footwear. Review of the 01/18/2025 facility fall incident report showed Resident 30 had an unwitnessed fall reaching for their call light at 1:15 AM. Upon assessment a bump was noted to the back of Resident 30's head and neurological (neuro, series of simple tests done to assess how the brain and nervous system was functioning) assessment was initiated. Review of the attached neurological flow sheet instructed staff to obtain vital signs and complete neuro checks every 15 minutes x one hour, then every 30 minutes x one hour, then every hour x four hours, then every four hours x 24 hours. The form documented vital signs, and neuro checks every 15 min x the first hour through 2:15 AM, then starting again at 6:00 AM, nearly four hours later, not as instructed on the form. Review of the January 2025 nursing progress notes showed Resident 30 had an unwitnessed fall on 01/18/2025 at 1:15 AM. No documentation of vital signs or neuro assessment was found between 2:15 AM and 6:00 AM. At 7:04 AM, Resident 30 was medicated for a headache. At 1:44 PM, Resident 30's family member visited and was unhappy with cares. The provider was notified of Resident 30's fall that morning, the provider assessed Resident 30, and Resident 30 was transported to the hospital for further evaluation related to hitting their head after having a recent craniotomy. Review of 01/18/2025 provider progress note showed Resident 30 sustained a fall around 1:00 AM with redness and swelling noted to the right side of the head. Resident 30 reported 5 out of 10 pain (on a scale of 0-10, 0 being no pain and 10 being worst pain experienced). Resident 30 explained they hit the same location on their head as the previous fall that occurred on 12/23/2024 (prior to admission) that resulted in a craniotomy. Resident 30 was transferred to the hospital for additional testing. In an interview on 01/31/2025 at 4:06 PM, Resident 30's family member explained Resident 30 had a recent fall out of bed and hit their head. Resident 30 was on blood thinners and experienced a brain bleed before. Resident 30's family member had to insist Resident 30 be sent to the hospital for further evaluation because the facility was not monitoring them. In an interview on 02/06/2025 at 3:54 AM, Staff N, Registered Nurse, explained residents were assessed for fall risk upon admission, quarterly, and when a fall occurred. Staff N further stated when a fall was unwitnessed neuro checks were to be performed, a fall incident report was to be completed, and care plan updated with a new intervention. Staff N acknowledged if a new fall intervention was not implemented timely it could lead to further falls. In an interview on 02/07/2025 at 8:58 AM, Staff C, Resident Care Manager, explained neuro checks were performed for unwitnessed falls, if the resident was a poor historian and when a resident hit their head during a fall. Staff C further stated a resident was to be placed on alert charting to monitor for latent injuries and care plan updated with a new fall intervention to prevent reoccurrence. Staff C stated they expected staff to monitor residents and implement interventions when falls occurred. In an interview on 02/07/2025 at 9:18 AM, Staff B, Director of Nursing, defined a fall as any unplanned change in plane and explained a new intervention should be implemented each time a fall occurred to prevent further falls. Staff B stated staff were expected to complete fall incident reports, implement new interventions, and follow the facility fall policies when falls occurred. Reference WAC 388-97-1060 (3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure respiratory treatments had provider orders, that provider orders were carried out, and care plan goals and interventions were developed for 3 of 3 sampled residents (Residents 71, 358 and 359), reviewed for respiratory care. These failures placed residents at risk for respiratory complications and a diminished quality of life. Findings included . Review of the facility policy titled, Quality of Care Respiratory Care dated July 2018, showed the facility would provide residents with necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan and choices. The policy included a list of respiratory therapy modalities that could be provided at the facility which included breathing techniques, CPAP (continuous positive air pressure, a treatment that used pressure to keep the airway open by way of a mask) use, and oxygenation support. Staff were to assess and monitor a resident's respiratory condition, including their response to therapy provided and any changes in respiratory conditions. The policy further showed residents who required respiratory services would have physician orders and a resident-centered respiratory care plan implemented. Oxygen therapy could be provided through various delivery systems, and the provider order was to include an indication for use, equipment to be used, oxygen levels to initiate and/or discontinue oxygen therapy. <Resident 359> Per the 01/29/2025 admission assessment, Resident 359 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease that made it hard to breathe) and cardiomyopathy (heart muscles too weak to pump blood). The assessment further showed Resident 359 did not receive oxygen therapy. Resident 359 was cognitively intact and able to clearly verbalize their needs. Review of provider orders as of 02/06/2025 showed Resident 359 had no orders for oxygen therapy administration, care and/or maintenance of oxygen equipment and tubing. Review of the January 2025 through February 2025 nursing progress notes showed Resident 359's oxygen level was 96% on 01/24/2025 and 92% on 01/30/2025, with use of oxygen via nasal cannula (tubing used for oxygen flow). Review of the 01/28/2025 COPD care plan instructed staff to administer medications as ordered, include resident in care planning, and identify ways to reduce sources of respiratory irritations. Review of the 01/30/2025 altered respiratory status care plan instructed staff to elevate the head of the bed, monitor for signs and/or symptoms of respiratory infection, respiratory distress, and abnormal breathing patterns. No documentation was found to show Resident 359 received oxygen therapy or how to maintain oxygen equipment or tubing. In an observation on 01/28/2025 at 1:04 PM, there was an oxygen concentrator (a medical device that supplies oxygen for breathing) plugged in with an attached nasal cannula at Resident 359's bedside. There was an Oxygen in Use sign posted on the door. Similar observations were made on 01/29/2025 at 11:49 AM and 01/31/2025 at 9:23 AM. In an observation and interview on 01/28/2025 at 3:46 PM, Resident 359 was in bed and the oxygen concentrator was at their bedside. Resident 359 stated they used 2 liters (L) of oxygen nightly. In a follow-up observation and interview on 02/03/2025 at 10:43 AM, Resident 359 was in bed and had an oxygen nasal canula in their nose. Resident 359 stated they recently completed a physical therapy session and applied the oxygen afterwards. A similar observation was made on 02/05/2025 at 4:25 PM. In an interview on 02/06/2025 at 12:35 PM, Staff T, Licensed Practical Nurse (LPN), stated residents who had lung disease would generally have orders for oxygen therapy in place to enable their breathing to perform daily activities. Staff T reviewed Resident 359's medical record. Staff T acknowledged Resident 359 had no orders for oxygen therapy. In an interview on 02/06/2025 at 1:26 PM, Staff U, Resident Care Manager (RCM), stated Resident 359 should have had oxygen therapy orders in place along with a care plan. <Resident 358> Per the 01/30/2025 admission assessment, Resident 358 had diagnoses including heart failure (heart cannot pump enough blood) and sleep apnea (a sleep disorder in which breathing stopped and started repeatedly during sleep). The assessment further showed Resident 358 used oxygen therapy and did not use a CPAP. Resident 358 was cognitively intact to verbalize their needs. In an observation and interview on 01/28/2025, Resident 358 was sitting in their wheelchair, and a CPAP machine was on their nightstand. Resident 358 stated they were admitted to the facility on [DATE] with their personal CPAP machine. Resident 358 explained during the admission process, an unknown staff told them not to be concerned about wearing their CPAP because it would be set up that night. Resident 358 stated their CPAP machine was assembled three days later on 01/27/2025 and they wore it for three hours. Per review of the provider orders as of 02/07/2025 showed Resident 358 had no order for routine CPAP use, CPAP settings, cleaning and/or changing the filter. Review of the 01/24/2025 self-care deficit care plan showed Resident 358 was dependent on staff assist to perform most activities of daily living. The 01/24/2025 altered respiratory status care plan instructed staff to elevate the head of the bed, administer oxygen therapy via nasal cannula, monitor for signs and/or symptoms of respiratory distress and changes in breathing pattern. No documentation was found for Resident 358 to wear a CPAP routinely, CPAP settings, cleaning and/or changing the machine filter. Review of the January 2025 nursing progress notes showed no documentation Resident 358 used or had a CPAP machine. In an observation on 01/28/2025 at 3:46 PM, Resident 358 was asleep in bed and their CPAP machine sitting on the nightstand. During an interview and observation on 01/29/2025 at 11:12 AM, Resident 358 stated they forgot to use their CPAP machine last night. Resident 358 stated staff assisted them by putting on the CPAP mask and filling the reservoir with distilled water. The CPAP machine remained on the nightstand with a jug of distilled water. Similar observations were made on 02/03/2025 at 10:17 AM and 02/05/2025 at 4:26 PM. In an interview on 02/06/2025 at 12:14 PM, Staff V, Nursing Assistant, stated they had not observed Resident 358 with their CPAP mask in place the mornings they worked. Staff V acknowledged Resident 358 has had the CPAP machine in their room since they were admitted to the facility. In an interview on 02/06/2025 at 12:20 PM, Staff T, LPN, stated Resident 358 utilized their CPAP machine at night since their admission and were monitored every hour when they went to bed. Staff T reviewed Resident 358's medical record. Staff T acknowledged Resident 358 had no provider orders for use of their CPAP machine, CPAP settings, cleaning and/or changing the machine filter. Staff T further stated Resident 358 should have CPAP orders implemented so staff were informed of the respiratory care needs. In an interview on 02/06/2025 at 1:24 PM, Staff U, RCM, stated that when a resident was admitted with their own CPAP machine, staff acknowledged their settings used at home. Staff U further stated it was important to have physician orders for CPAP use so staff were able to appropriately care for the resident. <Resident 71> Per the 01/02/2025 quarterly assessment, Resident 71 had diagnoses including respiratory failure (serious condition where the lungs cannot get enough oxygen), COPD and sleep apnea. Resident 71 was cognitively intact and able to make decisions regarding their care. In an observation and interview on 01/29/2025 at 9:50 AM, Resident 71 was lying in their bed and had their personal CPAP machine on their nightstand. Resident 71 stated they had not worn their CPAP machine for the last two nights because they fell asleep before they could apply it. In an observation and interview on 01/31/2025 at 08:49 AM, Resident 71 was laying in their bed. Resident 71 again stated they did not wear their CPAP machine last night because they were tired and fell asleep before they could apply it. In an observation and interview on 02/03/2025 at 10:20 AM, Resident 71 stated if they were asleep, staff did not wake them up to apply their CPAP. In an observation and interview on 02/05/2025 at 9:50 AM, Resident 71 was laying in their bed and was hardly able to keep their eyes open. Resident 71 again stated they did not use the CPAP machine last night and were tired. In an observation and interview on 02/6/2025 at 3:35 PM, Resident 71 was lying in their bed and more alert than previous days. Resident 71 stated they used their CPAP machine last night. Review of the 12/05/2024 self-care deficit care plan showed Resident 71 was dependent on staff assist to perform most activities of daily living. The 12/05/2024 altered respiratory status care plan instructed staff to elevate the head of the bed, monitor for respiratory distress, administer medications as ordered, and use a CPAP per home settings. No documentation was found for CPAP cleaning and/or changing the machine filter. Per review of the provider orders showed an active 12/21/2024 order for Resident 71 to wear a CPAP nightly, refill the distilled water chamber at bedtime, remove the CPAP mask in the morning and cleanse with hot water and dish soap. Record review of the medication administration record from 01/26/2025 to 02/03/2025, documented Resident 71 wore their CPAP at bedtime daily, when Resident 71 voiced it had not been worn. During an interview on 02/06/2025 at 12:35 PM, Staff T, LPN, stated the night shift nurse monitored Resident 71 when they used the CPAP machine. Staff T reviewed Resident 71's medical records. Staff T stated documentation showed Resident 71 wore the CPAP machine nightly and they were unaware Resident 71 had not been wearing it. In an interview on 02/06/2025 at 1:41 PM, Staff U, RCM, acknowledged Resident 71 had been sick recently and had not used their CPAP machine. Reference WAC 388-97-1060 (3)(j)(ii)

Based on interview and record review the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 2 of 5 sampled staff (Staff P and Y), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included . Review of the following Nursing Assistant (NA) personnel files found no documentation that showed a yearly performance evaluation had been completed following: - Staff Y, Nursing Assistant - Staff P, Nursing Assistant In an interview on 02/03/2025 at 1:36 PM, Staff A, Administrator, stated they had not been aware there was not a process in place for completing yearly performance evaluations, and the facility was in the process of getting evaluations started. Reference (WAC): 388-97-1680 (1), (2)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 22> According to the 01/06/2025 quarterly assessment, Resident 22 had diagnoses including depression and bipolar disorder (a mental illness that caused extreme mood swings that affected thinking, behaviors, and sleep). Ressident 22 was able to make decisions regarding their care. Review of the Order Summary Report from 05/22/2024 through 01/31/2025 showed when Resident 22 had been admitted to the facility on [DATE], the physician had prescribed psychotropic medications (Abilify and Celexa) to treat the symptoms of the bipolar disorder and depression. admission orders included instruction to the licensed staff to monitor for behaviors which may indicate a change in the resident's mental health, and to monitor for any potential adverse side effects of the psychotropic medications. Review of the care plan showed interventions which instructed the nursing staff to monitor for behavior changes and possible adverse side effects related to the use of the psychotropic medications had been implemented on 05/20/2020. Review of the January 2025 Medication Treatment Record on 01/31/2025 found on the following dates and shifts, the documentation for the behavior and adverse side effect monitors were blank and had not been completed: - day shift from 01/02/2025 through 02/05/2025, and 02/08/2025 through 02/11/2025 - evening shift on 01/11/2025, - night shift on 01/03/2025, 01/05/2025, 01/09/2025, 01/17/2025, 01/24/2025, and 01/25/2025. In an interview on 02/05/2025 at 11:03 AM, Staff N, Registered Nurse, stated the expectation was that all charting/documentation was completed each shift as ordered and a progress note made if there were any issues or concerns. Staff N reviewed Resident 22's medical record. Staff N acknowledged documentation was blank as stated above. <Resident 23> According to the 11/21/2024 admission assessment, Resident 23 had diagnoses which included anxiety and depression. Resident 23 was cognitively intact and able to make decisions regarding their care. Review of the Order Summary Report from 11/15/2024 through 02/04/2025 showed when Resident 23 admitted to the facility on [DATE], the physician had prescribed psychotropic medications (Elavil and Ambien) to treat the symptoms of depression and anxiety. Additional orders included instruction to the licensed staff to monitor for any potential adverse side effects of the psychotropic medications. Review of the care plan showed interventions had been implemented on the day of admission and instructed the nursing staff to monitor for adverse side effects and behaviors that were unusual for the resident. Review of the January 2025 Medication Treatment Record on 01/31/2025 found the documentation for the adverse side effect monitors were blank and had not been completed on the following dates and shifts: - day shift on 01/05/2025 - evening shift on 01/09/2025, 01/14/2025, and 01/26/2025. In an interview on 02/05/2025 at 10:14 AM, Staff R, Licensed Practical Nurse, stated all documentation needed to be completed each shift as ordered and confirmed some of the documentation had not been done. In an interview on 02/05/2025 at 1:21 PM, Staff B, Director of Nursing, stated documentation for the behavior and adverse side effects monitors was completed before the end of each shift. Staff B reviewed Resident 22 and 23's records. Staff B acknowledged documentation had not been completed consistently. Reference (WAC): 388-97--1060 (3)(k)(i) Refer to F552 and F661 for additonal information. Based on interview and record review the facility failed to ensure residents were not given psychotropic medications (medication that affected the mind, emotions, and behaviors) unless the medication was necessary to treat specific conditions documented in the clinical record, residents received non-medication behavioral interventions, and behavior and adverse side effect monitoring was consistently done for 3 of 6 sampled residents (Residents 22, 23 and 90), reviewed for unnecessary medications. This failure placed residents at risk of being chemically restrained, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Chemical Restraint dated November 2017, showed the facility would provide a safe environment that was free from abuse including the use of chemical restraints not required to treat the resident's medical symptoms. The policy defined a chemical restraint as any drug that was used for discipline or staff convenience and not required to treat medical symptoms. The policy further showed if it was determined administration of a medication was being used to treat a medical symptom, the facility would review the use of the medication and ensure it was supported by adequate indication and rationale for use, was used at the correct dose and duration with adequate monitoring. Documentation would include behavioral interventions unless contraindicated, monitoring for medication effectiveness and potential adverse consequences. The policy included examples of chemical restraint as administering medication to prevent wandering and to quiet a resident who continually called out, without attempting alternative interventions. <Resident 90> According to the 11/26/2024 admission assessment, Resident 90 admitted to the facility on [DATE] with diagnoses including dementia, traumatic brain injury (TBI- brain damage caused by an external force), anxiety, and depression. Resident 90 had severe cognitive impairment with fluctuating inattention, disorganized thinking and no altered level of consciousness. Review of November 2024 nursing progress notes showed on 11/18/2024 the facility transported Resident 90 from the hospital to the facility for admission. During transport Resident 90 repeatedly attempted to get out of their wheelchair (WC) while the vehicle was in motion requiring the driver to pull over three times. Once at the facility, staff attempted to admit Resident 90, but the resident was too impulsive to participate in the admission process with several attempts to self-transfer out of the WC, bed, and off the toilet with redirection only successful for a short time. Resident 90 was unaware of their safety needs and required constant supervision as they would transfer in less than a minute and seemingly required one on one supervision as Resident 90's safety would be compromised if left alone at any time. Resident 90 was transported back to the hospital for more adequate and safer placement at a later time. Resident 90 returned to the facility for admission on [DATE]. The notes further showed Resident 90 sustained three falls prior to having one-on-one supervision initiated. The 11/18/2024 facility order summary documented Resident 90 had no active orders for antipsychotic medications. The 11/18/2024 hospital progress notes showed Resident 90 was very pleasant, made eye contact, and did not show agitation. The hospital received report from the facility Resident 90 was agitated, impulsive, lacked judgement and behaved agressively. The resident had been sent to the care facility earlier in the day, but challenges had arisen due to the facility report of understaffing and inablity to provide Resident 90 with 1:1 supervision. The resident was started on a low dose antipsychotic medication, Seroquel. Review of the 11/20/2024 hospital discharge medication list showed Resident 90 was to be administered Seroquel 25 milligrams (mg) twice daily after discharge. Review of the 11/21/2024 facility order summary showed Resident 90 was to be administered Seroquel 25 mg twice daily for psychophysical visual disturbances, violent behavior, restlessness and agitation. Review of the 11/21/2024 provider progress note showed Resident 90 was started on low dose Seroquel due to dementia with behavioral disturbances. The provider's treatment plan included continued use of Seroquel at 25 mg twice daily. The provider's note also included the following general recommendations for environmental treatment of agitation: frequent orientation with cues, staffing consistency, communicate with short clear statements and requests, maintain day/night structure especially with lighting, minimize noise/stimuli especially at night, ensure the resident had freedom of mobility within confines of medical treatment and plan, ensure pain was addressed related to resident may not be able to vocalize which may lead to agitation, and correct any sensory deficits by ensuring the resident wore hearing aides and/or glasses as needed. Review of the 11/20/2024 self-care performance deficit care plan showed Resident 90 required partial staff assistance to perform most activities of daily living including bed mobility and transfers. The 11/21/2024 psychotropic medication use care plan instructed staff to administer medications as ordered, monitor for adverse side effects, orient to reality and clarify mistaken beliefs. The 11/27/2024 delirium (sudden and severe state of confusion) care plan instructed staff to call Resident 90 by their preferred name, encourage resident family, friends, and care givers to be at bedside during episodes of confusion. The 11/30/2024 impaired cognitive function care plan instructed staff to administer medications as ordered, monitor for potential side effects and medication effectiveness. No documentation was found to show the provider's 11/21/2024 recommendations for evironmental treatment of agitation were care planned or implemented. Review of the 11/23/2024 provider progress note showed Resident 90 had moments of agitation with garbled speech. The provider's plan showed Resident 90 was responding well to Seroquel therapy and the provider continued Seroquel 25 mg twice daily. Review of the 11/25/2024 provider progress note showed Resident 90 sustained a fall, was transferred to the hospital for evaluation and returned with multiple recommendations for behaviors. The provider's note further showed the hospital increased Resident 90's Seroquel from 25mg to 50mg twice daily and advised continued increase by 25 mg twice daily to reduce hyperactivity and agitation until symptoms were controlled or max dose of 750 mg/ 24 hours was reached. The provider noted Resident 90 was currently on Seroquel 75mg daily with reported increased fatigue and Resident 90 was more sedated today. The hospital also recommended starting use of Ativan (antianxiety medication) orally for anxiety and in an injectable form for severe agitation and combativeness. Review of the 11/26/2024 provider note showed Resident 90 had frequent falls associated with behaviors including violent aggression. Resident 90 was now being administered Seroquel 75 mg twice daily with some improvement in behaviors and anxiety. Review of the 12/03/2024 provider progress note showed Resident 90's behaviors were controlled with the recent Seroquel dose increase to 75 mg twice daily. Review of the 12/06/2024 provider progress note showed Resident 90 was administered the as needed antianxiety medication five times in the last two weeks. Resident 90 was to continue receiving Seroquel 75 mg twice daily and use the as needed Ativan. Review of the 12/10/2024 provider progress note showed Resident 90 reported intermittent sleep issues. The provider's plan was to increase Seroquel to 100mg twice daily and continue the as needed Ativan. The provider note did not document any behaviors Resident 90 experienced, if any. Review of the 12/10/2024 psychotropic medication review showed Resident 90 was taking Seroquel 100 mg twice daily, which was an increased dose, with behaviors documented as agitation and acting out. The notes did not include details or specific examples of what acting out meant. Review of December 2024 point of care behavior task documentation showed Resident 90 only experienced behaviors on 12/15/2024, 12/16/2024, 12/18/2024, 12/21/2024, 12/22/2024, 12/23/2024, and 12/26/2024. Review of the December 2024 through January 2025 medication administration record (MAR) behavior monitoring showed inconsistent behavior monitoring with omissions in documentation on the following dates: December- Dayshift 12/05/2024, 12/13/2024, 12/17/2024, 12/19/2024, 12/21/2024 through 12/23/2024, 12/26/2024 through 12/28/2024. Night shifts 12/08/2024, 12/14/2024, 12/16/2024, 12/17/2024, 12/20/2024 through 12/23/2024 and 12/26/2024. January- Dayshift 01/06/2025, 01/08/2025, 01/10/2025 through 01/13/2025, 01/20/2025, and 01/21/2025. Night shifts 01/02/2025, 01/03/2025, 01/05/2025, 01/09/2025, 01/10/2025, 01/13/2025, 01/14/2025, 01/16/2025, 01/20/2025, and 01/21/2025. Review of the 01/08/2025 provider progress note showed Resident 90 had increased behaviors and impulsiveness. Resident 90 had been making more sexual inappropriate gestures, comments and just inappropriateness. Resident 90 had another fall due to impulsiveness. The provider's plan was to increase the Seroquel to 100 mg three times daily due to impulsiveness which leads to falls, inappropriate behaviors, and sexual inappropriateness. The note further showed the as needed Ativan was not effective at managing impulsiveness, Resident 90 continued to be a fall risk, and the provider scheduled Ativan 1 mg twice daily routinely. Review of the 01/09/2025 psychotropic medication review showed Resident 90 was taking Seroquel 50 mg twice daily, not 100mg three times daily as ordered by the provider, with behaviors listed as impulsive, jumps out of bed, and agitation. Review of November 2024 through January 2025 nursing progress notes showed Resident 90 was alert to self only, not redirectable, was short with staff, cursed at times, self-transferred often, had unsteady gait, experienced frequent falls, was confused, and anxious at times. The notes further showed Resident 90 was administered as needed Ativan for restlessness and anxiousness, minimal vague documentation was found to show what non-medication interventions were attempted prior to medicating, intervention effectiveness and/or specific details of the behaviors Resident 90 experienced. No documentation of violent, aggressive or combative behavior was found. According to the 01/14/2025 quarterly assessment, Resident 90 had diagnoses including violent behavior, restlessness and agitation. Resident 90 had severe cognitive impairment, continuous nonfluctuating inattention, disorganized thinking, and an altered level of consciousness. Review of the 01/22/2025 provider discharge summary showed Resident 90 sustained repeat falls secondary to impulsiveness. Resident 90 discharged the facility with provider orders to administer Seroquel 100 mg three times daily, Ativan 1 mg routinely twice daily and Ativan 1 mg every four hours as needed for agitation. In an interview on 02/05/2025 at 2:28 PM, Resident 90's power of attorney (POA- person who could make healthcare decisions when someone was unable to do so for themselves) stated the facility informed them Resident 90 was being administered medication to help with behavioral outbursts. Resident 90's POA further stated they felt Resident 90 was overmedicated. The POA explained Resident 90 admitted to the facility requiring one person transfer assist using a walker but upon discharge Resident 90 could barely hold their head up and it took three persons to stand pivot transfer Resident 90 out of the WC. In an interview on 02/06/2025 at 12:38 PM, Staff L, Social Service Director, explained nurses monitored resident behaviors through the MAR and nursing assistants via point of care behavior task documentation. Staff L reviewed Resident 90's medical record. Staff L acknowledged there were significant omissions in the MAR behavior monitoring documentation and nursing progress notes with behavior details was lacking. Staff L further stated behavior documentation was critical because it was reviewed and used to determine potential medication adjustments, either decreases or increases. In an interview on 02/07/2025 at 8:47 AM, Staff C, Resident Care Manager, explained resident behaviors were monitored through progress notes, behavior monitors in the MAR and task documentation. Staff C explained Resident 90 had behaviors which included anxiousness and agitation related to waking up from sleeping demanding to see their spouse, jumping out of bed, walking into the hall and difficult with redirection. Staff C reviewed Resident 90's medical record. Staff C acknowledged Resident 90's behavior documentation was lacking. In an interview on 02/07/2025 at 9:11 AM, Staff B, Director of Nursing, explained behaviors were monitored various ways including behavior monitoring in the MAR and nursing progress notes. Staff B stated Resident 90's behaviors included being impulsive, yelling out, and sexually inappropriate behaviors. Staff B stated they expected staff to document behaviors with sufficient detail to justify medication adjustments.

Based on interview and record review, the facility failed to ensure 3 of 5 sampled residents (Residents 22, 46 and 71), reviewed for medication administration, received medication as ordered by the physician. Failure to administer insulin, a medication used to treat diabetes, and consistently monitor blood sugar levels, a test done that checked the level of sugar in the blood stream, and failure to follow the parameters for holding a blood pressure medication created significant medication errors, and placed the residents at risk for medical complications, unintended health consequences and diminished quality of life. Findings included . INSULIN AND BLOOD SUGAR MONITORING <Resident 22> The 01/06/2025 quarterly assessment documented Resident 22 was able to make decisions regarding their care and had diagnoses which included high blood pressure and Diabetes, a medical condition caused when the body was unable to breakdown sugar. In addition, the assessment documented the resident received insulin, a medication used in the treatment of diabetes to keep blood sugar levels in the blood stream at normal ranges. The provider ordered the following medications: - On 01/23/2023, Humalog, a fast-acting insulin that started to work within 15 minutes, was to be administered three times a day, - On 01/24/2023 blood sugar checks were to be done before meals, and - On 11/07/2024, Lantus, a long-acting insulin, was to be administered twice a day Review of the January 2025 Medication Administration Records (MARS) on 01/31/2025 found the following: - On 01/02/2025, the Lantus was not given during the evening shift - On 1/11/2025, the blood sugar checks had not been done before any of the meals, and neither the Humalog nor the Lantus had been given. - On 01/24/2025, the blood sugar checks had not been done before breakfast or lunch nor had the Humalog been given, and the Lantus was not given during the dayshift. There was no documentation that explained the reason for the omission of the blood sugars and administrations of the Humalog and Lantus on the dates above. In an interview on 02/04/2025 at 11:01 AM, Staff N, Registered Nurse, (RN), stated medications needed to be administered as ordered by the physician and documented in the MAR and/or the progress notes if not given or there were concerns. After review of Resident 22's record, Staff N confirmed no documentation was made that showed why the insulin and blood sugar orders had not been administered as ordered. <Resident 71> The 01/02/2025 quarterly assessment documented Resident 71 had diagnoses that included end-stage renal (kidney) disease dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer functioned), diabetes and ketoacidosis (lack of insulin that causes the breakdown of fat for energy, which caused acid to build up in the blood). Resident 71 was cognitively intact and received insulin injections. A review of Resident 71's active orders documented the resident was to have their blood sugar level obtained before meals and at bedtime. The resident was also to receive an injection of 13 units of Humalog insulin three times daily. On 01/15/2025, an order was given for resident 71 to receive additional insulin coverage after their meals and at bedtime. The amount of insulin to be received was based on the result of their blood sugar check. Additional orders were given for Resident 71 to take sevelamer (lowered the amount of phosphorous in the blood) 2400 milligrams three times a day with meals, and to have dialysis sessions every Monday, Wednesday and Friday from 1:20 PM to 5:20 PM. A review of the medication/treatment administration records (MAR/TAR) for January 2025 through February 05, 2025 documented Humalog insulin13 units injections were scheduled to be given each day at 7:30 AM, 11:30 AM, and 4:30 PM. On Mondays, Wednesdays and Fridays during the resident's dialysis treatments when Resident 71 was out of the facility, they missed their insulin on the following dates and times: 11:30 AM- 01/06/2025, 01/10/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025, 01/31/2025 and 02/05/2025. 4:30 PM-01/01/2025, 01/03/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/15/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025, 01/31/2025 and 02/05/2025. Blood sugar checks with insulin coverages beginning 01/15/2025 were scheduled on the MARs to be checked and administered at mealtimes daily during the following timeframes of 6:00 AM to 10:00 AM, 10:00 AM to 2:00 PM, and 2:00 PM to 6:00 PM. Resident 71's blood sugar checks and insulin coverage were omitted on the following dates and times: 10:00 AM to 2:00 PM-01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025 and 01/31/2025. 2:00 PM to 6:00 PM-01/15/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025 and 01/31/2025. Resident 71 also had doses of sevelamer omitted on the following dates in January 2025: 01/03/2025, 01/06/2025, 01/10/2025, 01/15/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025, 01/29/2025 and 01/31/2025. In the areas on the MARS where the staff were to enter that the medications listed above had been administered, there was a code 1 entered. The key on the MAR documented that a code 1 indicated the resident was out of the facility without their medications. During an interview on 02/07/2025 at 9:03 AM, Resident 71 stated they brought a lunch with them to their dialysis sessions, but they did not receive any medications during their sessions. During an interview on 02/07/2025 at 9:04 AM, Staff CC, Licensed Practical Nurse, stated they gave Resident 71 their medications and on the days the resident had dialysis sessions, the resident left the facility at around 10:20 AM and did not return until after 6:00 PM. Staff CC did not send any medications to dialysis with Resident 71 and entered the code 1 on the MAR. Staff CC stated they were unsure if the providers were aware the resident was not receiving their medications on dialysis days. During an interview on 02/07/2025 at 9:50 AM, Staff DD, Physician Assistant, reviewed Resident 71's MARs with the surveyor. Staff DD stated there had been no communication from staff regarding the timing of the resident's insulins and sevelamer. Staff DD stated they would have expected staff to communicate with them regarding this so that medication doses could be adjusted or dosed differently if able so that doses were not omitted. Staff DD stated staff could assess Resident 71 to see if they were able to self-administer their medication at dialysis. If so, this also prevented doses from being omitted depending on the assessment. BLOOD PRESSURE PARAMETERS <Resident 22> During review of Resident 22's January 2025 MARS on 01/31/2025, an order was found that documented on 11/23/2024, the physician had prescribed a medication (Metoprolol) to manage Resident 22's high blood pressure. The instructions directed the nursing staff to assess Resident 22's heart rate prior to administering the medication. If the heart rate was below 50 beats per minute (bpm) the Metoprolol was to be held. On 01/26/2025 and 01/27/2025, Resident 22's heart rate was documented to be below the parameter of 50 bpm, but the documentation indicated the Metoprolol was still given, and not held as directed in the order. No documentation was found that showed why the medication had not been held. In an interview on 02/04/2025 at 10:57 AM, Staff N, Registered Nurse, reviewed Resident 22's record and confirmed no documentation was found that explained the reason for giving the Metoprolol when the heart rate was below the ordered parameters. In an interview on 02/05/2025 at 1:21 PM, Staff B, Director of Nursing, stated the expectation was medications, insulin and blood sugar monitoring were to be done as ordered by the physician. After review of Resident 22's record, Staff B confirmed the blood sugars and insulins had not been administered as ordered. With regards to Resident 22's Metoprolol, Staff B was able to locate progress notes on the dates in question, that documented the physician was notified of the low heart rate values, but no order was given to administer the medication with the low heart rate. Staff B stated the Metoprolol should have been held. <Resident 46> The 12/04/2024 quarterly assessment documented Resident 46 was able to make decisions regarding their care and had diagnoses which included high blood pressure. A review of the resident's January MARS showed the physician had prescribed a medication (Metoprolol) on 11/27/2024 to manage Resident 46's high blood pressure. The instructions directed the nursing staff to assess the resident's blood pressure and heart rate and if the systolic blood pressure (SBP, the top number of the blood pressure reading) was less than 120 and the heart rate was less than 60 bpm the Metoprolol was to be held. On 01/02/2025, 01/06/2025, 01/08/2025, 01/11/2025, 01/12/2025, and 01/27/2025, Resident 46's SBP was documented to be below the parameter of 120, but the documentation indicated the Metoprolol was still given and not held as directed in the order. No documentation was found that showed why the medication had not been held. In an interview on 02/06/2025 at 10:16 AM, Staff N, Registered Nurse, stated blood pressure medications needed to be held per the parameters and this was important because the resident could have a bad outcome. During an interview on 02/06/2025 at 10:32 AM, Staff C, Resident Care Manager, stated the blood pressure medications should have been held and the provider should have been notified. Reference: WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview, and record review the facility failed to ensure medications were stored under proper temperature controls in 2 of 3 sampled medication rooms (East and West) and in 1 of 3 medication storage refrigerators (East), reviewed for medication storage. This failure placed residents at risk of receiving less than the optimum dose of their medications, adverse side effects, and diminished quality of life. Findings included . <West Medication Room> During observation on 02/05/2024 at 1:16 PM, the [NAME] medication room was observed with Staff F, Licensed Practical Nurse. No thermometer was observed in the medication room where various medications were stored at room temperature. <East Medication Room> During observation, interview, and record review on 02/07/2025 at 7:42 AM, the East medication room was observed with Staff B, Director of Nursing. No thermometer was observed in the medication room where various medications were stored at room temperature. Staff B acknowledged the East medication room did not have a thermometer to monitor the temperature of the room where various medications were stored. The refrigerator contained various insulins, intravenous medications and concentrated oral antianxiety medications. Staff B stated staff checked the medication room refrigerator temperatures every night shift. Review of the February 2025 temperature log showed only one entry of 32 degrees on 02/06/2025. Review of the January 2025 temperature log showed temperature entries for 13 out of 31 days. Staff B acknowledged the medication room refrigerator temperature log had numerous omissions. Staff B stated they expected staff to check the temperatures in the medication refrigerator because storing medications at inappropriate temperatures could potentially affect the quality of medications. During an interview on 02/07/2025 at 10:35 AM, Staff A, Administrator, stated they expected staff to check the medication room refrigerator temperatures because storing medications at incorrect temperatures could potentially affect medication quality. A policy on medication storage was requested at that time and again at 3:30 PM. No documentation was provided. Reference WAC 388-97-1300 (2), -2340

Based on observation, interview and record review, the facility failed to provide appetizing and palatable food for 5 of 9 sampled residents (Residents 18, 23, 36, 48 and 54) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, and a diminished quality of life. Findings included . <Resident 18> The 01/13/2025 quarterly assessment documented Resident 18 was cognitively intact and able to make decisions regarding their care. On 01/29/2025 at 9:05 AM, Resident 18 was observed in their room seated in their recliner. Resident 18 stated the food was not good, that the vegetables were mushy and any chicken they got was a processed patty. The resident stated they had been at the facility for years and could not remember when they had last seen a real chicken breast or real drumstick. Resident 18 stated the food was just thrown on the plate so that it did not look appetizing. They stated they had talked about their concerns with the dietary staff but there had been no results. <Resident 23> The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care. On 01/28/2025 at 3:27 PM, Resident 23 was observed lying in bed watching television. When asked about the food, Resident 23 stated, they sent it back often, it was not good, they sent it back a lot, the eggs at breakfast were not edible, I have no idea what they do to them, but it smells and tastes terrible. On 01/31/2025 at 9:20 AM, Resident 23 was observed lying in bed watching television. When asked how breakfast was, Resident 23 stated it was good, had sausage, but one time the meal looked like scraps, like someone had eaten and they were served the left-over plate. <Resident 36> The 12/16/2024 quarterly assessment documented Resident 36 was cognitively intact to make decisions regarding their care. During an interview on 01/28/2025 at 10:26 AM, Resident 36 stated they were a lousy cook and the facility cook was even worse. The resident stated the food was inedible, too salty, and most of the time they usually did not eat the food, just had a sandwich. On 01/31/2025 at 11:56 AM, Resident 36 stated they wanted a sandwich, the lunch did not taste like it should and they did not like it. At 12:18 PM, the resident received a sandwich and stated it was good. <Resident 48> The 01/09/2025 comprehensive assessment documented Resident 48 had diagnoses which included gastroesophageal reflux disease (GERD) (a chronic digestive disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining) and esophageal ulcer (a sore that develops in the lining of the esophagus) with bleeding. The resident was cognitively intact to make decisions regarding their care. In an observation and interview on 02/03/2025 at 12:48 PM, Resident 48 was lying in bed, eating their lunch meal (pork roast with gravy, spinach, rice, coffee, milk, and lemonade). The resident stated that the food was sometimes too salty and did not have enough flavor or seasoning. <Resident 54> The 10/22/2024 quarterly assessment documented Resident 54 was cognitively intact to make decisions regarding their care. During an interview on 01/28/2025 at 10:40 AM, Resident 54 stated the food was not good and they used too much salt. Resident 54 stated they requested sandwiches, soup and fruit. In an interview on 01/28/2025 at 11:42 AM, Resident 54's representative stated the food was extremely bad and the meat was too tough. In an observation on 01/31/2025 at 11:59 AM, Resident 54 was served fish, vegetables and cake. Resident 54 stated they did not like the food and had requested a sandwich. During an observation on 02/03/2025 at 11:53 AM, Resident 54 stated they did not like the meat and had requested a sandwich. <Test Tray> On 02/04/2025 at 12:49 PM, a test tray of the lunch meal was sampled by the survey team. The meal consisted of a chicken taco, baked apples, rice, and beans. The alternative entree was bar-be-que pork. The chicken in the taco tasted like it was canned and the rice and beans were bland without taste or flavor. The appearance of the meal was unappetizing, brown in appearance and without color. The bar-be-que pork was the only item that tasted good and had flavor. A subsequent test tray was obtained from the last cart being served during the breakfast meal and sampled by the survey team on 02/07/2025 at 8:36 AM. The temperature of the food was lukewarm. The meal consisted of hashbrowns, scrambled eggs, oatmeal with brown sugar and diced mangos. The hashbrowns tasted like they were seasoned with a salt substitute that was not appetizing. The scrambled eggs tasted flavorless and had large mushy curds. The oatmeal with brown sugar tasted bland and was soupy. The diced mangos were hard, unripe and had no fruit flavor. In an interview on 02/04/2025 at 11:34 AM, Staff W, Dietary Manager, stated they tasted the food while cooking or before tray line to assure that the food was palatable. Staff W stated that this was important for adequate meal consumption and maintaining nutrition for the healing of residents. During an interview on 02/04/2025 at 2:32 PM, a representative from the State Ombudsman office reported to the survey team residents had expressed to their office multiple concerns related to the food and had requested Staff W to attend the Resident Council meetings so the concerns related to the temperature and taste of the food could be discussed, and it took six months before Staff W attended. Reference WAC 388-97-1100 (1), (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Residents 14, 60, 90), reviewed for arbitration. This failure placed residents at risk of being uninformed of their rights, loss of legal protection, loss of right to pursue legal action and a diminished quality of life. Findings included . The Avalon Healthcare Management Patient and Facility Arbitration Agreement stated the parties understood that any dispute would be resolved by arbitration, and not by a lawsuit or court process. The policy further stated that the parties understood and agreed that by entering the arbitration agreement, they waived their constitutional right to a jury trial, and that by signing the agreement, they acknowledge they have read, and understood that the arbitrator's decision was binding, could not be appealed, and could be enforced by a court. <Resident 14> The 12/03/2024 admission agreement documented Resident 14 admitted to the facility on [DATE], was severely cognitively impaired and had diagnoses which included non-Alzheimer's dementia. Review of Resident 14's record showed the facility's arbitration agreement was e-signed on 12/04/2024 by Resident 14, and not their legal representative. Review of the progress notes from 11/27/2024 through 02/04/2025 showed Resident 14 was cognitively impaired, had dementia, was alert to self only, but able to make needs known at times. On 02/05/2025 at 9:47 AM, Resident 14 was observed sitting in their wheelchair in the hallway. When asked how long they had lived at the facility, the resident stated they had lived there since the facility opened. When asked what the date was today, the resident stated they didn't know. <Resident 60> The 06/06/2025 admission assessment documented Resident 60 admitted to the facility 05/31/2024, was severely cognitively impaired and had diagnoses which included Alzheimer's dementia. Review of Resident 60's record showed the facility's arbitration agreement was electronically signed on 06/03/2024 by the severly cognitively impaired Resident 60, and not their legal representative. Review of the progress notes from 05/31/2025 through 02/05/2025 showed Resident 60 was cognitively impaired, oriented to self only, but able to make needs known at times to staff. On 02/05/2025 at 11:53 AM, Resident 60 was observed sitting in their wheelchair in their room. When asked if the facility's arbitration agreement had been explained to them, and if they had signed the agreement, Resident 60 stated when they were in the Air Force, they were going to make decisions about the airplane. I am not the pilot, just a person on the plane. Resident 60 pointed to their amputated left knee and stated that was all they had left, there was no fuel. Resident 60 then made a gesture with their hands and then stated I had a tube this size, I can't find it. <Resident 90> The 11/26/2024 admission assessment documented Resident 90 admitted to the facility 11/20/2025, was severely cognitively impaired and had diagnoses which included non-Alzheimer's dementia. Review of Resident 90's record showed on 11/21/2025 the facility's arbitration agreement was e-signed by the resident and not their legal representative. A progress note on 11/21/2024, the day Resident 90 signed the arbitration agreement, Staff AA, Physician Assistant, documented Resident 90 had dementia and believed they were in Hood River, Oregon. In an interview on 02/05/2025 at 2:28 PM, the arbitration agreement was explained to Resident 90's power of attorney (POA, person who can make healthcare decisions when a person is unable to do so). The POA stated Resident 90 was confused and could not sign an arbitration agreement. The POA acknowledged the facility did not review the arbitration agreement with them, Resident 90's legal representative. In an interview on 02/05/2025 at 12:07 PM, Staff Z, admission Director stated the arbitration agreement was offered when residents admitted to the facility. When asked if the facility had a process in place or if an assessment was done prior to the agreement being offered to determine if a resident was cognitively able and/or had the mental capacity to enter into and sign an arbitration agreement, Staff Z stated they reviewed the residents records that were received when they admitted to determine if the resident was able to understand and sign the agreement, and if they were not, then the agreement would be offered to the resident's representative and/or Power of Attorney (POA). When asked if the resident and/or representative gave up the right to go to court if they entered into an agreement, Staff Z stated they did not believe they gave up the right, but they would ask Staff A, Administrator. In an interview on 02/05/2025 at 12:17 PM, Staff A, Administrator, confirmed arbitration was used to settle disputes and the resident and/or representative gave up the right to go to court if entered into an agreement, and it remained in effect if the resident discharged and admitted at a later date. Staff Z stated they did not know that the agreement would be valid after the resident discharged . When informed Residents 14, 60 and 90 all had severe cognitive impairments and had signed the arbitration agreements, Staff A stated the agreement should have been offered to the resident's representatives and/or POA. No Associated WAC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were implemented when indicated for 2 of 4 sampled residents (Residents 46 and 54 ) reviewed that had draining wounds and that hand hygiene was completed when indicated during 1 of 2 dining observations and 1 of 2 wound treatments observed. Additionally, N95 respirator-style masks were not donned correctly in accordance with the Centers for Disease Control (CDC) guidelines by 7 Staff (R, HH, II, JJ, X, T, and KK) when reviewing infection control practices, infection prevention and control policies were not reviewed yearly as required and a water management plan was not fully developed. These failures put residents and staff at risk of becoming ill with contagious viral and bacterial infections and spreading those illnesses to others. Findings included . The 04/02/2024 Centers for Disease Control (CDC) publication Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant organisms (MDROs) described Enhanced Barrier Precautions as the use of gown and gloves during high-contact resident care activities to prevent the transfer of MDROs from resident to resident through contact with staff hands and clothing. High contact resident care activities included dressing, bathing, showering, changing linens, providing hygiene, changing briefs, wound care, or care for devices such as catheters or feeding tubes. Enhanced barrier precautions were intended to remain in place for the duration of the resident's stay, or until the resolution of the wound or medical device that placed them at risk. The 05/16/2023 CDC publication, How to use Your N95 Respirator, stated N95 respirators (a special type of tight-fitting mask that filters particles) must form a seal to the face to work properly. The document showed the mask was to be placed under the chin, with the nose piece bar at the top, the top strap pulled over the head and placed near the crown, and the bottom strap placed at the back of the neck, below the ears. The straps were to lay flat, be untwisted, and not be crisscrossed. At the time of the survey, the facility had an outbreak of COVID-19, a highly contagious viral illness that caused difficult breathing, fever, body aches, lethargy and serious health consequences in vulnerable populations. <N95 Respirator Use> On 01/28/2025 at 9:49 AM, Staff R, Licensed Practical Nurse (LPN), was observed wearing an N95 mask with both mask straps placed above the ears towards the top of the head. On 01/28/2025 at 10:00 AM, Staff HH, LPN, was observed wearing an N95 mask with both straps positioned above the ears around the back of the head. On 01/28/2025 at 11:04 AM, Staff R, LPN, was again observed wearing an N95 mask with both straps positioned above the ears towards the top of the head. On 01/28/2025 at 11:42 AM , Staff II, Nursing Assistant (NA), was observed wearing a stocking hat and a neck scarf. Staff II wore an N95 mask with the top strap of the mask positioned on top of the head, over the stocking hat, the bottom strap of the mask was positioned over the back of the scarf. On 01/28/2025 at 12:01 PM, Staff II's N95 mask straps continued to be positioned incorrectly, with the top strap over the stocking hat and the bottom strap lying over the back of the scarf. Several other staff members were present in the hallway and nobody corrected or redirected Staff II about the positioning of the straps. On 01/28/2025 at 12:03 PM Staff JJ, Occupational Therapist, was observed wearing an N95 mask with the top strap positioned correctly, but the bottom strap was positioned over their long hair, and not around the back of the neck. On 01/28/2025 at 12:16 PM, Staff X, NA, was observed wearing an N95 mask with both straps positioned above the ears on the back of their head. When asked about the positioning of the straps, Staff X stated they had received training on PPE, and knew one strap was supposed to be on the top of the head, and the bottom one behind the neck, but it was inconvenient to place the straps like that because of their hair clip. On 01/28/2025 at 12:27 PM, Staff II donned a gown and gloves prior to entering room [ROOM NUMBER] to deliver lunch trays. Staff II removed the stocking hat and positioned the top strap correctly prior to entering the room, but the bottom strap was still lying over the back of the neck scarf. At 12:32 PM, Staff II exited the room, doffed the gown/gloves and N95, put the stocking hat back on, donned a new N95 and positioned the top strap of the mask over the stocking hat on the top of head. Staff II stated they had received training regarding PPE and the wearing of N95 masks. When informed about the proper placement of the N95 straps, Staff II stated they were not aware that the top strap needed to be directly on the head and wearing over a hat or other items could interfere with the mask creating a seal. Staff II then positioned the straps correctly. On 01/31/2025 at 9:32 AM, Staff X, NA, was observed walking down the hall wearing an N95 mask with both straps positioned on the top of the head. When Staff X saw the surveyor, they adjusted the bottom strap behind the neck. On 02/03/2025 at 10:01 AM, Staff T, LPN, was observed wearing an N95 with the straps placed behind their neck. Staff T stated the straps slid down, so they wore them behind the neck to get a tight seal. On 02/05/2025 at 11:55 AM, Staff KK, NA, was observed wearing both straps of their N95 around the top of the head, above the ears. Staff KK stated one strap was supposed to be behind the neck, but it bothered their skin to wear it like that and started to cause a rash. Staff KK expressed understanding about the importance of wearing the straps correctly to get a better seal. On 02/05/2025 at 2:21 PM, Staff KK was observed with their N95 mask below their chin. In an interview on 02/05/2025 at 10:20 AM, Staff R, LPN, was again observed with both N95 straps positioned above the ears. When asked about the placement of the straps, Staff R felt the straps and stated it was incorrect and positioned them properly. In an interview on 02/07/2025 at 9:10 AM, observations and concerns related to the improper wearing of N95 masks and not following CDC guidelines during an active COVID-19 outbreak was discussed with Staff A, Administrator, Staff B, Director of Nursing (DNS), and Staff LL, Corporate Registered Nurse (RN). Staff A acknowledged the concerns. <Enhanced Barrier Precautions> In an observation on 01/31/2025 at 8:54 PM, Resident 54 was lying in bed watching television. The resident was not wearing their foam boot to their left heel and there was yellow drainage from their heel wound on the pillowcase. There was no enhanced barrier sign on the resident's door and no PPE nearby. Similar observations of Resident 54 without an enhanced barrier sign on the door were made on 02/03/2025 at 9:50 AM, 02/05/2025 at 11:28 AM and 02/06/2025 at 1:30 PM. In an interview on 02/06/2025 at 2:57 PM, Staff B, DNS, stated residents with wounds needed to be on enhanced barrier precautions and this was important to stop the spread of germs. In an observation and interview on 02/05/2025 at 11:54 AM, Resident 46 was lying in bed. The resident had bloody drainage on their shirt under their right armpit. The resident stated they had a sore under their armpit. Resident 46 did not have an enhanced barrier sign on their door and there was no PPE nearby. Review of the January 2025 medication administration record showed a 01/17/2025 provider order to cleanse the right armpit with wound cleanser and to apply a dressing every day and as needed. In an interview on 02/06/2025 at 2:22 PM, Staff C, Resident Care Manager, stated Resident 54 should have been on enhanced barrier precautions. <Wound Care> In an observation on 02/06/2025 at 1:30 PM, Staff BB, RN, put on a pair of gloves, touched Resident 54's foam boot, adjusted the resident's bed with their bed controls, obtained a pad out of the resident's bag, touched items in a bin that was filled with treatment supplies, cut the resident's pad in half, lifted the resident's left heel, opened betadine swabs and applied it to their heel while wearing the same pair of gloves. Staff BB, wearing the same pair of gloves, placed the resident's foot back into the foam boot, placed pillows under their leg, then removed their gloves, turned the light off in the room and then performed hand hygiene. During an interview on 02/06/2025 at 1:42 PM, Staff BB stated they should have changed their gloves and performed hand hygiene before the wound care, and this was important to prevent the spread of germs. <Dining Service> In an observation on 01/28/2025 at 11:03 AM, Staff W, Dietary Manager, passed a tray to a resident, then touched another resident's glass of juice to move it, without performing hand hygiene, passed another tray, then touched the glass on the serving cart, touched another resident's plate, opened the resident's ketchup, picked up the salt and pepper holder and moved it to another location, then sanitized their hands. In an interview on 01/28/2025 at 11:27 AM, Staff W stated hand hygiene should have been completed after every tray was passed, and after touching things such as cups, clothing, and the glass on the serving cart. During an interview on 02/07/2025 at 1:17 PM, Staff D, Infection Preventionist, stated all nurses should be able to determine who needed enhanced barrier precautions. The expectation would be for staff to follow the guidance on the enhanced barrier sign, and this was important because it breaks the chain of infection and stops the spread of germs. Staff D stated staff needed to clean their hands between every person and when they removed their gloves. <Infection Prevention Program policies and procedures> A review of the Infection Prevention policies documented the policies were created or revised on the following dates and were not current: -Antibiotic Stewardship (11/2017, revised 03/2019) -Antibiotic Stewardship Program (05/2019, revised 11/2020, 04/2022) -Infection Prevention and Control Program (11/2017, revised 06/2022) -Infection Preventionist (09/2018) -Influenza and Pneumococcal Immunizations (11/2017, revised 06/08/2022) -Standard Precautions, Enhanced Barrier Precautions and Transmission-based Precautions (07/26/2022) -Vaccination Requirement for SARS-Cov-2 (COVID-19) (01/27/2022, revised 03/21/2022, 06/29/2022) During an interview on 02/07/2025 at 11:13 AM, Staff A, Administrator acknowledged the policies were not current. <Water Management Plan> On 02/05/2025, documents for the facility water management plan were requested. A document titled, Risk Management Plan for Legionella Control in the Operation and Management of the Water Systems of 'Facility Name' was provided. The document was a template and had not been completed with facility specific information. On 02/07/2025 at 11:13 AM, Staff A, Administrator, stated they would check to see if the completed document was in the maintenance department. Staff A returned with a binder that included hot water temperature checks that had been done weekly and a sample of the water chlorine test kit that the facility used to test chlorine levels in their water system. After review with the surveyor, Staff A acknowledged that the water management plan needed to be further developed so that all the elements that were required were included. There had been no cases of Legionnaires disease since the prior survey. Reference: WAC 388-97-1320 (2)(b), 1320 (1)(c)

Based on observation, interview, and record review the facility failed to store, discard and distribute food, and monitor temperatures of foods being served in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised 01/18/2023, showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be discarded as directed by the food manufacturer's use-by-date. The U.S. FDA Food Code 2022 also showed that there was an increased risk of contamination when food was held, cooled and reheated at improper temperatures. Thus, temperatures of food must be taken and monitored. Records must be maintained to verify food temperatures are within the parameters required for food safety. <Food Storage> During a kitchen observation and interview on 01/28/2025 at 9:07 AM, the walk-in refrigerator contained a crate of approximately 36 pasteurized eggs with an expiration date of 09/17/2024. Staff W, Dietary Manager, acknowledged that the eggs were expired and quickly disposed of the crate of eggs. In an interview on 02/04/2025 at 12:00 PM, Staff W stated the eggs should have been discarded. Staff W stated that it was important for the prevention of bacterial growth and resident illness. <Food Preparation and Service> During an observation of a tray line service held in the dining room on 02/04/2025 at 10:54 AM, Staff FF, Assistant Dietary Manager, began using a digital thermometer to check the temperatures of the food items resting in the steam table. Staff FF checked the food temperatures for the food items being served from the steam table. In an observation and interview on 02/02/2025 at 11:10 AM, a resident was observed eating a chef's salad in the dining room. Staff FF did not check the temperature for the chef's salad. Staff W stated the salad was brought out of the refrigerator in the kitchen. During an observation of a tray line service held in the kitchen on 02/04/2025 at 11:18 AM, Staff FF unloaded the food items that were served in the dining room off a cart and onto the steam table in the kitchen. No staff checked the temperatures of the food from the steam table before the start of tray line. When prompted by the surveyor, Staff W stated the facility did not check temperatures at the steam table in the kitchen. In an interview on 02/04/2025 at 11:45 AM, Staff W stated the facility did not check temperatures of foods after the first tray line was completed in the dining room. They stated the second tray line completed in the kitchen consisted of randomly checking temperatures of various foods and those temperatures were not documented. Staff W stated that it was important to monitor temperatures for prevention of food contamination and bacterial growth. Record review on 02/04/2025 of the temperature logs from 01/27/2024 through 02/04/2025 for both serving locations (dining room and kitchen) showed no documentation of temperatures for the kitchen tray line. Reference: WAC 388-97-1100(3), -2980

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegations of potential misappropriation were reported immediately to facility administration and the State Survey Agency as required, for 1 of 5 sampled residents (Resident 9) reviewed for abuse/neglect. This failure placed the resident at risk for abuse. Findings included . Review of Resident 9's November 2024 progress notes showed an entry on 11/14/2024 by Staff C, Social Services, which documented the resident reported an allegation that a staff member was rough with the resident. Review of the facility's Incident Log for November 2024 did not show any entries related to Resident 9. In an interview on 12/10/2024 at 2:29 PM Staff C confirmed Resident 9 reported an allegation of abuse to them on 11/14/2024. Staff C stated they reported the resident's allegation the same day and unidentified staff were investigating the incident while Staff C was out of the facility. Staff C stated they returned to the facility on [DATE] and were directed to report the allegation of abuse to the State Survey Agency at that time. Staff C stated they typically reported abuse allegations to Staff A, Administrator, but they were unable to recall who they reported the initial abuse allegation to and/or who directed them to report the incident. In an interview at 2:55 PM the same day, Staff A stated they were notified of Resident 9's allegation of abuse during a clinical meeting on the morning on 11/18/2024 and they immediately reported the incident to the State Survey Agency as required. Staff A was asked for any additional information related to the delay in reporting after the initial allegation on 11/14/2024. Staff A reviewed the documentation present in Resident 9's progress note (see above) and stated they had not previously aware of the delay in reporting. Reference: (WAC) 388-97-0640 (5)(a)

Based on interview and record review the facility failed to provide the necessary care and services for 1 of 4 residents (Resident 3), reviewed for wound care. Failure to perform wound treatments as ordered placed the resident at risk for delayed wound healing, worsening of wounds, and/or potential infection and a diminished quality of life. Findings included . Review of the October 2024 Treatment Administration Record for Resident 3 showed an order for wound vacuum therapy (treatment consisting of a specialized dressing and a machine that applies gentle suction to a wound to aid in healing) at 125 mmHg (millimeters of mercury; a unit of pressure). The order showed the dressing was to be changed every Tuesday, Thursday, and Saturday. Review of Resident 3's October 2024 progress notes showed the following: - On 10/09/2024 the resident admitted to the facility with an open surgical wound to their abdomen that required a wound vacuum dressing, which would be applied by the wound nurse the following day (10/10/2024). - On 10/11/2024 Staff D, Registered Nurse, documented the resident's wound vacuum dressing was removed and replaced with a wet-to-dry dressing. The note did not include why the ordered wound vacuum dressing was removed, when it would be reapplied, and/or if the medical provider was notified of the change in dressing type. -On 10/12/2024 Staff E, Licensed Practical Nurse, documented the resident was concerned about the removal of their wound vacuum dressing after eight hours when they were supposed to receive it for 24 hours. In an interview on 10/23/2024 at 2:31 PM Staff B, Director of Nursing, stated they were notified on 10/12/2024 that Resident 3 had concerns with the care of their abdominal wound and their wound vacuum dressing, so they came came into the facility to investigate. Staff B stated staff caring for Resident 3 were not familiar with wound vacuum therapy and did not know the wound vacuum dressing and machine were to be applied continuously. Staff B stated staff had interpreted the dressing change days (Tuesday, Thursday, and Saturday) as the only days the wound vacuum was to be applied. Staff B stated they applied the resident's ordered wound vacuum treatment and educated the assigned nurse on the resident's wound vacuum therapy. In an interview on 12/10/2024 at 3:01 PM Staff A, Administrator, stated the facility had identified concerns with skin/wound care and had been providing staff with additional training. Documents related to staff wound education were requested. On 12/11/2024 the facility submitted a document titled, ONE-ON-ONE EDUCATION, dated 10/12/2024, which showed wound vacuum therapy education was provided to Staff F, Licensed Practical Nurse. No documentation was provided showing education on wound vacuum therapy for Staff D, Staff E, and/or additional staff responsible for wound care. Reference: (WAC) 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 1 of 3 sampled residents (Resident 1), reviewed for misappropriation. This failure placed residents at risk for pain and a diminished quality of life. Findings included . Review of the pharmacy policy titled, LTC Facility's Pharmacy Services and Procedure Manual, revised 08/01/2024, showed the facility should maintain separate records on controlled substance medications and medications with a potential for abuse or diversion. The facility should reconcile the total number of controlled medications on hand, add newly received medications to the inventory and remove medications that are completed or discontinued from the inventory, pursuant to the controlled substance shift count sheet (logbook). Review of a 09/11/2024 facility investigation report showed Resident 1 reported receiving a pain pill that dissolved in their mouth three times during the past month from Staff B, Registered Nurse. Per the investigation the resident was alert and oriented and knew their medications, which did not normally dissolve. The facility determined Resident 1 was not prescribed any medications that dissolved, and controlled substance medications were signed out of the logbook for the resident and then not documented as administered in the Mediation Administration Record (MAR). Additionally, the facility found controlled substance medications for additional unsampled residents were missing and/or destroyed by Staff B without a second nurse present to witness the destruction. The investigation report documented that a reasonable suspicion of drug diversion (misappropriation) was substantiated, and Staff B was terminated from employment. In an interview on 10/09/2024 at 2:21 PM, Staff A, Director of Nursing, stated that after Resident 1 reported diversion of their controlled substance pain medication a thorough investigation was completed by the facility and inconsistencies with Staff B's medication administration were identified. Per Staff A, Staff B documented removing controlled substance medications from the logbook but did not sign them as administered on the MAR, and Staff B destroyed controlled substances by themself. In a follow-up interview at 4:39 PM the same day, Staff A stated the destroyed medications belonged to residents who had already gotten replacements ordered and that no other residents reported missing medications and/or uncontrolled pain. Staff B was unavailable for interview. Reference: (WAC) 388-97-0640 (2)(a), (3)(c)(d)

Based on interview and record review, the facility failed to notify the provider of a change in a resident's oxygen saturations for 1 of 4 sampled residents (Resident 1) reviewed for notification of changes. Failure to notify the provider of low oxygen saturations did not allow for interventions to be put in place prior to the resident's departure to the hospital. Findings included . A review of the record documented Resident 1 had diagnoses including pneumonia and heart failure (inability for the heart to pump blood efficiently to meet the needs of the body). The 08/22/2024 admission assessment documented Resident 1 was cognitively impaired, wandered and had behavioral symptoms. The 08/17/2024 care plan documented Resident 1 had altered cardiovascular status; Staff were instructed to assess the resident for shortness of breath, monitor vital signs and notify the provider of significant abnormalities, and apply oxygen at 2 liters by nasal cannula as needed. The 08/16/2024 hospital discharge orders included to give oxygen at 1-2 liters as needed for oxygen saturations less than 92%. The 08/17/2024 facility provider orders instructed staff to check oxygen saturations and give oxygen at 2 liters as needed for dyspnea (difficulty breathing). A review of Resident 1's oxygen saturations obtained daily from 08/17/2024 to 08/25/2024 showed the resident's oxygen saturations were maintained above 90% on room air until 08/25/2024. Saturations documented on 08/25/2024 showed oxygen saturations were maintained at 92% with the use of supplemental oxygen administration. The 08/24/2024 at 6:39 PM progress note by Staff G, Licensed Practical Nurse (LPN), documented Resident 1 had increased anxiety and was unable to follow simple commands. The family was requested to come and sit with the resident. At 8:13 PM, Resident 1's oxygen saturation was checked and was found to be low at 85%. Oxygen was applied, and their saturation improved to 94%. The progress note did not include if the provider was notified of the low oxygen level. The 08/25/2024 at 2:55 AM progress note by Staff H, LPN, documented a loud noise was heard and Resident 1 was found standing in the corner of their room and had knocked over their oxygen concentrator (the machine that delivers supplemental oxygen). The note detailed that the resident was assisted back to bed, was uninjured but was visibly exerted. At 4:50, Staff H documented Resident 1's oxygen saturation was 83% on the concentrator that was knocked over. The concentrator was replaced, and when rechecked, Resident 1's oxygen saturation was 92% on 2 liters of supplemental oxygen, but their saturation dropped to 88% when mouth breathing. The note did not include if the provider had been notified of the low oxygen saturations. During an interview on 09/30/2024 at 8:57 AM, Staff G stated on the night of 08/24/2024, Resident 1 was in bed and was grabbing at something in the air, so Staff G checked their oxygen saturation, and it was low. Staff G stated they already had an order to apply oxygen so they did and the resident's saturation level came up so they did not attempt to notify the provider. Staff G stated the resident's breathing was normal and there was no other indication of a change in their status except that they were grabbing at the air. During an interview on 09/30/2024 at 11:34AM, Staff H stated on 08/25/2024, Resident 1 had a low oxygen saturation but would not leave their oxygen on. Staff H stated the resident kept repeating phrases over and over until they were out of breath, so their saturations would go low. Staff H stated they had not discussed the low oxygen saturations with the provider. During an interview on 10/02/2024 at 10:02 AM, Staff B, Director of Nursing, stated Resident 1 was easily agitated and impulsive. Staff B stated the resident's oxygen saturations were fine if they left their oxygen on, but they kept pulling it off. The Resident's confusion and low oxygen saturations could have been a sign that there was something else going on with Resident 1 so should be discussed with the provider. Reference: WAC 388-97-0320

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess a resident for removal of an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) for 1 of 3 sampled residents (Resident 9), reviewed for catheter use. Additionally, the facility failed to ensure indwelling urinary catheters were properly secured for 2 of 3 sampled residents (Resident 8 and 9). This failure placed the residents at increased risk of acquiring potentially preventable catheter associated urinary tract infections, pain, and urethral trauma. Findings included . Per the Centers for Disease Control 03/25/2024 Summary of Recommendations of the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html) indwelling catheters should be properly secured after insertion to prevent movement and urethral traction (pulling). <Resident 9> Review of the facility's policy titled, Urinary Catheterization, dated April 2021, showed a resident who entered the facility with an indwelling urinary catheter would be assessed for removal of the catheter as soon as possible unless their condition indicated that catheterization was necessary. Per the policy the resident would be involved in the discussion of the risks and benefits of the use of the catheter and the medical provider would document the rationale for the use of the catheter. Review of the 06/12/2024 admission assessment showed Resident 9 had an indwelling urinary catheter, no diagnosis of a neurogenic bladder (condition that affects bladder function due to nervous system damage or disease), and no prognosis of life expectancy less than six months. Review of a bowel and bladder evaluation, dated 06/06/2024, showed Resident 9's urinary continence was not rated due to use of a catheter. The assessment was marked as no for a current toileting program or trial. Review of the progress notes from June 2024 to September 2024 showed no documentation regarding whether Resident 9's urinary catheter had been assessed for removal and/or was determined to be necessary. Additionally, the notes showed no documentation the use of the urinary catheter had been discussed with the resident. In an interview on 09/10/2024 at 4:04 PM Resident 9 stated they had major problems with their urinary catheter including pain and bleeding for the past month. The resident stated they were not sure why the catheter was still in place or whether the facility was arranging for a urinary specialist to review their use of the catheter. Observation showed the resident's catheter bag and tubing had bright red urine with red sediment (particles in the urine). In an interview at 4:18 PM the same day, Staff N, Resident Care Manager, stated Resident 9 had blood in their catheter for two days and had complained of urethral pain, and the provider had ordered a urinary laboratory test that day. Staff N stated the resident had recurrent urinary tract infections and they were not sure why the resident had a catheter as they did not have a diagnosis requiring one. On 10/02/2024 at 1:26 PM Resident 9's urinary catheter was observed with Staff O, Licensed Practical Nurse. The urinary catheter tubing was not secured, and the resident jerked in bed and exclaimed, Oh! when Staff O touched the tubing. Staff O applied a securement device to the resident's leg then secured the catheter tubing and asked the resident if they were having pain. The resident stated they got a sharp pain in their bladder whenever the catheter was touched/moved, and Staff O stated the securement device should help. <Resident 8> Review of the admission assessment dated [DATE] showed Resident 8 had a diagnosis of benign prostatic hyperplasia (enlarged prostate; a condition that can block the flow of urine out of the bladder) and used an indwelling urinary catheter. Review of the May and June 2024 progress notes showed Resident 8 had a catheter inserted for difficulty emptying their bladder and a failed attempt at bladder re-training. Per the notes the resident had irritation to the catheter insertion site, discomfort to their penis, and bloody urine in the catheter collection bag intermittently. The notes did not indicate if the resident's catheter tubing was secured when the resident had complaints of urethral pain. Review of the 06/12/2024 urology (doctor who specializes in care of the urinary tract) notes showed the resident continued to report discomfort associated with their urinary catheter. Per the urology notes, the catheter was uncomfortable due to lack of securement and an adhesive securement device was applied. In an interview on 09/09/2024 at 5:47 PM a representative for Resident 8 stated the resident had reported concerns about the care of their urinary catheter while at the facility, including frequent bloody urine and pain associated with their catheter. In an interview on 09/10/2024 at 4:25 PM, Staff C, Social Services, confirmed Resident 8 did have complaints about pain and blood in their catheter throughout the course of their stay at the facility. Reference: WAC 388-97-1060 (3)(c)

Based on interview and record review the facility failed to ensure 3 of 5 Licensed Nurses (Staff J, K, and L) were evaluated by the facility for competency with skills and techniques prior to working with residents with indwelling urinary catheters (flexible tube inserted into the bladder to drain urine). This failure placed residents at risk for clinical complications. Findings included . Review of the May 2024 Treatment Administration Records (TAR) for Resident 8 showed Staff K and L, Licensed Practical Nurses (LPNs) were responsible for care and monitoring of the resident's indwelling urinary catheter. Review of the May 2024 progress notes showed Staff J, LPN, was responsible for monitoring Resident 8's bladder and potentially placing a urinary catheter based upon the resident's status. Review of the June 2024 TAR for Resident 10 showed Staff J, K, and L all provided care and monitoring of the resident's indwelling urinary catheter. Per the TAR, each LPN flushed and irrigated the resident's catheter (procedure to remove any substances clogging the catheter). In an interview on 09/09/2024 at 5:47 PM a representative for Resident 8 stated the resident had concerns related to the competency of the staff who inserted and monitored their urinary catheter. In an interview on 09/11/2024 at 10:02 AM Resident 10 stated they had concerns regarding the competency of the nurses who provided them urinary catheter care. In an interview on 10/02/2024 at 12:41 PM Staff M, Registered Nurse/Staff Development Coordinator, stated new staff were paired with an experienced staff member for training and evaluation of their clinical skills, which were then documented on a two-to-three-page skills check off sheet, then turned in to Staff M for evaluation. Staff M stated staff were to be evaluated by another staff of equal or higher competency before independently performing skills (such as urinary catheter care). Information regarding competency evaluations for Staff J, K, and L was requested. In a follow-up interview at 1:34 PM the same day, Staff M stated Staff J and K no longer worked for the facility and did not have any documentation of clinical skills competency evaluations in their files. Staff M stated Staff L also did not have any documentation of a clinical skills competency evaluation in their file, and Staff M had reached out to them on 08/05/2024 (approximately two months prior) to come in for a skills evaluation. In an interview at 4:46 PM on 10/02/2024 Staff A, Administrator, and Staff B, Director of Nursing, stated Staff M was new to the position and was working on staff skills and competency evaluations. Refer to F-690 for additional information. Reference (WAC) 388-97-1080(1)(9)(10)(c)

Based on interview and record review, the facility failed to ensure blood pressure medications were held when indicated for 1 of 3 sampled residents (Resident 1) reviewed for medication administration. This failure put residents at risk for unintended health consequences related to low blood pressures. Findings included . A review of the record documented Resident 1 had diagnoses including hypertensive kidney disease (kidney damage caused by long term high blood pressure) and primary pulmonary hypertension (high blood pressure that affects the arteries of the lungs and causes the heart to work harder to pump blood to the lungs). The 08/22/2024 admission assessment documented Resident 1 was cognitively impaired and relied on assistance of staff for most of their activities of daily living (ADLs). A review of the 08/2024 medication administration record (MAR) documented Resident 1 had the following medication orders: -Lisinopril 40 milligrams (mg) once daily for hypertensive kidney disease; hold medication and notify the provider if the systolic blood pressure (SBP, the upper number of a blood pressure reading) is below 100 or if the heart rate is less than 50. -Metoprolol Succinate 24 hour extended release 25mg once daily for hypertensive kidney disease; hold medication and notify provider if SBP is less than 100 or heart rate is less than 50. On 08/20/2024, the MAR showed Resident 1's blood pressure reading was 99/59, and the Lisinopril and Metoprolol were held. Further review of the MAR revealed that on 08/21/2024, Resident 1's blood pressure reading was 94/55, indicating the Lisinopril and the Metoprolol were to be held for a SBP of less than 100 as ordered. The medications were checked that they were administered. A review of nursing progress notes had no documentation that the provider was notified that Resident 1's medications were held for a low SBP on 08/20/2024, or that the Resident's medications should have been held on 08/21/2024 but were not. A review of the provider communication binder (a book staff used to notify the provider group of non-emergent occurrences related to resident cares or requests) had no entries regarding Resident 1's low SBP on 08/20/2024 and 08/21/2024, or that the medications should have been held but were not on 08/21/2024. During an interview on 09/30/2024 at 10:10 AM, Staff E, Resident Care Manager, stated if there were instructions to hold medications for certain parameters, they expected the staff to hold the medications and notify the provider. Staff E reviewed Resident 1's record and was unable to find documentation that Resident 1's SBP was low and the medications were held, or that the medications were given but should have been held. During an interview on 10/02/2024 at 10:02 AM, Staff B, Director of Nursing stated if there were parameters for medications to be held, they expected staff to hold the medications and notify the provider. Staff B stated it was important to hold the medications when indicated to prevent a resident's blood pressure from getting even lower. Reference: WAC 388-97-1060(3)(k)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure showers were completed as careplanned and call lights were answered timely for 3 of 4 sampled residents (5, 6, 7) reviewed for activities of daily living (ADLs). This failure put residents at risk for skin breakdown, incontinence episodes, or unmet care needs. Findings included . <Resident 6> The 08/28/2024 quarterly assessment documented Resident 6 had diagnoses including morbid obesity and diabetes. Resident 6 was cognitively intact, and was dependent on staff for toileting, personal hygiene and bathing. The 11/29/2022 care plan documented Resident 6 had an ADL self-care deficit; They required substantial/maximum assistance of 1 staff to provide bathing/showering. Resident 6 preferred showers twice weekly and as necessary. The undated Nursing Assistant Care Card ([NAME]) documented Resident 6 preferred twice weekly showers on Tuesdays and Fridays. The Nursing Assistant Showering Task documentation reviewed for the previous 30 days from 08/29/2024 to 09/27/2024 documented Resident 6 received showers on Fridays 08/30/2024, 09/06/2024, 09/13/2024 and 09/20/2024. During an interview on 09/25/2024 at 2:07 PM, Resident 6 stated the facility staff were mostly helpful, some were not, but the resident declined to mention any names. Resident 6 stated they used to get showered twice a week but lately it was only once a week on Fridays because the facility had no shower aide. They preferred to be showered at least twice a week. Resident 6 stated it took staff time to get to them when they rang their call bell, and then the staff had to change their whole bed because it took too long for the staff to come and by then their linens were soiled. Resident 6 stated they have gotten used to waiting 30 minutes for their call light to be answered. Resident 6 stated they would be given a washcloth and water to wash their hands and face but only if they requested it. <Resident 5> The 09/02/2024 annual assessment documented Resident 5 had diagnoses including rheumatoid arthritis (painful swelling in joints that can cause the joints to be deformed) and macular degeneration (eye disease that causes vision loss). Resident 5 was cognitively intact, able to participate in their care decisions and was independent for most ADLs. The 11/08/2023 care plan documented Resident 5 was resistive to care by refusing showers. Staff were to allow the resident to make decisions about their care, offer assistance, and if refused, offer again in 5-10 minutes, provide a consistent routine and caregivers as much as possible. On 09/25/2024 at 1:50 PM, Resident 5 was observed in their room in their wheelchair. Their fingers were curled in, and the resident communicated by writing on a white board. Resident 5 stated the staff showered them every three days or so, but they were more concerned about their call light not getting answered. Resident 5 stated they waited up to 30 minutes for their call light to be answered, and if not, they had to get in their wheelchair and go down the hall and look for staff if they felt it was something urgent. They stated this happened most often on the overnight shift. <Resident 7> The 07/13/2024 annual assessment documented Resident 7 had diagnoses including stroke with paralysis on one side of their body. Resident 7 was cognitively intact, did not refuse care, and required substantial assistance for toileting, personal hygiene and was dependent on staff for showering. The 08/24/2023 care plan showed Resident 7 had an ADL self-care deficit; they required maximum assistance of 1 staff to provide showers twice weekly and as necessary. The Nursing Assistant Showering Task documentation reviewed for the previous 30 days from 08/29/2024 to 09/27/2024 documented Resident 7 received showers on Friday 08/30/2024, Saturday 09/07/2024, Friday 09/13/2024, Thursday 09/19/2024and Tuesday 09/24/2024. During an interview on 09/30/2024 at 5:20 AM, Staff I, Nursing Assistant (NAC), stated they had just worked a double shift to help with staffing. Staff I stated it depended on who they worked with if they were able to get all their tasks done. During an interview on 09/30/2024 at 7:20AM, Staff P, NAC, stated there were normally two or three NACs for the [NAME] unit because there were many call-ins. Staff P stated they tried to do what they could for showers; residents were supposed to have two showers a week but they had not had any shower aides lately. They tried to answer call bells timely but it depended on how many staff they had. During an interview on 09/30/2024 at 9:55 AM, Staff Q, NAC, stated at the beginning of their shift, they had four NACs, but one was pulled to do showers, so now they had an assignment of 17 residents. Staff Q stated residents were to be showered twice weekly but both the shower aides were gone so showers were not getting done. During an interview on 10/02/2024 at 10:02 AM, Staff B, Director of Nursing, stated both of the shower aides were out on leave and a new one had just been hired. The facility had also provided bonus moneys when staff picked up an extra shift. The facility was also working with a staffing agency to bring in 5 additional NACs. Staff B stated they had no way on the [NAME] unit to track how long call bells rang like they did on the East unit, but all staff were expected to answer call bells. Staff B stated they expected call bells to be answered in 10 minutes or less and expected residents to get showered twice weekly as care planned. Reference: WAC 388-97-1080(1), 1090(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan to address assessed risks for accident hazards for 2 of 8 sample residents (Resident 2 and 8) reviewed for care planning. This failure placed residents at risk of unmet care needs. Findings included . <Resident 2> Review of the 06/10/2024 hospital discharge orders showed Resident 2 had dementia (group of symptoms affecting memory, thinking, and social abilities) and was at risk for falls. A facility fall assessment dated [DATE] showed the resident received a fall risk score of 11, which indicated they were at risk for falls. Review of the care plan initiated 06/13/2024 showed no interventions related to the resident's identified fall risk. In an interview on 08/26/2024 at 1:07 PM Staff E, Resident Care Manager, stated Resident 2 was at risk for falls due to their fall assessment score and confirmed a care plan related to fall prevention was not present in Resident 2's record. <Resident 8> Review of a 08/12/2024 facility wander risk assessment for Resident 8 showed they had a diagnosis of dementia and received a wandering/elopement risk score of 9, which placed them in the category of at risk for wandering/elopement. The care plan section of the assessment was marked as no. Review of the August 2024 progress notes for Resident 8 showed on 08/14/2024 the resident reported to Staff C, Social Services, that they did not belong in the facility and I just want to be free, I want to go home. Per the note the resident was severely confused but agreed to wait for staff to arrange a safe discharge. Review of Resident 8's care plan, initiated 08/12/2024, showed interventions related to risk for wandering and elopement were added on 08/24/2024. In an interview on 08/26/2024 at 11:30 AM, Staff A, Administrator, and Staff B, Director of Nursing, confirmed Resident 8 was assessed as at risk for wandering/elopement on 08/12/2024. Staff B stated the staff member who completed the assessment felt the resident was not at risk for wandering/elopement, despite their assessment score, due to the resident following directions at that time. Staff A and B confirmed a care plan with interventions to prevent wandering/elopement was not developed until after the resident had an elopement on 08/24/2024. Reference: WAC 388-97-1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to promptly resolve resident grievances and provide written grievance decisions for 3 out of 3 sample residents (Resident 2, 6, 7), reviewed for grievances. In addition, the facility failed to establish a grievance policy with all the required components. These failures placed the residents at risk of having unresolved grievances and a diminished quality of life. Findings included . Review of the June 2024 through August 2024 Grievance Report Log showed blank spaces under the disposition of grievances for the following: -06/11/2024 Resident 7 aid concerns -06/17/2024 Resident 2 ants -07/29/2024 Resident 6 missing glasses -08/13/2024 Resident 7 activities and wound rounds -08/14/2024 Resident 7 nurse concerns -08/14/2024 Resident 7 food -08/15/2024 Resident 7 color urine In an interview on 08/23/2024 at 10:59 AM Resident 7 stated they had filed multiple complaints about their care at the facility and had provided grievance forms to Staff D, Social Services, and Staff F, Resident Care Manager, but the facility had never responded to any of their concerns. Review of the associated grievance forms showed Resident 2's ants concern had been followed up with pest control, but no resolution was provided to the resident. The associated grievance form for Resident 6's missing glasses documented the resident's representative was verbally informed the facility would reimburse the missing property. A sticky note on the form documented needs to be reimbursed. Of the five listed grievances for Resident 7, one did not have an associated grievance form, one was marked as resolved but no follow-up for the resident was listed, and three were marked as resolved with verbal follow-up provided to the resident. In an interview on 08/23/2024 at 12:13 PM Staff A, Administrator, stated the facility was still in the process of following up on reimbursement for Resident 6's glasses. At 12:38 PM the same day Staff A stated Resident 2's grievance had been followed up with the resident/resident's representative verbally but had not been documented. Staff A also stated Resident 7 had many grievances and not all of them had been resolved yet as the investigations required additional information from multiple departments. Per Staff A, the facility had identified issues with timeliness of grievance follow-ups several months previously and were still in the process of fixing the grievance system. In an interview at 3:53 PM Staff A and Staff B, Director of Nursing, stated they did not know that written grievance resolutions were required to be provided to residents and was not listed in the facility's policy. The facility's policy related to grievances was requested but not provided. Reference WAC 388-97-0460

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) and/or their representatives, reviewed for quality of care, received timely notification of a transfer to the hospital when the resident's condition declined. This failure placed the resident at risk of delayed access to care, inability to participate in care planning, and diminished quality of life. Findings included . Review of a 05/17/2024 nurse progress note showed Resident 2 was transferred to the hospital at 1:15 AM that day due to a change of condition. Per the note the resident was less alert than usual, disoriented, was pale, and their vital signs were outside the normal range, including a blood pressure that was unobtainable. The note showed the nurse on the oncoming shift was notified of the resident's transfer later that morning, and a voicemail was left for the resident's representative. There was no documentation showing the time of the representative notification. In an interview on 05/28/2024 at 10:42 AM a representative for Resident 2 stated they were not notified of the resident's transfer to the hospital until more than five hours afterwards, after they had already started receiving automated messages from the hospital showing tests were being completed for the resident. In an interview at 10:49 AM the same day Resident 2 stated they were shipped out of the facility for an emergency in the middle of the night and that they were under a lot of physical and mental stress. The resident stated they were not sure where they were or what was happening and needed a representative when they arrived at the hospital. In an interview on 05/30/2024 at 1:15 PM, Staff D, Licensed Practical Nurse, stated they had called emergency medical services to transport the resident to the hospital on [DATE] due to a rapid decline in their medical condition. Staff D stated after the resident was transferred they attempted to call the resident's representative, but it was a busy night and they were not able to call until later in the shift. Staff D was not able to provide a time and stated they called and left a message later in the morning. In an interview on 05/28/2024 at 11:38 AM Staff A, Resident Care Manager, stated if a resident had a non-emergent issue in the middle of the night staff could wait until the morning to notify their family of the issue, but if a resident was transferred to the hospital their family/representative should be notified immediately. Staff A stated Resident 2 was self-responsible and had gone back and forth on how much they wanted their representative involved in decision-making, but since the resident had an altered mental status and was not able to advocate for themself, their representative should have been notified of the hospital transfer immediately. Reference: (WAC) 388-97-0320 (1)(b)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess for and accommodate resident preferences and intolerances for 1 of 3 sampled residents (Resident 2) reviewed for nutrition. This failure placed the resident at risk for dissatisfaction with food, decreased nutritional intake, unplanned weight loss, and a diminished quality of life. Findings included . Review of the admission assessment dated [DATE] showed Resident 2 had a diagnosis of Crohn's disease (chronic inflammatory bowel disease), had an ostomy (an opening in the abdominal wall for intestinal waste to bypass portions of the intestine), and was at risk for malnutrition. Per the assessment the resident did not have a specialty diet ordered. Review of Resident 2's nutrition care plan, initiated 04/24/2024, showed the Registered Dietician (RD) would evaluate and make diet change recommendations as needed. According to the National Institutes of Health (https://www.niddk.nih.gov/health-information/digestive-diseases/crohns-disease/eating-diet-nutrition) dietary changes could help reduce symptoms of Crohn's disease. Recommendations included avoiding popcorn, vegetable skins, nuts, and other high-fiber foods, eating smaller meals more often, and eating high-calorie and low-fat diets. Review of Resident 2's Diet Requisition Form, dated 04/24/2024, showed they had a regular diet ordered, with regular textures and regular fluids. The diet requisition listed the resident's allergies but did not list their food preferences and/or intolerances. Review of the 04/29/2024 Nutritional Screen and 05/06/2024 Nutritional Evaluation for Resident 2 showed the resident was assessed for meal intake, weight loss/gain and energy needs. The resident's food preferences and/or intolerances were not included. In a telephone interview on 05/28/2024 at 10:42 AM a representative for Resident 2 stated the resident had been receiving foods that they could not eat with their current diagnoses while at the facility, including salads and high-fiber foods. The representative stated the resident was sent to the hospital from the facility and was found to have signs of malnourishment, which they attributed to the resident's diet. In a telephone interview at 10:49 AM the same day Resident 2 stated they needed certain foods due to their intestinal surgery and had attempted to talk to several staff about their dietary needs but did not see changes to the meals that they received. In an interview on 05/28/2024 at 11:18 AM, Staff B, Dietary Manger, stated dietary staff reviewed resident diet tickets during meal service to see what foods individual residents could or could not be served, and the diet tickets were based upon the information listed on the Diet Requisition Form. Staff B reviewed Resident 2's dietary form and stated the resident was ordered a regular diet and the only thing the resident could not have was blue dye per their allergy list. Staff B stated they had not been able to complete an assessment of the resident's preferences and intolerances during the resident's stay at the facility and were not aware of Resident 2's concerns with being served foods they could not tolerate. In an interview at 1:03 PM the same day, Staff C, RD, stated they would attempt to interview residents during their nutritional screening and evaluations, but Resident 2 was asleep during their attempts, so their evaluations were based upon chart review only. Staff C stated the dietary manager was responsible for interviewing the resident regarding their food preferences and intolerances. Staff C stated they received an electronic communication from Resident 2's representative on 05/10/2024 listing foods the resident could and could not tolerate, which they discussed with Staff B. Staff C stated a new Diet Requisition Form based upon the reported concerns was not completed as Staff B stated they were already aware of the resident's food intolerances. Reference: (WAC) 388-97-1100 (1); - 1120 (3)(a); -1140 (6)

Based on interview and record review, the facility failed to ensure labs were obtained as ordered, for 1 of 4 sampled residents (Resident 5), reviewed for laboratory (lab) services. This failure placed the resident at risk for delayed treatment, and a decline in condition. Findings included . Review of Resident 5's November 2023 Medication Administration Record showed an order for the nurse to call in an order to the lab for a CBC (complete blood count; measures parts and features of the blood), CMP (complete metabolic panel; measures substances related to the body's chemical balance and metabolism) and CRP (C-reactive protein; measures level of inflammation in the body) was signed as completed on 11/19/2023 and 11/26/2023. Additionally, an order for the lab to collect a CBC and CMP was signed as completed on 11/22/2023. A laboratory report dated 11/20/2023 showed the CBC, CMP and CRP were completed and a low sodium level resulted. No interventions related to the low sodium level were noted in the resident's record. Additionally, no results for the repeated labs ordered 11/22/2023 were found. In an interview on 12/12/2023 at 9:41 AM a representative for Resident 5 stated on 11/27/2023 the resident was confused and not acting like themself. The representative stated they asked about the resident's lab results because the resident had previously acted confused when their sodium and/or magnesium levels were low, but were told there were no recent results. In an interview on 12/12/2023 at 3:28 PM Staff D, Licensed Practical Nurse, confirmed Resident 5's sodium level was low on their last lab result on 11/20/2023, and that repeat labs were ordered for 11/22/2023 and 11/26/2023, but results for those dates were not available in the resident's record. Per Staff D, Staff E, Advanced Registered Nurse Practitioner, ordered another CBC and CMP on 11/27/2023 due to the resident's complaints of feeling tired and unwell. In an interview on 12/13/2023 at 2:23 PM Staff A, Administrator, and Staff B, Director of Nursing, confirmed the ordered laboratory tests on 11/22/2023 were signed as completed by facility staff, but not done, which the provider (Staff E) was not aware of. Additionally, the ordered lab tests ordered on 11/26/2023 had been drawn but not resulted by the time the new labs were ordered on 11/27/2023, so they were cancelled by the laboratory staff. Reference: (WAC) 388-97-1620(2)(b)(i)

Based on observations, interviews, and record review the facility failed to ensure resident's preferences for bathing were honored for 1 of 1 sampled residents (43), reviewed for choices. This failure placed the resident at risk for decreased quality of life. Findings included . According to the 09/18/2023 annual assessment, Resident 43 was able to make decisions regarding care, had diagnoses which included Rheumatoid Arthritis, a chronic inflammatory disease that caused swelling, stiffness and painful joints, and chronic pain. In addition, the assessment showed the resident required assistance from nursing staff to complete activities of daily living such as bathing. On 10/30/2023 at 9:58 AM, Resident 43 was observed sitting in their wheelchair in their room. When asked how they were doing, the resident stated their neck hurt and they missed the hot tub they had at home because it helped with the pain caused by the arthritis. When asked if they were allowed to take a tub bath at the facility, Resident 43 stated they preferred a tub bath, but the facility did not have a tub, only showers were available. Review of the 09/26/2023 care plan showed resident 43 preferred to be bathed/showered on Mondays and Thursdays. In an interview on 11/03/2023 at 9:18 AM, Staff P, bath aide, stated resident's care plans instructed them what the resident's preferences for bathing were. When asked if the facility had a working bathtub, Staff P stated yes, but no residents had asked to use it that they were aware of. On 11/08/2023 at 10:33 AM Staff I, Licensed Practical Nurse (LPN) stated each unit had a bathtub. When asked if residents were offered a choice between a tub or shower, Staff I stated no, because there wasn't a working bathtub in the facility, so only showers were available. Observation of the tub room on the [NAME] unit with Staff I, showed the room was being used for storage, and the whirlpool tub contained a wheelchair and other medical equipment. In an interview on 11/08/2023 at 10:58 AM Staff N, Nursing Assistant, stated they had only worked at the facility for a few weeks. Per Staff N, there were 2 shower rooms on the East unit, but they had never been in the one located at the end of the hallway, and there was no bathtub in the facility that they were aware of. Observation of the shower room at the end of the hallway with Staff N, showed the room was being used for storage, and the whirlpool tub was filled with medical equipment. In an interview on 11/08/2023 at 11:03 AM, Staff R, Maintenance Director, stated they began employment at the facility about a year and a half ago, and they had checked the bathtubs at that time, and both were working properly. During an interview on 11/08/2023 at 11:07 AM, Staff B, Director of Nursing, stated, residents were told upon admission to the facility that showers were given twice a week, and they were asked their preference for days/times. When asked if ta bathtub was available, Staff B stated the bathtubs had not been working for about eight months. When informed of the interview with Staff R, and the status of the shower rooms, Staff B said they did not know the bathtubs were functional, and the rooms would need to be cleared of items so the tubs could be used. At 11:37 AM, that same day, when informed that Resident 43 stated soaking in a hot tub helped with pain, Staff B stated they would let the bath aide know and get that started for the resident. Reference WAC 388-97-0900(1)(3)

Based on record review and interview, the facility failed to inform and provide written information concerning the right of their residents to formulate an advance directive for 2 of 4 sampled residents (22, 76) reviewed. This failure placed residents at risk of not being able to exercise their rights and not having their wishes honored. Findings included . The 11/2017 Resident Rights, Advance Directives facility policy documented that upon admission, if the resident had not formulated an advance directive, the facility was to inform the resident of their right to establish an advance directive and assist the resident in developing one. The medical record was to reflect that the discussion of advance directives occurred and the resident's acceptance or declination of assistance. <Resident 22> A review of the record showed Resident 22 had diagnoses including left lower leg fracture, and chronic obstructive pulmonary disease (COPD, inflammation in the lungs causing difficult breathing.) The record did not contain documentation that Resident 22 had been informed of their right to form an advance directive or if they had accepted assistance in forming one. <Resident 76> A review of the record showed Resident 76 had diagnoses including dementia, and right femur (upper leg bone) fracture. The record did not contain documentation that Resident 76 had been informed of their right to form an advanced directive or if they had accepted assistance in forming one. During an interview on 11/09/2023 at 11:54 AM, Staff C, East Unit Social Worker, stated they talked with residents when the residents had questions about their POLST form (Physician Orders for Life Sustaining Treatment, a form that specified the type of treatment a resident wanted during serious illness) and the nurse that admitted the resident discussed advance directives. During an interview on 11/09/2023 at 12:19 PM, Staff B, Director of Nursing, stated the Social Workers were responsible for entering the interventions and information regarding advance directives into resident's care plans. When asked about Residents 22 and 76, Staff B stated, the lack of documentation it was probably a result of miscommunication. Reference: WAC 388-97-0300(1)(b), (3)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize a reported incident as an allegation of possible abuse/neglect and therefore did not report to the state survey agency in the required timeframe, for 1 of 3 residents, investigated for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect. Findings included . According to an admission assessment dated [DATE], Resident 281 had a diagnosis of infection in the soft tissue of the leg. The resident was cognitively intact and was able to make their needs known. During an interview on 10/30/2023 at 11:30 AM, Resident 281 stated that most of the staff was good, but there was one aide that was mean and rude. The resident further stated they used the call light for help picking up their blanket that had fallen. The aide refused and repeatedly said to do it themselves. The resident reported they had not told any other staff about the incident. On 10/31/2023 at 4:25 PM, informed Staff A, Administrator and Staff B, Director of Nursing (DON) of Resident 281's allegation against the staff member. A description of the aide and approximate time they worked was included in this discussion. Staff B stated the resident had discharged earlier that day, but they would contact the resident and start an investigation. On 11/03/2023 at 4:00 PM, when asked for an update on information on Resident 281, Staff A stated they had tried to call them twice without any response and would try again. They further stated that they were unable to determine which staff the resident was referring to. On 11/06/2023, an undated Grievance Form, provided and signed by Staff A was reviewed. The form showed that Resident 281 reported an aide said they could do it for themselves when they were asking for assistance. The report further showed they were unable to identify the staff member, they had attempted to reach the former resident and were keeping the incident open until able to speak with them. The recommendation shown was to speak to staff related to customer service/perception. During an interview on 11/07/2023 at 3:00 PM, Staff K, Nursing Assistant (NA) stated that if they saw or heard of a resident being treated or spoken to harshly, they would immediately let the nurse or Staff B know and report it to the State. This surveyor then described the same scenario (exactly as described to Staff A and Staff B) and asked what they would do? Staff K responded they definitely would call that in. During an interview on 11/08/2023 at 12:04 PM, Staff MM, NA stated they would make sure the resident was safe and as a mandatory reporter would report to the State and the nurse or Staff B. This surveyor then described the same scenario. Staff MM stated would call that into the State. During an interview on 11/08/2023 at 2:26 PM, Staff X, Licensed Practical Nurse (LPN) stated that if they saw a staff member treating or talking harshly to a resident, they would first talk to the resident and staff to determine if it was a misunderstanding, reassign the staff until it was sorted out and notify Staff A or Staff C, Director of Social Services. When asked what they would do if a resident told them what Resident 281 described, Staff X stated to fill out a grievance, give to Staff C or Staff A and talk to the resident. When asked the difference between a grievance and an allegation of abuse or neglect, they stated to start with the grievance form and management would possibly change it to a reportable incident. During an interview on 11/08/2023 at 2:52 PM, Staff Y, LPN, stated that if they saw a staff member treating or talking harshly to a resident, they would write a progress note that would flag for the management to review in their morning meeting. They further stated they would not have the staff work with the resident and would have them trade assignments. When asked what they would do if a resident told them what Resident 281 described, Staff Y stated would do the same (put into the computer and trade staff), but if the allegation was more substantial, they would send the employee home. During a follow-up interview on 11/08/2023 at 3:26 PM, Staff B stated regarding the incident with Resident 281, they couldn't do more because the resident had not called them back, so the incident was ongoing. When Staff B was asked if a resident claimed that an aide was a mean, rude and repeatedly refused to help them constituted an allegation of possible abuse or neglect, they stated a physical abuse allegation was more clear-cut and needed to be called in. On 11/08/2023 at 4:12 PM, Staff B submitted an online incident report to the state agency. This report was made 8 days after Staff A and Staff B were informed of the allegation. During an interview on 11/09/2023 at 4:38 PM, Staff A stated that they initially took it as the staff likely was encouraging independence. Staff A acknowledged it should have been called in to the state. Reference: WAC 388-97-0640(5)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** *AMENDED - All Amendments are in bold Based on observation, interview, and record review, the facility failed to implement interventions necessary to prevent the development of a wound for 1 of 5 sampled residents (65), reviewed for pressure ulcers. This placed the resident at risk for developing pressure ulcers and delayed wound healing. Findings included . The facility's Quality of Care for Skin Integrity policy dated 08/2018 stated based on a resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical conditions demonstrates that they were unavoidable. Per the policy, a resident identified as at risk for developing pressure ulcers will have individualized interventions implemented to attempt to prevent pressure ulcers from developing, interventions will be monitored for effectiveness and the care plan will reflect the interventions. Per the 02/28/2023 admission assessment, Resident 65 was admitted [DATE] and had diagnoses which included malnutrition, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and diabetes. The assessment also showed the resident needed assistance from staff for repositioning and turning in bed, and that the resident was identified as being at risk to develop pressure ulcers and had a Stage 1 pressure ulcer (intact skin with an area of redness that does not turn white when pressiure is applied to the area) to their coccyx (tailbone). The assessment showed Resident 65 had no other pressure ulcers. Review of Resident 65's care plan dated 02/20/2023 showed Resident 65 had potential for pressure ulcer development related to immobility, diabetes, history of prior pressure ulcer and poor circulation. Interventions implemented to prevent pressure ulcers were not implemented until 03/06/2023 and included: administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness and follow facility policies/protocols for the prevention/treatment of skin breakdown. No other interventions specific to resident's care needs were found regarding treatment and prevention of pressure ulcers. On 07/04/2023 at 8:00 AM, a nursing progress note showed Resident 65 complained of pain to their left heel and a nickel sized black area was noted. A facility incident investigation completed that same day stated Resident 65 had limited ability to change position in bed independently and when they were checked on that morning, their heel was not floated off the mattress. On 07/05/2023, Resident 65 was assessed by a contracted wound specialist and noted to have a pressure ulcer that was unstageable (full thickness skin and tissue loss) and measured 2.0 centimeters x 3.0 centimeters. On 07/05/2023, the care plan was updated to inform staff Resident 65 had a diabetic ulcer and instructed staff to ensure appropriate protective devices were applied to affected areas (no device was named), to position resident off the affected area and to change position every two hours and as needed. Review of the Order Summary Report showed no orders for a protective device to be applied to Resident 65's left heel. During a conversation on 10/30/2023 at 12:34 PM, Resident 65 stated the wound started out as a small scab and increased in size. Resident 65 added they have a boot, but forgets to ask staff to put it on. Resident was sitting in their recliner with heel resting on the foot of recliner, without any device in place to offload pressure from the wound. Additional observations of Resident 65 without any device in place to offload pressure from the wound were made on 10/31/2023 at 11:59 AM, 10/31/2023 at 1:58 PM, 10/31/2023 at 3:31 PM, 11/02/2023 at 9:16 AM, 11/02/2023 at 11:56 AM, 11/02/2023 at 1:51 AM, 11/02/2023 at 3:04 PM, 11/03/2023 at 9:46 AM and 11/03/2023 at 12:05 PM. During an observation of Resident 65's wound on 11/07/2023 at 11:56 AM, Contracted Wound Specialist, stated a pillow, or an offloading boot could be used to provide pressure relief from the wound and if there was pressure on the wound it would impact healing. During an interview on 11/08/2023 at 2:52 PM, Staff B, Director of Nursing, stated Resident 65 was at risk for skin breakdown and should have their heel floated to provide pressure relief. Staff B stated staff would not know what device to use on Resident 65's heel because it was not listed on the care plan and the device was not added to the care plan until after the wound occurred. Staff B added that when Resident 65 went to the hospital for a different issue, the doctor diagnosed the wound on the heel as a diabetic ulcer. Reference: WAC 388-97-1060 (3)(b)

<Resident 7> A review of the 08/21/2023 admission comprehensive assessment showed Resident 7 had diagnoses including congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Resident 7 was severely cognitively impaired and wore oxygen. On 10/07/2021, orders were obtained to give Resident 7 oxygen via nasal cannula 1-4 liters per minute (lpm) while sleeping and to titrate as needed and supplemental oxygen as needed to maintain oxygen saturation greater than 90% for hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level). The comprehensive care plan dated 12/13/2017, documented Resident 7 had ineffective gas exchange. Staff were to monitor for changes in orientation, increased restlessness, anxiety, lethargy, confusion and apply oxygen when resident was sleeping at 2 lpm. Per observation on 10/30/2023 at 2:57 PM, Resident 7 was lying in bed asleep with no oxygen on. Additional observations of Resident 7 asleep in bed without oxygen were made on 10/31/2023 at 2:24 PM, 11/02/2023 at 1:45 PM, 11/02/2023 at 3:09 PM and 11/03/2023 at 3:24 PM. On 11/02/2023 at 9:48 AM, Resident 7's oxygen tubing and nasal cannula, dated 10/29/2023 was lying on the floor. The same observations were made on 11/02/2023 at 11:36 AM, 1:45 PM, and 3:09 PM. During an observation on 11/03/2023 at 9:06 AM, Staff L stated Resident 7 was wearing the oxygen tubing that was connected to the concentrator when they entered the room. The date on the tubing of 10/29/2023, lying on the floor, showed the tubing had not been changed. During an interview on 11/08/2023 at 2:01 PM, Staff E, Unit Manager stated Resident 7 needed oxygen while asleep and since the order stated 1-4 lpm, an order would be needed to not administer the oxygen. Staff E added oxygen tubing lying on the floor needed to be changed as this can cause an infection. During an interview on 11/08/2023 at 2:44 PM, Staff B, Director of Nursing stated oxygen tubing lying on the floor needed to be replaced as this could cause a respiratory infection. Staff B stated Resident 7 would need their oxygen on while sleeping per the order. Reference: WAC 388-97-1060(3)(j)(vi) Based on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards for 2 of 3 sampled residents (7 and 22) reviewed. Resident 22 had no orders for the provision of oxygen and care of their nebulizer equipment and Resident 7's orders for their oxygen were not followed and their equipment was not maintained in a clean manner. This failure placed residents at risk for respiratory difficulties and infections. Findings included . <Resident 22> A review of the 09/24/2023 admission comprehensive assessment showed Resident 22 had diagnoses including chronic obstructive pulmonary disease (COPD, inflammation and increased mucous production in the lungs that causes difficult breathing.) Resident 22 was mildly cognitively impaired and wore oxygen both prior to admission and while a resident. On 09/18/2023, orders were obtained to give Resident 22 an albuterol nebulizer (medication administered by a mist that is breathed into the lungs using a mask that covers the mouth and nose) every 6 hours for COPD, and an ipratropium bromide nebulizer every 6 hours as needed for shortness of breath. The 09/21/2023 respiratory care plan included interventions for staff to monitor vital signs, assess for shortness of breath, notify the provider of any abnormalities, and give oxygen at 3 liters (L) through a nasal cannula. Further review of Resident 22's record revealed there were no orders for what rate the oxygen was to be set at, the care and maintenance of the oxygen tubing, oxygen concentrator, filter or nebulizer mask and equipment. There were no care planned interventions specific to Resident 22's COPD and oxygenation. On 10/31/2023 at 11:51 AM, Resident 22 was observed seated in their wheelchair. They had on a nasal cannula, and the gauge on the oxygen concentrator (the machine that delivers the oxygen through tubing to the resident) was set at 3L. Resident 22 stated they used 3L of oxygen when they were home as well. The oxygen tubing did not have a label on it showing when it had last been changed. A nebulizer, mask and tubing were observed on the overbed table. The mask was clear plastic, was covered in a filmy substance, and the inside of the mask had dried splatters and matter on the inside of it. Resident 22 stated the mask had not been washed since they had been admitted . The nebulizer mask and oxygen tubing were observed in the same condition on 11/02/2023 at 9:15 AM, and 2:00 PM, and on 11/06/2023 at 8:05 AM. The oxygen concentrator had an air flow vent on the back. This was observed to have a layer of dust in it. When interviewed on 11/06/2023 at 8:15 AM, Staff J, Nursing Assistant, stated nurses were responsible for cleaning and replacing oxygen or nebulizer equipment. When interviewed on 11/06/2023 at 8:17 AM, Staff K, Certified Medication Assistant, stated nebulizer masks were replaced every week, but were not washed. The oxygen and nebulizer tubings were to be labeled with the date they were changed, and this was to be documented on the treatment administration record (TAR). Staff K stated the resident care manager put orders in the electronic record for oxygen tubing changes and nebulizer cleaning so the treatments could be documented. Staff K observed the nebulizer mask with the surveyor and stated they had not noticed the mask was not clean and should have noticed that. When interviewed on 11/09/2023 at 3:25 PM, Staff B, Director of Nursing, stated nebulizer masks were changed when the oxygen tubing was changed. The medical records department entered in admission orders, and it looked like orders for Resident 22's oxygen therapies got missed. Staff B stated monitoring of the resident's oxygenation status was important for their respiratory care, and unclean masks was an infection control concern.

Based on observation, interview and record review, the facility failed to provide person-centered pain management for 1 of 3 sampled residents (131). Resident 131 was not offered non-pharmacological pain interventions, an ordered pain relieving gel was not available, and doses of narcotic pain medications were removed from the narcotic locked drawer, but not documented they were administered. These failures placed residents at risk for increased pain, and decreased quality of life. Findings included . A 10/24/2023 re-admission assessment showed Resident 131 had diagnoses which included chronic osteomyelitis of the right ankle and foot (infection of the bone), fibromyalgia (widespread muscle pain and tenderness), and borderline personality disorder, a mental illness that severely impacts a person's ability to manage their emotions. In addition, the assessment showed the resident was cognitively intact to make decisions regarding their care, had a surgical wound with dressings to the feet, had verbal behaviors directed towards others, and took anti-anxiety, anti-depressant, and narcotic pain medication daily. Review of the 09/20/2023 comprehensive care plan showed the following care areas and interventions: - Pain related to recent surgery and chronic pain; interventions included to administer analgesia per order, anticipate the need for pain relief and respond immediately to any complaint of pain, evaluate effectiveness of pain interventions every shift, and monitor and report to nurse resident complaints of pain or requests for pain treatment. - Behavior of making false allegations related to poor adjustment and borderline personality disorder; interventions included to administer medications as ordered, anticipate, and meet the resident's needs, provide care in pairs, triggers for allegations include not getting medications when wanted versus how they are ordered. On 10/31/2023, the care area was updated to include investigate all allegations in a neutral manner, do not presume allegation is not accurate based on history of allegations. The 10/24/2023 readmission provider note documented the resident was reporting significant pain at their right heel wound site. The plan was for Resident 131 to take Tizanidine (a muscle relaxer) and Gabapentin (treated nerve pain) for the chronic pain, fibromyalgia, and arthritis. In addition, the resident was to take Oxycontin (a long-acting narcotic) 40 mg every 8 hours and Oxycodone (a short acting narcotic) 5-10mg every 6 hours as needed for pain. Review of the orders showed staff were to attempt and document non-pharmacological interventions prior to administration of the oxycodone, but the orders did not list what those interventions were. In addition, the physician had also ordered Tylenol every 4 hours as needed for pain, and Diclofenac 1% external gel (topical pain-relieving gel) every 6 hours as needed for pain. When interviewed on 10/30/2023 at 3:17 PM, Resident 131 stated they had fibromyalgia and arthritis and took medication for these prior to their admission to the facility. Resident 131 stated they also had surgery on their foot that required the use of a wound suctioning system, and this was painful. When asked about their pain, the resident stated the pain in their heel was a 9 on a scale of 0 (no pain) to 10 (excruciating pain) and stated their pain medications were not being given as ordered. The resident further stated they were told this morning the facility had run out of their pain medication (oxycodone) and they were not going to be able to get any more today. When reviewed on 10/30/2023 at 4:30 PM, the medication administration record (MAR) showed Resident 131 had not received oxycodone since 10/29/2023 at 11:30 PM, the night prior. No progress notes or documentation was found that showed the provider was contacted, what attempts were made to retrieve the medication, or what non-pharmacological pain-relieving interventions had been attempted. During a follow-up interview on 11/03/2023 at 3:05 PM, Resident 131 was observed seated on the side of their bed rocking back and forth and stated they were in pain. Resident 131 stated they had not been given the full 40 mg of their oxycontin the night prior because their prescription had run out. The resident stated by the time the staff were able to speak to the provider, it was 10:00 AM, and they finally got their morning dose at that time, but they were told they would not get the 2:00 PM dose because they got their morning dose late and the doses had to be spread out. Resident 131 stated one of the managers created a binder for the resident and staff to sign so that the resident could keep track of when their pain medications had been administered, but the binder did no good and they stopped using it. Resident 131 stated they were legally blind and unable to see what they were signing for, and not all of the staff had signed the binder either. A review of the 11/2023 MAR showed Resident 131 received a partial dose of oxycontin on 11/02/2023 at 10:00 PM, as the resident stated. The medication binder created for the resident was reviewed and showed multiple pain medication doses were not entered in the binder when given in 10/2023 and 11/2023, as intended for the resident's benefit. Further reviews of Resident 131's record showed there were no progress notes or other documentation that stated what non-pharmacological interventions were attempted to help relieve Resident 131's pain. Additional reviews of the 10/2023 and 11/2023 MARS revealed Resident 131 had not received any doses of the as needed diclofenac pain relieving gel. Comparison reviews of the narcotic log book (documentation required that showed when narcotics were removed from inventory for administration to residents) and Resident 131's 10/2023 MARS showed the following: On 10/13/2023, there were four separate times that Oxycodone 10mg was signed out of the narcotic log book, but none of those doses were documented in the MAR as given to the resident. On 10/30/2023, there were two times that an Oxycodone dose was signed out of the narcotic log book, but neither of those doses were documented in the MAR as given. On 11/06/2023 at 7:26 AM, an observation of Resident 131's pain medication was observed with Staff CC, Registered Nurse (RN). Resident 131 was seated on the side of their bed, rocking back and forth, the room was dimly lit, and Resident 131 rated their pain an 8 when asked. Staff CC administered Tizanidine, Butalbital (medication for migraine pain), and two 5mg tablets of Oxycodone. When the surveyor asked Resident 131 if there were other interventions that helped their pain, the resident stated they had a topical gel ordered that helped their joints but every time they asked for it none of the staff could find any. Resident 131 also stated warm showers were helpful; the pain was worse when they were cold. Resident 131 requested their heat be turned up, and Staff CC did so. Staff CC provided Resident 131 a warm robe after suggested by the surveyor, but did not offer any non-pharmacological interventions to Resident 131. During an interview on 11/08/2023 at 11:48 AM, Staff Y, LPN, stated two nurses were required to verify the number of pills listed in the narcotic count book with the number of pills in the medication cart. Staff Y stated Resident 131 accused staff of not giving them their pain medication, so they implemented the binder. Staff Y stated they never knew what good the binder would do because Resident 131 was legally blind. Staff Y stated if they removed medications from the narcotic count book, then did not document that they gave them in the MAR, it created a discrepancy. After review of the narcotic log book and MAR with Staff Y, they stated they just got busy and forgot to document that they gave Resident 131 the oxycodone. When interviewed on 11/09/2023 at 10:08 AM, Staff G, Certified Medication Assistant (MAC), reviewed Resident 131's MAR and stated the diclofenac topical gel was still on order from the pharmacy since 10/23/2023. Staff G stated this was probably never followed up on because the gel was ordered to be given as needed, and the resident never asked for any. When asked if they offered the gel to the resident, Staff G stated no. When asked if Resident 131 was given warm showers, Staff G stated Resident 131 wanted showers on their own time, not when their shower was scheduled. During a follow-up interview on 11/09/23 at 1:50 PM, Staff Y stated there was not a place in the electronic medical record (EMR) to document non-pharmacological interventions. When asked what non-pharmacological interventions they offered Resident 131, Staff Y stated they used to offer to reposition or help them to bed but they did not offer that anymore; Resident 131 just wanted their oxys. During an interview on 11/09/2023 at 3:44 PM with Staff B, Director of Nursing, and Staff EE, Corporate Registered Nurse, Staff B stated Resident 131 was resistant to non-pharmacological pain management. They had offered cold packs, warm packs, and muscle rub creams. Staff B was not aware Resident 131 was not receiving the diclofenac gel. Staff EE stated diclofenac gel could be purchased over the counter now so the pharmacy might have put it on a do not send list. Staff B stated their pharmacy did not always notify the facility when that happened. Staff EE stated if a resident refused non-pharmacological pain interventions that was to be documented and should be part of the resident's care plan as well. See also F658, services provided meet professional standards. Reference (WAC): 388-97-1060(1)

Based on interview and record review, the facility failed to identify a resident was taking an ordered medication twice a day, instead of once daily as ordered, for 1 of 5 sampled residents (27), reviewed for unnecessary medications. This failure resulted in the resident receiving twice the intended amount of the medication for 13 days, and placed them at increased risk for side effects such as low blood pressure, fainting and heart issues. Findings included . According to the website www.mayoclinic.org, the medication Tamsulosin is also known by the trade name of Flomax. According to a 10/11/2023 admission assessment, Resident 27 had diagnoses which included diabetes, high blood pressure and Benign Prostatic Hyperplasia (BPH or an enlarged prostate) which can make urinating more difficult. The resident was cognitively intact and able to make their needs known. The Medication Administration Record (MAR) for October 2023, showed Tamsulosin 0.4mg daily at bedtime, was started on 10/05/2023. This medication was used to treat the symptoms of BPH. A provider progress note, dated 10/25/2023 showed the resident requested to restart taking their Tamsulosin. A further review of the October 2023 MAR showed a additional order for Flomax (Tamsulosin) 0.4mg daily in the morning, was started on 10/27/2023. The order for Tamsulosin from 10/05/2023 was not discontinued, so the resident was getting it twice daily. During an interview on 11/08/2023 at 10:34 AM, Staff X, Licensed Practical Nurse (LPN) was shown Resident 27's current MAR, which showed 2 separate orders for the same medication. One was listed by the generic name Tamsulosin, and one by the trade name of Flomax. Staff X stated that maybe it wasn't noted because it was ordered at 2 different times and given by 2 different nurses. They acknowledged that they should have checked with the provider to clarify. During an interview on 11/08/2023 at 12:16 PM, Staff Z, Nurse Practitioner admitted they were unaware the resident was already on Tamsulosin, and they had mistakenly ordered it a second time. During an interview on 11/08/2023 at 2:52 PM, Staff Y, LPN stated that they hadn't noticed the duplicate order for Tamsulosin for Resident 27 and that they should have checked in case it was an error. During an interview on 11/08/2023 at 3:25 PM, Staff B, Director of Nursing acknowledged that the facility had been giving the medication at double the intended dose and staff should have clarified the dose with the provider, when it was written. Reference: WAC 388-97-1060(3)(k)(i)

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 storage rooms. The facility failed to maintain temperatures to ensure medications were properly stored. The facility further failed to ensure narcotics were counted and locked in the permanently affixed narcotic containers for 2 of 2 medication rooms. This failure placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . During an observation on the east unit of the narcotic count on 11/06/2023 at 6:44 AM, there was a bottle of Ativan (medication used to treat anxiety) in the portable lockbox. Staff H, Registered Nurse stated the Ativan was from the Omnicell (a medicine storage unit that held commonly given medications for an emergency supply) stock, and since it was unopened it was not being counted during the change of shift narcotic count. During an observation on 11/07/2023 at 2:34 PM, of the west unit medication storage room, with Staff E, Unit Manager, showed an expired vial of Tubersol (medication injected under the skin to determine exposure to Tuberculosis, that must be discarded after 30 days of use) and an opened vial of Ativan, which must be kept in a locked container. The vial had been opened on 09/30/2023 and should have been discarded on 10/30/2023. The narcotic boxes were not permanently affixed as required. Per observation of the east medication cart on 11/07/2023 at 3:53 PM, there was an opened vial of insulin with no open date. The insulin needed to be discarded in 28 days. Staff F, Nurse Technician stated the bottle of insulin needed to be discarded because there was no open date on the bottle. During an interview with Staff A, Administrator and Staff B, Director of Nursing on 11/09/2023 at 12:07 PM, Staff A stated they were aware the narcotic containers needed to be affixed. Staff B stated the Ativan needed to be placed in the narcotic book to be accounted for. Staff G, Certified Medication Assistant accompanied surveyor to west medication room on 11/09/2023 at 2:22 PM. The temperature in the refrigerator that contained Tubersol was 28 degrees. The temperature log posted on the refrigerator stated the temperature should be between 36-46 degrees. During an interview on 11/09/23 at 2:27 PM, Staff B stated 28 degrees was too cold and the Tubersol needed to be stored between 35-46 degrees. Reference: WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to ensure dietary staff had the required qualifications (current Food Worker Cards) for 4 dietary staff (S, T, U and W.) This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards showed the following: - Staff S, Dietary Aide's Food Service Card expired on 08/16/2023. - Staff T, Dietary Aide's Food Service Card expired on 09/12/2023 - Staff U, Dietary Aide's Food Service Card expired on 09/16/2023 - Staff W, Dietary Aide's Food Service Card expired on 11/06/2023 On 11/08/2023 from 10:40 AM to 11:30 AM, Staff U was observed working on the lunch meal preparation in the kitchen. On 11/09/2023 at 10:30 AM, Staff T Was observed prepping food in the kitchen. During an interview on 11/09/2023 at 10:30 AM, Staff V, Kitchen Manager acknowledged that they had not kept track of the expiration dates on the cards. They further reported that the staff were being notified to get the cards renewed as soon as they were able. On 11/09/2023 at 4:38 PM, Staff A, Administrator acknowledged that dietary staff should have a current Food Handler Card to be working. Reference: WAC 388-97-1160

Based on observation, interview and record review, the facility staff failed to perform hand hygiene when indicated during a dressing change for 1 of 5 sampled residents (Resident 69) reviewed for pressure ulcer management and during one meal observation on the [NAME] Unit. This failure placed residents at risk for contact with contaminated surfaces, contamination of wounds and spread of harmful bacteria. Findings included . <Resident 69> A review of the 10/03/2023 quarterly assessment documented Resident 69 had diagnoses including stage 4 pressure ulcer (a wound caused by pressure that extended to muscle, tendon or bone) and paraplegia (paralysis of the lower extremities). Resident 69 was cognitively intact and had two stage 3 pressure ulcers (a wound that has full thickness tissue loss with no bone, muscle or tendon exposed) present on admission, and one stage 4 pressure ulcer present on admission. The 07/06/2023 comprehensive care plan documented Resident 69 had pressure ulcers and had potential for more pressure ulcers related to immobility. Interventions included to provide treatments as ordered, assess, monitor and record wound healing weekly, measure where possible, and report improvements or declines. The 10/31/2023 wound care provider progress note included orders for treatments to the pressure ulcers on Resident 69's left buttocks and coccyx (tailbone area): -Cleanse left buttock wound with wound cleanser, apply skin prep (a tacky substance that adds a layer of protection to skin) to surrounding skin, apply Dakin's (solution that kills germs in wound beds) soaked gauze to wound bed, and secure with border dressing. Change twice daily and as needed. -Cleanse the coccyx wound with wound cleanser, apply skin prep to surrounding skin, apply hydrogel (promotes tissue growth by keeping a wound bed moist) to the base of wound, and secure with border dressing. Change daily and as needed. On 11/03/2023 at 11:31 AM, the treatments for Resident 69's wounds were observed with Staff M, Registered Nurse (RN), and Staff N, Nursing Assistant. Upon entrance to the resident's room, Staff M and Staff N had positioned Resident 69, and the old dressings had been removed. Staff M and Staff N were wearing a protective gown and disposable gloves. Staff M sprayed wound cleanser into the wound on Resident 69's left buttocks, then patted the area with dry gauze. At this time, hand hygiene and a change of gloves was indicated, and this was not completed. Staff N poured Dakin's solution on gauze, packed the gauze into the wound, then applied a border dressing over the area. At this time, staff N removed their gloves, cleaned their hands with hand sanitizer and donned clean gloves. Staff N then sprayed the wound on the coccyx area with wound cleanser and patted the area with dry gauze. Hand hygiene and a change of gloves was indicated at this time and was not completed. Staff N applied hydrogel to the wound bed and applied a border dressing over the area. Resident 69 was repositioned for comfort and tolerated the procedure well. Staff N removed their gloves and gown and washed their hands, then exited Resident 69's room. When interviewed after the dressing change was completed, Staff N stated they had donned clean gloves after removing the old dressings prior to the surveyor entering the room. Staff N stated they should have changed their gloves and completed hand hygiene after they washed the wounds with the wound cleanser. When interviewed on 11/09/2023 at 4:46 PM, Staff Q, Infection Control RN, stated they used tools from the Centers for Disease Control (CDC) in their infection control program and staff completed competencies regarding wound care. Staff were expected to perform hand hygiene and change gloves after removing soiled dressings and after cleaning wounds. <Dining> During an observation of dining on 10/30/2023 at 11:39 AM, Staff O, Nursing Assistant, passed meal trays to residents without completing hand hygiene between each room. Staff O removed a lid from a resident's cup and filled it with water, did not complete hand hygiene and proceeded to pass meal trays. Staff O removed apple juice from a resident's tray that they took into the room, brought the juice out of room, and placed it on tray of liquids to be passed to other residents. Staff O pushed a resident in their wheelchair into the room, did not perform hand hygiene and proceeded to load meal trays onto a cart, threw a dirty bag onto the floor, and proceeded to place trays on the meal cart. Staff O continued to pass meals trays without performing hand hygiene. Staff O then proceeded to assist a resident with eating and did not perform hand hygiene. During an observation at 11:59 AM, Staff O removed a tray from a room, pushed the meal cart down the hallway, no hand hygiene performed, entered a resident's room, repositioned the resident, took lid off tray, went to roommates' area, and removed their tray, no hand hygiene performed. During an interview on 10/30/2023 at 12:02 PM, Staff O stated hand hygiene should have been completed before the first tray was passed and would not have needed to do it again. Staff O stated hand hygiene would need to be completed after removing a tray and doing resident care. Staff O added that they do not use hand sanitizer and probably should have washed their hands before assisting the resident. During an interview on 11/09/2023 at 4:51 PM, Staff P, Infection Preventionist stated hand hygiene should have been completed between each room and between each resident tray, and before and after resident cares. Reference: WAC 388-97-(1)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that narcotics medications were accounted for and administered by nursing staff according to professional standards for 14 of 17 sampled residents (2, 12, 22, 43, 57, 71, 72, 76, 80, 131, 281, 410, 505, and 526) reviewed for unnecessary medications and medication administration. Specifically, narcotic medications were removed from the narcotic count books but not documented in the medication administration records {MARS} that they had been given, there were multiple entries in the narcotic count books that showed two nurses did not verify the counts were correct, and Resident 2's pain medications brought in from home were not inventoried, and six pills came up missing. These failures placed residents at risk for increased pain, decreased quality of life, and created an increased opportunity for drug diversion. Findings included . Narcotics doses removed from the counts but not documented as administered: <Resident 131> A 10/24/2023 re-admission assessment showed Resident 131 had diagnoses which included chronic osteomyelitis of the right ankle and foot (infection of the bone), fibromyalgia (widespread muscle pain and tenderness), and borderline personality disorder, a mental illness that severely impacts a person's ability to manage their emotions. In addition, the assessment showed the resident was cognitively intact to make decisions regarding their care, had a surgical wound with dressings to the feet, had verbal behaviors directed towards others, and took anti-anxiety, anti-depressant, and narcotic pain medication daily. When interviewed on 10/30/2023 at 3:17 PM, Resident 131 stated they had fibromyalgia and arthritis and took medication for these prior to their admission to the facility. Resident 131 stated they also had surgery on their foot that required the use of a wound suctioning system, and this was painful. When asked about their pain, the resident stated the pain in their heel was a 9 on a scale of 0 (no pain) to 10 (excruciating pain) and stated their pain medications were not being given as ordered. The resident further stated they were told this morning the facility had run out of their pain medication (oxycodone) and they were not going to be able to get any more today. The narcotic count book (documentation required that showed when narcotics were removed from inventory for administration to residents) when compared to Resident 131's MAR revealed the following: On 10/30/2023, Staff AA, Licensed Practical Nurse, (LPN), documented in the narcotic count book that they removed one 5mg tablet of oxycodone at 9:00 (did not document AM or PM) and two 5mg tablets of oxycodone at 8:45 (did not document AM or PM) from the locked narcotic drawer on the medication cart. No documentation was found in the MAR, or the resident's record to show the medication had been administered to the resident. Further comparisons of the narcotic count book and Resident's MARS revealed additional discrepancies as follows, where the narcotic pain medication had been signed out of the narcotic count book, but not documented in the MAR as being given: On 09/30/2023, Staff Y, LPN, documented in the narcotic count book they removed two 5mg tablets of oxycodone at 7:05 AM. On 10/13/2023, Staff Y, documented in the narcotic count book they removed two 5mg tablets of oxycodone from the locked narcotic drawer on the medication cart at 5:15 AM, 10:45 AM, and 10:25 PM. On 10/13/2023, Staff X, LPN, documented in the narcotic book they removed two 5mg tablets of oxycodone at 10:25 AM (this conflicted with the same number of tablets removed by Staff Y close to the same time), and 4:25 PM. The administration of the tablets removed at 4:25 PM was not documented on the MAR. Additional comparisons of the narcotic count books with other resident's MARs identified 12 additional residents that had doses of their narcotic pain medications removed from the locked narcotic drawer and signed out of the narcotic books, but not documented on the MAR that the medication was administered as follows: <Resident 2> Oxycontin ER 20mg, one tablet on 10/31/2023 at 5:30 AM, by Staff Y. <Resident 12> Hydrocodone 5-325mg, one tablet on 10/12/2023 at 9:00 PM, one tablet on 10/13/2023 at 2:00 AM, and one tablet on 10/14/2023 at 11:00 PM by Staff Y; and one tablet on 10/17/2023 at 5:30 AM by Staff BB, LPN. <Resident 22> Hydrocodone 5-325mg, one tablet on 10/28/2023 at 12:00 PM, one tablet on 10/30/2023 at 6:40 AM, and one tablet on 10/30/2023 at 12:00 PM, all by Staff AA. <Resident 43> Oxycodone 5mg, one tablet on 10/02/2023 at 9:01 PM by Staff FF, Registered Nurse (RN). <Resident 57> Oxycodone 5mg, two tablets on 10/11/2023 at 12:25 PM, only one tablet administered by Staff I, LPN; one tablet on 10/14/2023 at 1:20 AM by Staff HH, one tablet on 10/14/2023 at 9:25PM, signature not legible; one tablet each on 10/15/2023 at 11:00 PM, 2:00 AM, and 10/24/2023 at 10:30 AM by Staff AA; and one tablet each on 10/16/2023 at 7:45 PM and 10/23/2023 at 7:45 PM by Staff GG, LPN. <Resident 71> Oxycodone 5mg, two tablets on 10/10/2023 at 12:55 PM and one tablet on 10/28/2023 at 12:45 PM by Staff AA, one tablet on 10/11/2023 at 12:45 PM by Staff CC, RN, and two tablets on 10/13/2023 at 1:45 AM, one tablet on 10/13/2023 at 8:30 PM, two tablets on 10/14/2023 at 5:15 AM, two tablets on 10/29/2023 at 2:00 PM, and two tablets on 10/29/2023 at 5:45 PM by Staff Y. <Resident 72> Hydrocodone 5-325mg, one tablet on 10/5/2023 at 3:00 PM and 9:00 PM, signatures not legible, one tablet on 10/07/2023 at 10:40 PM, one tablet on 10/08/2023 at 8:30 PM and one tablet on 10/12/2023 at 4:00 PM by Staff AA. <Resident 76> Hydrocodone 5-325mg, one tablet on 10/12/2023 at 9:00 PM, one tablet on 10/13/2023 at 2:00 AM, one tablet on 10/14/2023 at 10:00 PM, one tablet on 10/15/2023 at 4:00 AM by Staff Y, and one tablet on 10/28/2023 at 5:00 PM by Staff AA. <Resident 80> Hydrocodone 10-325mg, one tablet on 10/14/2023 at 7:00 PM by Staff Y and one tablet on 10/15/2023 at 3:00 AM by Staff Y. <Resident 281> Oxycodone 5mg, one tablet on 10/30/2023 at 5:00 PM by Staff AA. <Resident 410> Hydrocodone 7.5-325mg, two tablets on 10/28/2023 at 9:43 AM by Staff CC; two tablets on 10/28/2023 at 1:45 PM by Staff AA; and two tablets on 10/29/2023 at 4:00 PM by Staff Y. <Resident 505> Hydrocodone 5-325mg, one tablet on 10/30/2023 at 9:00 AM by Staff AA. <Resident 526> Oxycodone 5mg, three half tablets on 10/28/2023 at 12:30 PM, three half tablets on 10/28/2023 at 4:30 PM, and two half tablets on 10/30/2023 at 9:00 AM by Staff AA. During an interview on 11/06/2023 at 11:41 AM, Staff AA, LPN, stated they worked for an agency and except for being oriented to the layout of the building, they had received no other orientation/training, nor had they been required to take a basic medication knowledge test or shadow a facility staff member. received little orientation when they started at the facility, only the layout of the building. They were not required to take a basic medication knowledge test or shadow a facility staff member assigned to the medication cart either. Staff AA stated all the narcotics were located on the medication carts in a locked drawer, and there were additional doses in the Omnicell (a medicine storage unit that held commonly given medications for an emergency supply) available if needed. Staff AA stated a code from the pharmacy was required to remove narcotics from the Omnicell, a second nurse had to witness it, and more than one dose could be removed. If narcotics were removed from the Omnicell, it was not required to add those to the inventory in the narcotic count book because the Omnicell recorded the transaction. Staff AA stated they checked the resident's MAR to see when a resident received their last dose of pain medication prior to removing another dose. When asked how a nurse would know when the last dose was given if there was no entry on the MAR, Staff AA stated they hoped the nurse would look at the narcotic count book. Staff AA stated if they did not record the narcotics removed from the Omnicell in the narcotic count book, another nurse would not know when those narcotics were given. During review of the narcotic count book and resident MARS, Staff AA verified that the signatures in the narcotic count sheets that documented the removal of 24 narcotic tablets for nine residents where the doses had not been documented in the MAR was theirs. Staff AA stated nurses were expected to sign out the narcotic and document in the resident's MARS that they gave the medication, but that was hard to do when they were busy. During an interview on 11/06/2023 at 12:47 PM, Staff E, [NAME] Unit Resident Care Manager, stated audits of the narcotic count books were not done unless something came up that required it. When asked about the process for using the Omnicell, Staff E stated nurses had to have a valid prescription and a code from the pharmacy to remove narcotics from the Omnicell and any doses had to be added to the narcotic count books. When asked what training agency nurses received, Staff E stated no training was provided, usually the staff would come to one or two hours early and get a tour of the facility, and only facility nursing staff were required to take a basic medication administration test. During an interview on 11/07/2023 at 10:31 AM, the consultant Pharmacist stated nurses had to call the pharmacy prior to removing narcotics so the pharmacy could approve it and provide a numerical code. When a code was authorized, the pharmacy kept a copy, and the facility was supposed to keep a copy of the code as well. Once given, the codes did not expire, but there were supposed to be two nurses witnessing the removal of the medications, and only one dose was to be removed. The pharmacist stated they were uncertain if the facility staff were comparing the doses of narcotics removed from the Omnicell with the narcotic count books. During an interview on 11/07/2023 at 2:11 PM, Staff CC stated they had to get a code from the pharmacy and have a second nurse witness when narcotics were removed from the Omnicell. Staff CC stated the code was good for one withdrawal, but the code did not have to be logged anywhere else, and they were not required to enter the medications in the narcotic count books because a second nurse had already witnessed them remove the medication from the Omnicell. When interviewed on 11/08/2023 at 11:48 AM, Staff Y stated they started employment at the facility as an Agency nurse. When asked if they had received an orientation or taken a basic medication administration test after being employed as a facility staff, Staff Y stated no. When discussed the findings from the review of the narcotic count book and resident MARS that showed Staff Y did not document the administration of 30 tablets of medication in the MAR for six residents, Staff Y stated when it was busy, they removed the narcotics from the locked drawer and entered it in the narcotic count book, but did not document in the MAR right away, and must have forgotten to do so later. Staff Y stated they had cared for Resident 131 before and the resident accused staff of not giving them their pain medication, and this was why it was important to document in the MAR that they were given. Narcotic counts not verified by two nurses: <East Unit> The narcotic count book on the East unit that was reviewed. The first three pages of the book were titled Shift Count Verification, and were dated 09/2023, 10/2023, and 11/2023. The shift count verifications were dated beginning 09/25/2023 to 11/06/2023. Review showed there were 44 instances during that period where two nurses, the one coming on shift and the one going off shift, did not document by their signature that the narcotic counts had been verified. On 11/06/2023 at 6:11 AM, Staff BB, Licensed Practical Nurse (LPN), was observed standing by Staff CC, Registered Nurse, (RN), at the medication cart while the narcotic medications were counted. Once completed, the staff left the vicinity of the medication cart, and the narcotic count book was reviewed at that time. Review showed Staff BB signed on 11/05/2023 at the 11-7 shift they were the on-coming nurse, then signed on 11/06/2023 at 7-3 shift they were the out-going nurse. There was no signature from Staff CC that showed they had verified the narcotic count for the 7-3 shift with Staff BB as the observation earlier showed. During an interview on 11/06/2023 at 11:41 AM, Staff AA, LPN, stated they had to wait for the oncoming shift, they then stood at the cart together and counted all the narcotics together, and the narcotic book was supposed to be signed at that time. If the counts were wrong, they notified Staff B, Director of Nursing or tried to determine why the count was wrong. During an interview on 11/08/2023 at11:48 AM, Staff Y, LPN, stated at the change of shift, a report was given to the oncoming nurse, and they then counted the medications. Staff Y stated the oncoming nurse looked at the pills, then Staff Y told them how many the narcotic count said would be in the medication cart, and both signed in the book the count was verified at that time. <West Unit> During an interview on 11/09/2023 at 5:06 PM with Staff B, Director of Nursing and Staff EE, Corporate Registered Nurse, Staff B stated they were given the narcotic books once the books were completed, but they did not do an audit on the books. Staff B stated they looked for staff signatures, then educated the staff when they were missing, but had not compared the narcotic count books to the MARs. Staff B stated nurses completed a medication knowledge test on hire and were paired with another nurse for 3 days. They were also given an annual competency and staff B thought narcotics management was part of the competency. Staff B stated agencies sent them a check off list and profile of their staff at hire. Staff B stated agency staff were not shadowed by another staff when they started. Staff B stated they expected nurses to sign the narcotic count book when they counted side by side with another nurse, and it was the expectation they were to sign out narcotics from the narcotic count book, remove the medication, administer it, then document on the MAR that it was given. If medications were not documented that they were administered, the next nurse could potentially give a resident another dose. Missing home narcotic medications: <Resident 2> According to a recent comprehensive assessment dated [DATE], Resident 2 was cognitively intact, able to make their needs know, and had diagnoses of chronic pain and chronic narcotic use related to bone disorders. On 10/24/2023, Oxycodone ER 20mg every 12 hours (an extended-release narcotic pain medication) was ordered by the resident's provider. During an observation of the shift change narcotic count on 11/06/23 at 06:28 AM, two nurses verified the correct count of pills in a medicine bottle, then put the pills back in the bottle and locked them back in the drawer. During an interview on 11/06/2023 at 12:23 PM, Staff B, Director of Nursing, informed this surveyor that on 11/02/2023, (prior to the above observation of the narcotic count,) they discovered that Resident 2 was missing six Oxycodone ER 20mg tabs from their medication bottle from home, which was kept in the locked drawer of the medication cart. Staff B and Staff A, Administrator stated the facility quickly began an investigation and notified the police. A review of the facility investigation showed that the medication count was 67 pills on 10/29/2023 at 6:18 PM, and the count on 11/02/2023 at 2:00 PM was 61 pills. The investigation further showed that the Staff X, LPN, admitted that they did not count the pills, because it was a home supply, and no one was supposed to be administering from it. The five nurses (NN, Y, X, AA and OO) who had access to the medication cart during that time received a written warning for failure to follow regulations related to the storage and handling of narcotics. As of the end of survey on 11/09/2023, no explanation was given to the survey team about what happened to the missing narcotics. Reference: WAC 388-97-1620(2)(b)(i)(ii)6(b)(i) See also F697 Pain Management, and F760 Free from Significant Medication Errors for additional information.

Based on observation, interview, and record review, the facility failed to consistently monitor and provide bowel care timely for 2 of 3 sampled residents (25, 7, and 50), reviewed for constipation. This failure placed the residents at risk for medical complications and unmet care needs. Findings included . <Resident 25> Per the 08/04/2023 annual assessment, Resident 25 was cognitively intact to make decisions regarding care and needed total assistance from nursing staff to complete activities of daily living such as toileting. On 11/02/2023 at 11:21 AM, Resident 25 was observed sitting in their wheelchair in their room watching television. During the conversation about care, the resident stated they had problems with constipation at times, but received something to help when it happened. Review of the October 2023 Medication Administration Record (MAR) showed on 01/23/2023, the physician had ordered a laxative (Senna tablets) to be given if the resident had not had a bowel movement in 48 hours, and if there still was no bowel movement 24 hours after receiving the senna, an additional laxative (Miralax) was to be given and the physician notified. Review of the bowel records from 10/04/2023 through 11/02/2023, showed Resident 25 had not had bowel movements for four days from 10/05/2023 through 10/08/2023, for four days from 10/11/2023 through 10/14/2023, and for six days from 10/27/2023 through 11/01/2023. Additional review of the MARS for October and November 2023, showed the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 25's record that stated the reason for the omissions or whether the physician had been notified as instructed. In an interview on 11/09/2023 at 1:39 PM, Staff DD, Licensed Practical Nurse stated the night shift nurses checked the residents bowel records, would make a list of those who needed bowel medication, and the list was given to the day shift nurses. After discussion and review of Resident 25's record which included the MARS, progress notes and physcian orders, Staff DD confirmed that bowel medication should have been given on the dates identified. <Resident 7> Per the 06/02/2023 annual assessment, Resident 7 was unable to make decisions regarding care, and needed assistance from staff for activities of daily living, such as toileting. Review of the care plan showed the resident was at risk for constipation, and interventions were initiated on 08/12/2020, which instructed nursing staff to monitor bowel movements and initiate interventions per orders. Review of the physician orders showed Resident 7 should have received Senna in 48 hours for no bowel movement and a Bisacodyl suppository for no bowel movement in 3 days. Review of the resident's bowel record from 10/04/2023 through 11/02/2023 showed the resident had no bowel movement (BM) from 10/21/2023 through 10/25/2023 (five days). Review of the October 2023 Medication Administration Record (MAR) showed the resident did not receive Senna after two days of not having a bowel movement, as directed in the orders. Resident 7 was not given Senna until 10/25/2023 and a Bisacodyl suppository on 10/26/2023. <Resident 50> Per the 08/12/2023 quarterly assessment, Resident 50 was able to make decisions regarding cares and needed assistance from staff to complete activities of daily living, such as toileting. Review of the care plan showed the resident was at risk for constipation, and interventions were initiated on 07/07/2021, which instructed nursing staff to monitor bowel movements and initiate interventions per orders. Review of the bowel record from 10/11/2023 through 11/09/2023 showed the resident had no BM from 10/14/2023 through 10/19/2023 (six days). Review of the October 2023 MAR showed the resident did not receive Senna after two days of not having a bowel movement, as directed in the orders. In addition, no documentation was found that showed the physician had been notified when the resident had no bowel movement for six days. Resident 50 was not given Senna and Miralax until 10/20/2023. During an interview on 11/08/2023 at 10:40 AM, Staff I, Licensed Practical Nurse, stated Senna should be administered for no bowel movement in forty-eight hours. During an interview on 11/08/2023 at 2:44 PM, Staff B, Director of Nursing, stated. recently the medical provider changed the orders and the expectaction was to give bowel medication on day three. Staff B changed the orders for bowel medications to start on day three on 11/01/2023. Staff B stated this was important to prevent bowel obstruction. Reference: WAC 388-97-1060 (1)

<Resident 57> According to the 8/23/2023 admission assessment, resident 57 had diagnoses which included fractured ribs. Review of the October 2023 (MARS) showed on 08/21/2023, the physician ordered a narcotic pain medication (Oxycodone) to be given every four hours as needed for pain. A comparison review of the October MAR and the narcotic book showed the nurse documented in the MAR, the resident received Oxycodone at 9:24 AM on 10/14/2023, but there were no entries in the narcotic log that showed the medication had been signed out of the locked narcotic drawer for that time frame. Additional review of the resident's record and October 2023 MAR found no documentation to state why the dose was not administered. <Resident 19> According to the 10/9/2023 quarterly assessment, Resident 19 had diagnoses which included spinal stenosis, a condition in which the spinal canal became abnormally small and resulted in pressure on the spinal cord. Review of the October 2023 Medication Administration Records (MARS) showed on 07/01/2020 the physician prescribed narcotic pain medication (Oxycodone) to be given three times a day for pain management. Per the review, the resident received the pain medication as ordered, however, when the narcotic log was reviewed, it showed the medication had not been signed out for the 4:00 PM dose on 10/11/2023. Additional review of the resident's record and October 2023 MAR found no documentation to state why the dose was not administered. <Resident 13> According to the 10/7/2023 admission assessment, Resident 13 had diagnoses which included left leg below knee amputation. In addition, the assessment showed the resident had frequent pain and received narcotic pain medication. Review of the October 2023 Medication Administration Records (MARS) showed on 09/27/2023, the physician prescribed narcotic pain medication (Oxycodone) to be given every six hours as needed for pain management. A comparison review of the October MAR showed the resident received the medication at 9:48 AM on 10/07/2023, but there were no entries in the narcotic log that showed the medication had been signed out. Additional review of the resident's record and October 2023 MAR found no documentation to state why the dose was not administered. In an interview on 11/08/2023 at 11:47, Staff Y, LPN, stated medication should be signed out of the narcotic book when removed, administered to the resident, and the MAR needed to be signed to show the medication was administered, and not doing so created discrepancies and potential risk for medication errors. During an interview on 11/09/2023 at 5:06 PM, Staff B, Director of Nursing, stated the expectation for nursing staff was to look at the MAR, pull the medication, sign it out of the narcotic book, give the medication to the resident and sign it out of the MAR to show it had been administered. Reference: WAC 388-97-1060 (3)(k)(iii) Based on record review and interview, the facility failed to ensure 6 of 17 sampled residents (7, 13, 19, 45, 57, 72), whose medications were reviewed, received their narcotic medications as ordered, received the appropriate doses of medication, and were free from significant medication errors. These failures placed the residents at risk for uncontrolled pain, over sedation and diminished quality of life. Findings included . The Omnicare Policy, General Dose Preparation and Medication Administration last revised on 01/01/2013 documented the nurse needed to observe the resident's consumption of the medication and document when medications were given. <Resident 7> Per the 08/21/2023 quarterly assessment, Resident 7 diagnoses included Alzheimer's, anxiety and had severe cognitive impairments. Per review of the physician's orders, showed Resident 7 had orders for Ativan 0.25 milligrams (mg) three times per day to treat anxiety, and the medication was to be administered at 8:00 AM, 12:00 PM and 8:00 PM. A review of the narcotic log book (a book that tracks and documents the amount of medication for medications that were required to be kept locked and secured) showed the following: Doses of Ativan 0.25mg were signed out of the narcotic book for the 8:00 AM and 12:00 PM doses on 10/21/2023, but there were two entries for the 8:00 PM dose. One entry was made at 8:08 PM, and eight minutes later, another dose was signed out at 8:16 PM. No documentation was found to show why an additional dose was pulled or whether the resident had received an extra dose. On 10/22/2023 at 4:02 PM, a dose of Ativan 0.25mg was signed out of the narcotic book for the resident. Review of the physician's orders and Resident 7's record found no documentation that there was an order for the medication to be given at that time. Review of the Medication Administration Record (MAR) for October 2023, showed a nurse signature for 10/27/2023 at 12:00 PM and 10/29/2023 at 8:00 PM, which indicated the medication was given. No entries were found in the narcotic book to show the Ativan doses has been signed out on 10/27/2023 at 12:00PM, and 10/29/2023 at 8:00 PM. <Resident 45> Per the 08/31/2023 significant change in condition assessment, Resident 45 diagnoses which included cyst of pancreas, anxiety and had severe cognitive impairments. Per review of the physician's orders, Resident 45 had orders for Hydrocodone 5mg/325mg (Norco) every 6 hours for pain management and the medication was scheduled to be given at midnight, 6:00 AM, 12:00 PM, and 6:00 PM. A review of the narcotic book showed no entries were made of the Hydrocodone being signed out of the narcotic drawer on 10/06/2023 at 6:00 PM, 10/11/2023 at midnight, 10/14/2023 at midnight, 10/29/2023 at midnight, 12:00 PM and 6:00 PM. Review of the MAR for October 2023 showed a nurse signature for the above dates, which indicated the medication was given, despite the medication not being pulled from the narcotic drawer. <Resident 72> According to the 08/27/2023 admission assessment, Resident 72 had diagnoses of Intervertebral Disc Disease (a breakdown of the cushioning discs in the back), Spondylosis (deterioration of the spinal column) and chronic pain. The resident was alert, oriented and made their needs known. On 08/21/2023, Hydrocodone-Acetaminophen (Norco) 5mg/325mg, 1 tablet by mouth every 6 hours, as needed for pain, was ordered by the resident's provider. A comparison of the narcotic book to the resident's (MAR) showed five instances where the Norco was documented as given in the MAR: 10/01/2023 at 10:53 PM, 10/2/2023 at 3:23 PM, 10/4/2023 at 2:13 PM, 10/20/2023 at 7:30 AM and 10/28/2023 at 11:40 AM, but no corresponding entries in the narcotic book were made to show those doses had been signed out and removed from the narcotic drawer.

Based on interview and record review, the facility failed to offer 1 of 5 sampled residents (Resident 4), reviewed for pneumococcal vaccinations, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer the resident the opportunity to be vaccinated with a Pneumococcal conjugate vaccine (PCV13, PCV15, and/or PCV20), and a Pneumococcal polysaccharide vaccine (PPSV23) - vaccines to prevent the development of pneumonia. This failed practice had the potential to increase the risk for the resident to contract pneumonia. Findings included . Review of a Centers for Disease Control and Prevention (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, updated 02/13/2023, showed pneumococcal vaccination was recommended for adults aged 19 through 64 years with certain chronic medical conditions. The list of conditions included chronic lung disease and asthma. Per the CDC website, for those who had not previously received any pneumococcal vaccine it was recommended to give one dose of PCV15 or PCV20, and if PCV15 was given, to follow up with PPSV23 in one year. (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html) Review of the facility policy titled, Influenza and Pneumococcal Immunizations, revised 06/08/2022, showed residents aged 19-64 with chronic medical conditions or other risk factors who had not previously received PCV, or whose previous vaccination history was unknown, were to be offered pneumococcal vaccination. Per the 04/03/2023 admission assessment Resident 4 was between the ages of 19 and 64, with diagnoses of chronic lung disease and respiratory failure, and used oxygen. Additionally, the assessment showed the resident was not up-to-date with pneumococcal vaccinations and a pneumococcal vaccination was not offered. Review of the Immunizations section of the resident's medical record did not show documentation any of the various pneumococcal vaccines were offered to the resident. During an interview on 08/04/2023 at 2:39 PM, Staff A, Director of Nursing, stated they were in charge of pneumococcal vaccinations as Staff B, Infection Preventionist, was responsible for a large amount of other duties related to infection prevention and control, including managing a current COVID-19 (a contagious viral illness that most often caused respiratory symptoms and ranged from mild to severe) outbreak in the facility. Staff A reviewed Resident 4's medical record and confirmed the resident was not offered any of the various pneumococcal vaccinations. In a follow-up interview on 08/08/2023 at 4:00 PM Staff A stated they had done additional review of the Washington State vaccine database and found no information regarding Resident 4's pneumococcal vaccination status. Per Staff A, Resident 4 was currently ill with COVID-19, and their medical provider recommended waiting until the resident recovered to offer the applicable vaccines. Reference (WAC): 388-97-1340 (1)(2)(3)

Based on observation, interview, and record review, the facility failed to implement standards of care to prevent elopement (leaving a facility without notice or supervision) for one of three sampled residents (Resident 4), reviewed for accidents/supervision. This failure placed the resident at risk of injury, becoming lost, and/or exposure to the elements. Findings included . Review of the 05/06/2023 admission assessment showed Resident 4 had a diagnosis of dementia, was moderately cognitively impaired, and required supervision with walking. During the assessment period the resident had no wandering behaviors. Per Resident 4's care plan, initiated 04/28/2023, they walked independently with a walker or a cane, and staff were to distract the resident from wandering by offering diversions such as activities or conversation. Review of the 05/24/2023 progress notes showed a care conference for Resident 4 was held that day, and included planning for discharge. Per the notes, the resident's home was an unsafe option due to the environment and the resident's need for supervision; long term care placement was discussed. Review of a 05/26/2023 facility investigation showed Resident 4 left the facility unattended without notifying staff that evening. Per the investigation, the resident was assisted out of the facility around 8:30 PM by another resident (Resident 2) who assumed Resident 4 was a visitor. Resident 4 was walking with a cane and holding a lunch box, and fell twice in the parking lot per Resident 2, who returned to the facility and reported the unidentified person (Resident 4) falling in the parking lot to nursing staff. Staff D, Medication Technician, observed the unidentified person (Resident 4) walking away from the facility, but was unable to see who the person was as they were at a distance. Staff C, Licensed Practical Nurse, searched the area where the person (Resident 4) was last seen, but they were no longer there once Staff C reached the area. Per the investigation, Staff E, Nursing Assistant, was the assigned staff for Resident 4 at the time of the incident, and at 10:00 PM that night, Staff E reported to Staff F, Nursing Assistant, that all residents in their assigned section were accounted for. In an attached statement by Staff G, Nursing Assistant, Resident 4 was last seen at 7:00 PM that night. At 12:30 AM on 05/27/2023, Staff F checked for Resident 4 in their room, were unable to locate the resident, and a search was initiated. The resident's family members and police were called; the resident was located at their home at 4:30 AM on 05/27/2023, and agreed to return to the facility when the unsafe conditions of their home and the risk to their safety was discussed. At 12:43 PM on 06/12/2023 Resident 4 was observed in their room in the facility with a Wanderguard (a device that alarms when in close proximity to a sensor placed on exit doors), attached to a bracelet on their wrist. The resident was very confused and stated they had been in the hospital for several months and had tried to leave the hospital, so the Wanderguard bracelet had been placed on them prior to coming to the facility. During the interview, the resident denied making any attempts to leave the nursing facility, denied staff discussing discharge plans with them, and denied being aware of any concerns about the safety of their living situation, stating only that their family members were cleaning up their home. In an interview at 3:34 PM the same day, Staff H, Licensed Practical Nurse, stated Resident 4 was sometimes confused and often wandered throughout the facility, and was currently wandering outside of their room. Staff H stated they knew the resident was still in the building because the Wanderguard alarm had not gone off, and that other staff would report to them periodically about the resident's whereabouts. Per Staff H, residents should be monitored at least every two hours if they were not at risk for wandering, and more frequently if they were. On 06/12/2023 at 4:13 PM, Staff B, Resident Care Manager, confirmed that residents should be checked on a minimum of every two hours, and was not sure why no staff had checked on Resident 4 from 7:00 PM on 05/26/2023 until 12:30 AM 05/27/2023 (5.5 hours). In an interview at 4:07 PM the same day, Staff A, Administrator, was asked for additional information regarding Staff E, the Nursing Assistant assigned to Resident 4 on the evening of 05/26/2023, including when the staff person had last seen the resident prior to their elopement. Staff A stated Staff E was from an agency and they would have to reach out to the staff member's agency for more information. In a follow-up interview at 4:26 PM, Staff A stated they had spoken to Staff E, who reported they thought the resident was independent and had been seen on their last rounds, prior to the report of the unidentified person (Resident 4) falling in the parking lot by another resident (Resident 2). Staff A confirmed the expectation that staff check on residents every two hours, and stated they would also have expected staff to perform a head count of all residents when Resident 2 made their report. This is a repeat deficiency; see F-689 Free of Accident Hazards/Supervision on Statement of Deficiencies dated 07/14/2022. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 6 and 7), reviewed for abuse and/or neglect, were treated with dignity and respect by all facility staff. This failure placed the residents at risk for feeling disrespected, and having a decreased quality of life. Findings included . <Resident 6> In an interview on 05/02/2023 at 1:35 PM, Resident 6 stated Staff G, Unit Secretary, was rude to them during a conversation about appointment scheduling. The resident stated the staff member became upset and raised their voice during the conversation, which took place in the resident's room, while on the phone with the State Agency. Per the resident, their scheduling concern had not been resolved so they later approached Staff G at the nursing station, where the staff member once again raised their voice at them. During the interview the resident was observed to wave their arms and increase the tone and speed of speaking (as if agitated). A written statement by a member of the State Agency dated 04/18/2023 at 9:40 AM showed while they were speaking with Resident 6 on the phone that day, a female staff member was talking to the resident in the background in a loud, harsh tone. The staff member told the resident you don't call them. After the staff member left the area, Resident 6 stated Staff G was in the room being rude and telling the resident they cannot call their doctor's office or make their own appointments. Per the written statement, the resident was not rude to the staff member during the call. Review of a facility investigation dated 04/18/2023 showed a verbal altercation between Staff G and Resident 6 at the nursing station was observed by facility staff at 11:09 AM that day. Per the report, Staff G was witnessed leaning towards the resident and pointing at them, while telling the resident they could not speak to staff that way, after the resident raised their voice and cussed at the staff member. The investigation showed Staff G was removed from the facility during the investigation, and terminated from employment. Additionally, the resident was monitored after the incident and stated they felt safe in the facility. In an interview on 05/02/2023 at 3:17 PM Staff C, Resident Care Manager, stated Resident 6 had some baseline anxiety and would become very focused on a particular area of their needs, which was sometimes difficult to redirect. Staff C stated on the morning of 04/18/2023, Staff G had gone to Resident 6's room to tell them staff had to make appointments (instead of the resident), but Staff C was not present to hear the details of that interaction. Per Staff C, Staff G and Resident 6 separated and the resident later came up to the nurse's station, where Staff C heard raised voices from their nearby office. Staff C stated both Resident 6 and Staff G were raising their voices as they talked back and forth and got into a who is gonna talk loudest issue before facility staff intervened, and assisted the resident to go for a walk. Per Staff C, Staff G's tone of voice was not aggressive or abusive. In an interview on 05/02/2023 at 4:15 PM, Staff H, Social Services, stated they were in their office near the nurse's station at the time of the incident. Staff H stated they left their office upon hearing yelling, and from the hallway saw Staff G pointing at Resident 6 and yelling, you can't talk to me like that. Per Staff H, the resident appeared surprised and confused (rather than scared) and both the resident and staff member were separated. At 3:40 PM the same day, Staff A, Administrator, stated Resident 6 wanted Staff G to schedule them a ride to Walmart on the same day as a doctor's appointment, so Staff G had to adjust the resident's schedule, which the resident did not like. Per Staff A, Staff G was terminated due to matching Resident 6's energy (rather than de-escalating the situation), when setting a boundary with the resident. <Resident 7> Review of an undated facility investigation showed a verbal altercation during the evening of 04/02/2023 between Resident 7 and Staff I, Nursing Assistant, which was reported to social services staff. The resident reported Staff I entered the room to provide care to their roommate, and when the resident asked for assistance with changing, Staff I responded they would return to assist Resident 7 after staff finished answering call lights for residents who were also waiting for care. Per the report, the resident was yelling and cussing so staff returned to the room and Staff I stated, if you keep yelling it will take longer. The resident was monitored after the incident and provided 1:1 time with social services staff to address their concerns; on 04/07/2023 Resident 7 reported that they felt safe in the facility A written statement from Staff I on 04/04/2023 documented they provided care to Resident 7's roommate and when Resident 7 requested care, Staff I told them they would return after checking on other residents whose call lights were also on. Per Staff I, they returned to Resident 7's room before finishing checking in with other residents due to hearing screaming coming from the room. Staff I documented they repeated that they would return after checking on other residents, the resident continued to scream at them, and Staff I told the resident it would take longer if the resident kept yelling. In an interview on 05/23/2023 at 1:10 PM, Staff B, Director of Nursing, stated Staff I's statement to Resident 7 was not intended as a threat of punishment or statement that staff would purposefully take longer to provide care, but as a factual statement that yelling at staff would not make the staff provide faster care or prioritize them over other residents. Per Staff B, the interaction was witnessed by another staff member who stated Staff I was not aggressive or demeaning, and additional residents were interviewed and denied concerns with Staff I's approach. Staff B stated Staff I was educated on appropriate verbal interactions with residents prior to returning to the facility. Reference: (WAC) 388-97-0860 (1)(a)

Based on interview and record review, the facility failed to follow physician orders related to follow-up appointments for 1 of 4 sampled residents (Resident 3), reviewed for skin and wound care. This failure placed the resident at risk of not receiving necessary post-operative monitoring. Findings included . Review of Resident 3's March 2023 diagnosis list showed they admitted to the facility for care after a vascular surgery (surgery related to arteries and/or veins). Per the facility admission orders, dated 03/10/2023, the resident was to have two follow-up appointments arranged by the skilled nursing facility, upon discharge from the hospital. One appointment was for post-operative care with their vascular surgery team, and one appointment was for heart conditions with their cardiologist. Review of the facility May 2023 physician orders showed an appointment with a cardiologist was set-up for Resident 3 on 03/13/2023, for two months in the future. Further review showed no appointments with the vascular surgery team for the resident. In an interview on 04/28/2023 at 4:00 PM, Resident 3's representative stated the resident was supposed to see their vascular surgeon for a post-operative visit, which the facility did not arrange. The representative stated they were not aware of the order for follow-up care until after the resident's discharge from the facility. On 05/23/2023 at 2:48 PM, Staff D, Staffing Coordinator, stated they were filling in the role of appointment and transportation scheduling temporarily as the previous scheduler (Staff G, Unit Secretary) left abruptly. (See F-557 for additional information). When asked about appointments made for Resident 3, Staff D confirmed the resident only had one appointment scheduled while they were at the facility. Staff D listed the physician (cardiologist, see above) was who the appointment was with, then stated that physician provided both cardiology and vascular services. At 3:31 PM the same day, a representative of the cardiologist's office stated the physician who Resident 3's appointment was scheduled with was a cardiologist only. Per the representative, a separate appointment with the vascular surgery team would be required for a patient requiring follow-up care from their vascular surgeon. In an interview on 05/26/2023 at 10:06 AM Staff B, Director of Nursing, stated the clinic for the cardiologist and vascular surgeon was the same, and the staff person responsible for making the follow-up appointment probably did not know that the orders for cardiologist and vascular surgeon required two separate appointments. Reference: (WAC) 388-97-1060 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of four sampled dependent residents (Residents 4, 5, 8, and 9), reviewed for activities of daily living (ADLs), received the appropriate number of baths per week. This failure placed the residents at risk for poor hygiene, loss of dignity, and a diminished quality of life. Findings included . <Resident 4> In an interview on 04/13/2023 at 2:59 PM, Resident 4 stated they were not receiving assistance with ADLs and were concerned because they had not received a shower in over a week. Per their ADL care plan, initiated 03/16/2023, Resident 4 required extensive assistance of two staff to provide a bath/shower as necessary. A frequency for bathing/showering was not listed, and there were no interventions listed for frequent refusal of ADL care. Review of the March and April 2023 Documentation Survey Report showed the resident received assistance with bathing/showering on 03/19/2023, 03/22/2023, 04/21/2023, and 04/29/2023. This represented a total of two showers per month, with a one month gap between showers. One resident refusal was listed on 04/28/2023. Observation on 05/02/2023 at 1:55 PM showed Resident 4 was lying in bed, was dressed and had no odor. The resident once again verbalized concerns for their ADL care, stating they had to put on their call light to request assistance and if they did not, it would take a long time before staff would provide care. In an interview on 05/02/2023 at 3:17 PM Staff C, Resident Care Manager, stated Resident 4 didn't always understand staff instruction related to their care plan, and would refuse to to get out of bed or refuse assistance sometimes. In a follow-up interview on 05/23/2023 at 2:45 PM, Staff C stated nursing staff turned in documentation related to bathing/showers to them, but they did not have time to review it (to ensure residents were receiving minimum standards for bathing) before turning in the documentation to Staff B, Director of Nursing. <Resident 5> In an interview on 04/28/2023 at 3:20 PM, a representative for Resident 5 stated the resident was unable to verbalize their own needs, and were dependent upon staff for assistance with ADLs. Per the representative, the resident had not received a bath during the first few weeks after admission to the facility, and did not receive showering assistance until they brought it up to staff in a care conference. Review of the ADL care plan, initiated 04/08/2023 (the day after the resident admitted ), Resident 5 required extensive assistance of one staff to provide showers twice weekly. Per the April and May 2023 Documentation Survey Report the resident received assistance with bathing/showering on 04/21/2023, 04/28/2023, and 05/03/2023. No showers/baths were documented for the first two weeks of the resident's stay at the facility. Additionally, this did not represent the two showers per week identified in the care plan. Observation on 05/02/2023 at 2:59 PM showed Resident 5 was lying in bed, dressed and without odor. The resident was only able to answer yes/no questions, and was unable to provide information related to assistance with ADLs, including bathing/showering. In an interview at 3:12 PM the same day, Staff E, Nursing Assistant, confirmed Resident 5 required assistance with ADLs, and was compliant with their care. On 05/23/2023 at 3:35 PM Staff B, Director of Nursing, stated when a resident had a shower, staff documented the condition of their skin on paper, which was turned in to nursing staff so skin concerns could be followed up on promptly. Per Staff B, that paperwork was only used for tracking new skin conditions, not to verify shower documentation and/or to audit for frequency of showers. Staff B was asked for additional documentation related to showers for Resident 5. A Skin Shower Review sheet dated 05/09/2023 was provided; however, no additional documentation showing showers in the first two weeks after admission, or showers provided at the frequency identified in the care plan (twice weekly) were available. <Resident 8> Review of the ADL care plan for Resident 8, initiated 03/30/2023, showed the resident required limited assistance of one staff for showers/baths. Review of the March and April 2023 Documentation Survey Report showed the resident received no baths/showers from the date of admission [DATE]) to the date of their discharge (04/07/2023), which was nine days. Per an electronic communication from Resident 8's representative to the facility, dated 04/06/2023, the resident had reported concerns related to a lack of ADL assistance to their family member, and the representative requested the resident be discharged from the facility the next day. Review of the April 2023 nursing progress notes showed the resident was compliant with care. <Resident 9> In an interview on 04/25/2023 at 10:59 AM, a representative for Resident 9 stated the resident was often seen in bed with unclean skin, unshaven, and covered in fecal matter, and they were concerned about the resident's care. Per Resident 9's ADL care plan, initiated 11/30/2022, the resident required extensive assistance of one staff for bathing/showering. No frequency was listed. Review of the March and April 2023 Documentation Survey Report showed the resident received assistance with bathing/showering on 04/15/2023 and 04/22/2023. There were no showers listed for March 2023, and no documented refusals in either month. In an interview on 05/02/2023 at 3:17 PM, Staff C, Resident Care Manager, stated Resident 9 was at the facility for wound care, and was forgetful but compliant with their care. Per Staff C, there had been no reports of refusals for hygiene/ADL assistance. On 05/23/2023 at 2:23 PM, Staff F, Medication Technician, stated the facility had two nursing staff on each hallway that were dedicated to shower duties. Staff F stated there was usually a shower aide scheduled each day, but the shower aide assigned that day had to leave early, prior to completing their scheduled showers. Staff F stated a binder was kept in the shower room with the unit's shower schedule, and each resident was scheduled for at least two showers and/or bed baths per week. Per Staff F, bathing and hygiene was documented in a computer system as well as on paper. When asked about shaving, Staff F stated shaving was typically performed by the shower staff during a shower, but nursing assistants could also provide shaving assistance between showers if needed. In an interview at 5:01 PM the same day, Staff B, Director of Nursing, confirmed the facility standard for bathing/showering was twice weekly. Staff B was notified of the concerns identified related to resident showers and hygiene; Staff B stated there was not currently a system in place to audit provision of bathing assistance. Reference: (WAC) 388-97-1060 (2)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written bed-hold notice at the time of, or within 24 hours of transfer to the hospital, for 1 of 3 sample residents (21), 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 Review of the facility's Notice of Bed Hold Policy Before/Upon Transfer, originally dated July 2018 and last revised November 2018, showed the facility would provide the resident and the representative a notice of written information specifying the duration of the state bed-hold policy at the time of transfer or within 24 hours, if the transfer was an emergency. Record review for Resident 21 showed they transferred to the hospital on [DATE], 05/27/2022, and again on 07/11/2022. Each transfer was related to a difficult to treat gastrointestinal bleed requiring hospital care. No documentation was found in the resident's record to show they or their representative were provided a copy of the bed-hold policy at the time of transfer, or within 24 hours of hospitalization, as required. In an interview on 07/13/2022 at 11:45 AM, Staff A, Administrator, stated that in the past, medical records had placed a bed-hold notice in the transfer packet when residents were sent out to the hospital for care and the nurses would, if possible, have the resident sign the notice before they left the building. Staff A further stated that they were not sure why, but this had not been happening since at least April of 2022, and there were no bed-holds found in Resident 21's record. Reference: WAC 388-97-0120 (4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure 1 of 1 sample residents (73), reviewed for non-pressure related skin conditions, was appropriately assessed and received treatment to ensure proper maintenance of skin that was not intact. This failure placed the resident at risk for worsening skin conditions, infection, and a diminished quality of life. Findings included . Review of Resident 73's admission record showed they were admitted to the facility on [DATE] with diagnoses including muscle weakness and diabetes. Review of the resident's 06/03/2022 quarterly Minimum Data Set (MDS) - a document which reviews the resident's condition in multiple areas, in order to develop a resident-centered/individualized plan of care, showed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating they were cognitively intact. The assessment also showed the resident was free of skin breakdown. Per review of the resident's undated Skin Care Plan showed Resident 73 had the potential for impairment to the skin, related to occasional incontinence and impaired mobility. Listed interventions included weekly treatment documentation, to include: measurement of each area of skin breakdown's width, length, depth, type of tissue, exudate (drainage), and any other notable changes or observations. Review of the resident's 07/06/2022 Order Summary Report showed an order for zinc oxide ointment - an ointment containing zinc, used to treat minor skin irritations. The report showed the ointment was to be applied to the upper gluteal cleft (the groove between the buttocks), every shift. Review of Resident 73's 07/11/2022 skin evaluation showed the resident had normal skin condition with no new wounds. Review of the resident's record contained no documentation regarding the open area to their gluteal cleft. During an observation with Staff B, Director of Nursing, on 07/12/2022 at 4:40 PM, they confirmed that Resident 73 had an open are on the left gluteal cleft that measured 0.5 centimeters (cm.) x 0.2 cm. x 0.2 cm, deep. Staff B stated that they did not know previously that the resident had an open skin area. During an interview with Staff D, Nursing Assistant, on 07/12/2022 at 4:51 PM, they stated they found the open area on the gluteal cleft a couple of weeks ago, and let the nurse know. Staff D stated being instructed to apply Z Guard (a skin protectant) to the area. During an interview with the Staff B on 07/14/2022 at 11:10 AM, they stated that it was their expectation that a nurse should have assessed the wound when it was reported on 07/06/2022, so that it could be measured and followed by the wound care team. Review of the facility's policy titled Quality of Care, Skin Integrity, dated 08/2018, showed: .29. Facility staff will monitor residents skin condition and be alert to potential changes in the residents' skin condition . Reference (WAC): 388-97-1060 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 71 was admitted to the facility on [DATE] from the hospital after sustaining multiple falls resulting in a subdural hematoma (a buildup of blood on the surface of the brain). Per the admission assessment dated [DATE], the resident had diagnoses of subdural hematoma, dementia with behavioral disturbance, repeated falls, hypoxemia (low blood oxygen level) and acute respiratory failure. The assessment also showed the resident was severely cognitively impaired, wandered, had unsteady balance, and needed extensive assistance of one staff for toileting, dressing and transfers. Wandering During observations of the resident on 07/11/2022, 07/12/2022, 07/13/2022, and 07/14/2022, the resident was seen ambulating independently in their wheelchair in the hallway and engaging in wandering type behavior. Staff would talk with the resident in passing or at the central nurses' station, but otherwise did not closely monitor the resident's movements. During these observations, a Wander Guard (a device worn by the resident that alerted staff when they were close to an exit) was on the resident's right ankle. Review of facility policy for Quality of Care for Accident Hazards/Supervision/Devices, dated 07/2018 showed that the facility would strive to identify potential safety issues for residents who wandered, and that residents who wandered would be evaluated to identify root causes to the degree possible. A care plan initiated on 06/23/2022 showed interventions related to the resident's risk for wandering/elopement. Interventions included identifying patterns of wandering and assessing the risk for falls. The care plan did not reflect a revision after 07/07/2022. In an interview on 07/12/2022 at 2:53 PM Staff S, Nursing Assistant, confirmed the presence of a Wander Guard on Resident 71's right ankle. Staff S stated that the resident wandered but mostly stayed in the hallways. In an interview on 07/13/2022 at 2:00 PM Staff X, Medication Technician, stated that in the past the restorative aides had checked the Wander Guards weekly to make sure they were working, but they were not sure if that was happening anymore. Staff X further stated they knew the Wander Guard was working because when the resident got near an exit there would be an alarm. In an interview on 07/13/2022 at 2:00 PM Staff Y, Licensed Practical Nurse, confirmed there was no order, consent, or care plan for the resident to wear a Wander Guard (which they were currently wearing on their ankle). In an interview on 07/13/2022 at 2:47 PM with Staff Q, Resident Care Manager, they stated that the resident had shown some exit-seeking behavior early on after their admission, and the staff had placed a Wander Guard on the resident on a Friday late afternoon, when they were found in the lobby near the front doors, to alert the staff if the resident was trying to exit the building over the weekend. It was determined within the next several days the resident had removed the device and thrown it away and Staff Q understood it was not to be replaced, and did not know by whom or when it had been replaced. The Wander Guard was removed from the resident's right ankle by nursing staff on 07/13/2022. Further evaluation of what level of supervision the resident required for safety related to wandering behaviors was not found in the resident record. Falls Review of the facility's incident log showed the same resident fell on [DATE], 07/10/2022, and again on 07/12/2022. Nursing progress notes from the falls on 07/01/2022 and 07/10/2022 showed that the resident was found on the floor in common areas. Each note determined the resident was attempting to independently transfer or walk. The nursing progress note on 07/12/2022 showed that the resident was found on the floor in their room. Review of facility policy for Quality of Care for Accident Hazards/Supervision/Devices, dated July 2018, showed that when a fall occurred the facility would determine if injuries occurred and provide necessary treatment. A care plan initiated on 06/23/2022 showed interventions related to the resident's high risk for falls. Interventions included ensuring the resident was wearing appropriate footwear when up in their wheelchair, encouraging the resident to remain in high visibility areas, encouraging the resident to use mobility aides when ambulating, ensuring commonly used items were within reach, and use of redirection and distraction by staff. The care plan did not reflect a revision after 07/07/2022. None of the falls were witnessed by staff, and the resident reported hitting their head on 07/01/2022 and possibly on 07/10/2022. In nursing progress notes for both falls, it was noted that a neurological (neuro) assessment (consists of a set of timed assessments completed by a nurse after a possible head injury to identify signs of disorders affecting the brain, spinal cord or nerves) was started. The note on 07/12/2022 showed that the resident stated they had not hit their head, and the nurse checked the resident and did not find any injury to their head. During record review, neurological assessment documentation was not found for any of the falls in the resident record. When requested to produce any supporting documentation related to post fall monitoring of the resident Staff B, Director of Nursing, found a partially completed neurological check for the fall on 07/10/2022, but not for either of the other falls. Investigations related to the falls were requested, and one investigation for the fall on 07/01/2022 was received from Staff B, Director of Nursing on 07/13/2022 at 2:47 PM. Staff B confirmed that the other two investigations had not been completed. The investigation, completed 07/13/2022, gave no evaluation of potential causal factors for the falls, and no suggestions for how to prevent further falls. In an interview on 07/13/2022 at 2:47 PM Staff B, Director of Nursing, stated they thought neurological checks should have been completed for two of the three falls, and it was not the facility practice to rely on a cognitively impaired resident to report if they hit their head or not. Staff B stated that the nurse visually checking the resident for any head injury on 07/12/2022 was adequate treatment. Reference: WAC 388-97-1060(3)(g) Based on record review and interview, the facility failed to ensure 2 of 5 sample residents (19, 71), reviewed for accidents, were appropriately assessed after they experienced a fall. Neurological checks were not completed for the residents, after they experienced falls during which they hit their head (or it was unknown if they hit their head). This failure placed the residents at risk for unidentified latent injuries. In addition, the facility failed to ensure that a wandering resident (71) was consistently assessed for the root cause of the behavior, and that additional interventions were put in place to prevent wandering, potentially outside of the facility unsupervised, and that an alarm was put in place without an assessment for neccesity, an order, or consent. This failed practice place the resident at risk for continued wandering behavior, distress from the alarm, and a diminished quality of life. Findings included . Review of Resident 19's admission record showed they were admitted to the facility on [DATE], with diagnoses including heart failure and pulmonary hypertension (high blood pressure in the blood vessels that supply the lungs). Per review of the resident's 03/07/2022 Fall Risk Care Plan showed they were at risk for falls. Interventions included anticipate and meet needs, and Encourage (Resident 19) to use mobility aides (walker) when ambulating/transferring. The 03/08/2022 Fall Risk Evaluation, showed a score of 5 (a low risk for falls). A progress note on 04/15/2022 showed, Resident had a fall this AM (morning). Was walking to the shower room for a weight with FWW (four-wheel walker). Became weak and fell. Reports that he hit the top of his head. Resident 19's quarterly assessment on 05/05/2022 showed the resident was moderately cognitively impaired, and required supervision from staff for set up only, for transfers to and from the bed or chair and with ambulation. The assessment also showed the resident experienced one fall with major injury since their admission date. Comprehensive review of the resident's record showed no neurological checks were completed after the fall on 04/15/2022, in which the resident reported hitting their head. During an interview with Staff B, Director of Nursing, on 07/14/2022 at 9:01 AM, they were unable to locate neurological checks for Resident 19 after the fall on 04/15/2022. Staff B stated their expectation was neurological checks would be completed if a a resident was known to have hit their head during a fall, or if it was undetermined whether or not a resident hit their head during a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently monitor nutritional status for 2 of 4 sample residents (21, 15), reviewed for weight loss. Failure to consistently monitor weights and/or reassess residents after a significant weight loss, placed the residents at risk for a decline in nutritional status, and further weight loss. Findings included: Resident 21 had three admissions and discharges between 04/22/2022 and 07/11/2022. The most recent assessment dated [DATE] showed the resident was severly cognitively impaired, and required total assistance via tube feeding to eat (therapy where a flexible tube is inserted through the abdomen to supplies nutrients to people who cannot get enough nutrition through eating). Review of weight records showed Resident 21 weighed 108.2 pounds on 04/23/2022. The resident's weight remained stable through 05/18/2022, when a weight of 108.5 pounds was recorded. The next documented weight was 103.4 pounds on 06/06/2022 (a loss of over five pounds in 18 days). Resident 21's weight showed a small increase on 06/08/2022 - up to 105.4 pounds, with the next recorded weight on 06/20/2022 of 102.0 pounds (a loss of over three pounds in 11 days). Per a 06/24/2022 nutrition progress note, the weight loss was identified, and nursing staff were to re-weigh the resident. The note also showed that if weight loss was confirmed upon re-weigh, the resident may be changed to a higher calorie formula. On 06/25/2022, the resident record showed a weight of 101 pounds. No further documentation, related to an assessment of the resident's weight loss or nutritional status was found, until a nutrition progress note on 07/05/2022. The note showed the same formula as prior to the weight loss, with an increase in the rate of administration on 07/05/2022, but over fewer total hours during the day. The note showed that this was done to encourage an appetite to develop for the resident, in order to begin trial food intake by mouth. The food trial by mouth was then held on 07/06/2022 until 07/11/2022, related to the resident having multiple appointments out of the facility. No further adjustment to tube feeding was made for this time period. On 07/11/022 at 8:40 AM, Resident 21 was observed laying in bed with the tube feeding disconnected. The resident looked thin and pale. The resident was not interviewable. In an interview on 07/13/2022 at 3:58 PM, Staff E, Registered Dietician, was asked about on-going monitoring after weight loss had been identified. Staff E stated that they attended a staff meeting weekly, to discuss residents with the interdisciplinary team. If a resident was determined to be losing weight, they would be weighed weekly for four weeks, or until their weight was stable. Staff E further stated Resident 21 was identified as having weight loss, and should have been weighed at least weekly. Staff E stated they were aware of the weight loss, and had made adjustments in the care plan. In an interview on 07/14/2022 at 11:31 AM with Staff R, Resident Care Manager, they stated that everyone on Resident 21's unit should be weighed weekly. Staff R confirmed the gap in recorded weights for Resident 21, and could not provide any concrete explanation for why it had happened. Per the 05/04/2022 admission assessment, Resident 15 had diagnoses which included inflammatory bowel disease, diabetes, and malnutrition. In addition, the assessment showed the resident received nutrition using a feeding tube (a flexible tube inserted through the abdominal wall into the stomach, to allow nutritional formula and fluids to be given), and weighed 198 pounds. Per the 04/29/2022 nutrition care plan, Resident 15 had a potential nutritional deficit due to poor appetite, diverticulosis (a disease that causes inflammation of the bowel, and alteration in the bodies ability to absorb nutrients), and the need for a feeding tube. Interventions instructed nursing staff to offer alternative food choices for food not eaten, monitor intake, and to weigh the resident at the same time of day and record the value. No instructions for how frequently the resident should be weighed were found. On 07/12/2022 at 9:12 AM, Resident 15 was observed lying in bed and stated they had lost a lot of weight since being admitted to the facility. Review of the Order Summary report from 04/28/2022 through 07/13/2022 showed Resident 15 had been prescribed diuretics, medication used to help the kidneys get rid of excess fluid in the bloodstream and tissues, as well as nutritional supplements/protein drinks. A review of the progress notes from 04/28/2022 through 07/13/2022 showed Resident 15 disliked the feeding tube and due to improvement in eating/intake, the feeding tube was discontinued on 05/09/2022. A review of the weight summary record showed Resident 15 weighed 201 pounds when admitted to the facility on [DATE]. The resident's weight remained stable from admission until 05/05/2022, at which time their weight was 202 pounds. The next recorded weight was thirteen days later (05/18/2022), and the resident weighed 178 pounds - a loss of 23 pounds. The resident was re-weighed later that same day and their weight was 175 pounds. On 05/19/2022, the resident was again reweighed and was at 176 pounds. Twelve days later, on 05/27/2022, the weight was recorded at 173.8 pounds, a total loss of 27.2 pounds since admission the month before. No documentation was found to show the resident was weighed again until 06/14/2022. At that time, the weight was 144.6 pounds, a loss of 56.4 pounds since admission, and 29.2 pounds since the previous weight done 18 days prior. No other recorded weight was found from 06/14/2022 until 07/05/2022, at which time the resident weighed 134.6 pounds, a loss of 66.4 pounds since admission. A review of the nutritional notes summary provided by Staff E, Dietician, on 07/14/2022, showed on 04/29/2022 during the new admission nutrition evaluation, the dietician recommended the resident be weighed weekly for four weeks and until stable, then monthly or per facility protocol. Further review of the nutritional progress notes from 04/28/2022 until 07/12/2022 showed on 05/19/2022, the resident was noted to have had a 26 pound weight loss which was the result of fluid loss from prescribed diuretics (medication that helps the kidneys get rid of excess fluid in the bloodstream and tissues), and the resident's poor intake. On 06/24/2022, Staff E requested staff to re-weigh Resident 15, due to rapid weight loss. On 07/12/2022, Staff E documented Resident 15 had lost 66 pounds since admission, and the loss was attributed to fluid loss and poor oral intake, and again recommended for the resident to be weighed weekly for four weeks. In an interview on 07/13/2022 at 11:54, Staff Q, Nursing Assistant, stated facility policy was to weigh the residents weekly unless ordered differently, and the values were given to the nurse to enter into the resident's record and follow up on any abnormal values. During a follow-up interview on 07/13/2022 at 4:09 PM, when asked about the weight loss, Resident 15 stated they had lost about sixty pounds, and that was because they had been very ill and did not have much of an appetite. Resident 15 further stated they did not want the feeding tube, and their appetite was still not very good, but was much better than before. In an interview on 07/14/2022 at 11:32 AM, Staff R, Resident Care Manager, confirmed weights were supposed to be done weekly, and the nurse documented the values. After review of Resident 15's records, Staff R confirmed weights had not been taken consistently, as was the facility policy. Staff R further stated that the resident was admitted with a lot of excess fluid, was very ill and could be resistive with allowing care, but refusals of weights and/or care should be documented. Reference: WAC 388-97-1060 (3)(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 sample residents (67), reviewed for unnecessary medications, had adequate justification for use of anti-psychotic medication (medication used to treat psychosis and other mental and emotional conditions). This failure placed the resident at risk for adverse side effects and a diminished quality of life. Findings included . Per review of admission records, Resident 67 was admitted to the facility on [DATE] with multiple diagnosis to include depression. A review of Resident 67's June and July 2022 Medication Administration Records (MAR) showed the resident received an antipsychotic medication for a diagnosis of depression. The record additionally showed that resident was receiving two other medications for depression. Per the record, the resident was seen by Staff W, Nurse Practitioner, on 06/22/2022, 06/27/2022, 06/29/2022, and 07/05/2022. All progress notes showed the resident had depression, fibromyalgia (a chronic disorder characterized by pain and fatigue), and chronic pain with a suspected underlying psychiatric issue. The resident was seen by Staff X, Medical Director, on 06/24/2022; the progress note showed diagnoses of depression with fibromyalgia, a question about the use of Risperdal (a medication used to treat psychosis and mood disorders), and most likely an underlying psychiatric component. In an interview on 07/13/2022 at 11:10 AM with Staff W, Nurse Practitioner, when asked why the resident was receiving Risperdal for a diagnosis of depression, they reported that the resident was admitted with this order from the hospital. Staff W also stated that the hospital had the diagnosis of depression and chronic pain for the justification of the anti-psychotic medication. They stated that the diagnosis was unspecific from the hospital, and they did not feel comfortable placing a diagnosis of a psychotic disorder at that time. Staff W, Nurse Practitioner added the diagnosis of a mood disorder on 07/12/2022. They added that the resident needed to go see a psychiatrist to get a diagnosis of a psychotic disorder. When asked if that service has been offered to the resident, they responded no. The record showed the resident was still on the anti-psychotic medication, with no specific diagnosis for its use. WAC: 483.45(c)(3)(e)(1)-(5)

Based on observation, interview, and record review, the facility failed to provide a variety of sugar-free fluid choices for 1 of 2 residents (234), reviewed for hydration. This failure placed the resident at risk for dehydration and a decreased quality of life. Findings included: Per the 06/23/2022 admission assessment, Resident 234 was able to make their needs known, and had a diagnosis of diabetes, a disease where the body is not able to break down the sugar from the food or fluids consumed, into energy. On 07/11/2022 at 11:16 AM, Resident 234 was observed lying on their bed watching television. When asked about the care at the facility, the resident stated the care was fine, but there needed to be more options for sugar-free drinks and juice aside from lemonade, water, or coffee. At 11:46 AM, while lunch trays were being passed, lemonade was observed on Resident 234's meal tray. On 07/13/2022 at 11:12 AM, an observation of the snack/beverage cart showed there was lemonade, sugar-free hot cocoa, coffee, and tea available (as the sugar-free options available). The cart also contained non-sugar free options of apple juice, orange juice, and cranberry juice. The 06/19/2022 admission dietary profile showed the resident liked orange juice. In an interview on 07/13/2022 at 11:25 AM, Staff Z, Medication Assistant/Nursing Assistant, stated there were no real sugar-free options except lemonade that they were aware of. At 11:55 AM the same day, when asked what sugar-free options were available, Staff Q, Nursing Assistant, stated the lemonade, coffee, and the sugar-free hot cocoa were the only options, to their knowledge. On 07/13/2022 at 4:14 PM, when asked what sugar-free options for fluids were available, Staff E, Dietician, confirmed the sugar-free lemonade and the sugar-free hot cocoa were the only options. Reference (WAC): 388-97-1060 (3)(i), 1100 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Per the 07/03/2022 admission assessment, Resident 82 was dependent on staff for assistance with bathing. According to the resident's care plan dated 06/27/2022, they were to receive a shower weekly and as needed. The resident's preference for baths or showers, and day of week were not listed on the care plan. A review of the bathing record from 06/27/2022 through 07/14/2022 showed resident had a bed bath on 07/13/2022 and 07/14/2022. The document showed the resident was unavailable for a bed bath on 06/27/2022. There were no other bed baths or showers documented on the bathing record, or elsewhere in Resident 82's record. On 07/12/2022 at 9:10 AM, the resident was observed receiving a bed bath. There was a 14-day gap from the time of admission until the bed bath was given on 07/12/2022. In an interview on 07/12/2022 at 11:04 AM, the resident stated they had received one bed bath since being in the facility, and it was that morning. In an interview on 07/13/2022 at 2:03 PM, Staff Q, Nursing Assistant, stated that they worked as a bath aide, and were often pulled to work the floor. They stated that the showers did not get done if they had to work the floor. They stated when they were able to complete showers, a list would be made as to when the residents last showers/baths were given, and they prioritized who needed them first. In an interview on 07/14/2022 at 10:40 AM, Staff R, Resident Care Manager, stated that the number of showers getting completed depended on the staffing for the day. Reference (WAC): 388-97-1060 (2)(c) Based on interview and record review, the facility failed to consistently provide showers for 5 of 8 sample residents (21, 10, 37, 234, 82), reviewed for bathing. This failure placed residents who were dependent on staff for care, at risk for poor hygiene and a diminished quality of life. Findings included: According to Resident 21's most recent admission assessment dated [DATE], they were dependent on staff for personal hygiene and bathing. Per review of the resident's care plan, they were to receive a shower weekly and as needed. The resident's preference for days of the week and/or showers or baths was not included in the care plan. Review of Resident 21's shower record from their most recent admission showed four showers were completed during the period of 05/27/2022 until 07/11/2022 (48 days). No refusals were documented during that time period. In an interview on 07/13/2022 at 11:52 AM., Staff Q, Shower Aide, stated they could not say how frequently they had been pulled from giving showers to work as a nursing assistant on the floor, but they did not come to work with the expectation of doing showers. Staff Q further stated that if there were enough nursing assistants working on any given day, then they would complete scheduled showers, and if not, the showers did not get done. On 07/13/2022 at 2:29 PM, Resident 21's shower record was reviewed with Staff B, Director of Nursing. Staff B stated that when a shower aide was pulled to the floor, staff tried their best to provide missed showers the next day. Staff B further stated they were aware that there were shower issues in general. Per the 06/23/2022 admission assessment, Resident 234 was admitted to the facility on [DATE], and needed assistance from one nursing staff to complete activities of daily living such as bathing. On 07/12/2022 at 9:50 AM, Resident 234 was observed lying on their bed watching television. When asked if they were getting assisted with cares such as bathing, the resident stated they were not being bathed. The 06/17/2022 admission care plan showed Resident 234 had an activities of daily living self-care deficit, and needed extensive assistance from one nursing staff to provide bathing/showers. A review of the bathing record from 06/27/2022 through 07/11/2022 showed Resident 234 had received a shower on 07/05/2022, 18 days after being admitted to the facility. No other documentation was found to show the resident had been bathed either before that date or afterwards. In an interview on 07/13/2022 at 11:52 AM, Staff Q, Shower Aide, stated the shower aides were sometimes pulled to work the floor to provide resident care, when there were not enough nursing assistants. Staff Q stated when that happened, the nursing assistants attempted to bathe the residents, but it was a challenge to get them done. During an interview on 07/13/2022, Staff B, Director of Nursing, confirmed that the shower aides were sometimes pulled to do resident care, and stated the facility was aware that there were issues with bathing not being completed. Review of the 11/03/2021 admission record showed Resident 10 was admitted to the facility with diagnoses including dementia and chronic obstructive pulmonary disease (COPD - a type of lung disease causing permanent damage to tissues in the lungs, making it hard to breath). Review of the resident's 04/22/2022 quarterly Minimum Data Set (MDS) - a document which is completed to determine a resident-centered/specific care plan, showed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which showed severe cognitive impairment. The assessment also showed the resident required extensive assistance from one staff member to complete personal hygiene. The assessment also showed bathing did not occur during the seven day assessment period. Review the Resident 10's undated ADL (Activities of Daily Living) Care Plan, showed they had a self-care performance deficit in that area. Interventions included, (Resident 10) is extensive assist of (1) staff member to provide bath/shower and as necessary. Per review of the the facility's undated shower schedule showed Resident 10 was to receive a shower weekly, on Mondays. Review of the resident's shower records for June and July 2022 showed they did not receive as scheduled showers on 06/04/2022, 06/11/2022, 06/18/2022, 06/25/2022, or 07/02/2022 (a period of almost a month). The document showed the resident received a shower on 07/09/2022. Resident 10 was not able to be interviewed, due to their poor cognition. During an interview with Staff D, Nursing Assistant, on 07/13/2022 at 1:58 PM, they stated Resident 10 wanted showers on Saturdays. Staff D stated they were often pulled to the floor to provide direct care (instead of providing showers). Staff D stated, If I get pulled (from giving showers to provide direct care on the floor), the showers just don't get done on that day. If I can't give all of them (scheduled showers in a day), I try to squeeze one or two in, in addition to the scheduled showers, on the next day. Review of Resident 37's 08/01/2017 admission record showed the resident was admitted with diagnoses including dementia and heart disease. Review of the resident's 05/27/2022 quarterly MDS (defined above) showed the resident had a BIMS score of six out of 15, which showed severe cognitive impairment. The assessment also showed the resident required extensive assistance from one staff member to complete hygiene and bathing. Review of Resident 37's undated ADL Care Plan, showed the resident had a self-care performance deficit in that area. Interventions included, (Resident 37) is dependent assist of (1) staff member to provide bath/shower twice weekly in the evening and as necessary. The facility's undated shower schedule showed the resident was to receive a shower twice weekly, on Sundays and Wednesdays. Review of the resident's shower records for June and July 2022 showed they did not receive as scheduled showers on 06/02/2022, 06/19/2022, 06/22/2022, 06/29/2022, or 07/06/2022 (a period of almost a month). The document showed the resident received a shower on 07/09/2022. Resident 37 was not able to be interviewed due to their poor cognition. During an interview with Staff D, Nursing Assistant, on 07/13/2022 at 2:08 PM, they stated Resident 37 did not like anyone to shower them but Staff D. They stated the resident had not been showered recently because Staff D had not been working as a shower aide on the side of the building where the resident resided. During an interview with Staff B, Director of Nursing, on 07/13/2022 at 2:30 PM, they stated if a resident's shower was missed, the shower aides were to try their best to catch up on the showers the next day. Staff B stated, We just try to add two or three (missed showers) to each the following day to try to catch them up. Staff B stated their expectation was showers were to be done as scheduled for each resident.

Based on record review and interview, the facility failed to ensure two nursing assistants (K, L), out of five staff reviewed for annual in-service training, were provided dementia training as required. This failure had the potential to affect the quality of life or care for those residents with dementia. Findings included . Review of the facility's Training Requirements policy dated 05/2019 read in part, 4. Training will be provided to staff upon hire, annually and as needed. 5. The training will address forms of abuse, neglect, misappropriation of resident property, exploitation and dementia training. 6 f. Education on factors related to dementia care and behavioral symptoms that may increase the risk of abuse and neglect . Review of Staff K, Nursing Assistant's (NA), personnel file showed the staff member was hired on 05/09/2022. Review of Staff K's training records showed none of the required dementia training had been completed. Review of Staff L, NA's personnel file showed the staff member was hired on 06/13/2022. Review of Staff L's training records showed none of the required dementia training had been completed. During an interview with Staff H, Director of Human Resources on 07/14/2022 at 10:12 AM, they stated staff members received dementia training through RELIAS (the facility's computerized training system). Staff H acknowledged dementia training was not completed for Staff K or Staff L. Staff B stated, New hires should get the dementia training on their first day, and annually for all employees. Reference (WAC): 388-97-1680 (1), (2)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide menus to allow residents the choice of an alternative mea1 for 4 of 11 residents (234, 15, 43, 78), reviewed for food. In addition, the facility failed to ensure Resident 73 received meals that accommodated the resident's preferences. These failed practices had the potential to negatively affect the nutritional needs of the residents, result in a diminished quality of life, and a lack of independence with choices. Findings included . According to the 06/23/2022 admission assessment, Resident 234 was cognitively intact and able to make decisions regarding their care. On 07/12/2022 at 2:23 PM, Resident 234 was lying on their bed watching television. When asked about the food, the resident stated, when they first admitted to the facility a weekly menu was handed out, but that stopped after about two weeks. There is an alternative meal you can request, but it had to be done 2 to 3 hours before the meal. How can you do that when you do not know what the meal is in the first place? The 05/04/2022 admission assessment showed Resident 15 was cognitively intact and able to make decisions regarding their care, and had diagnoses which included malnutrition and diabetes (a disease where the body cannot break down sugar in the food/fluid eaten into energy). On 07/12/2022 at 9:08 AM the resident was observed lying on their bed. When asked about the food, the resident stated the food was terrible, and often they did not know what was going to be served. At 2:43 PM, when asked how lunch was, Resident 15 pointed to their bedside table, stated they did not care for the lunch, and staff brought a sandwich and some grapes. No menu was observed on the lunch tray. In a follow-up interview on 07/13/2022 at 4:09 PM, Resident 15 stated, Sometimes there was a menu on the meal tray, but what good does that do when you get it after the tray comes? The 06/13/2022 admission assessment showed Resident 43 was cognitively intact and able to make decisions regarding their care. On 07/11/2022 at 3:08 PM, when asked about the food, Resident 43 stated, Each meal is a surprise, you don't get a menu unless you ask for one. On 07/12/2022 at 9:43 AM, Resident 43 was observed sitting up in bed watching television. The resident's breakfast tray was on the bedside table; no menu was observed on the tray. The 06/14/2022 admission assessment showed Resident 78 was cognitively intact and able to make decisions regarding their care. On 07/11/2022 at 3:37 PM, Resident 78 was observed lying on their bed reading a book. When asked about their care at the facility, the resident stated, You never know what the meal is going to be, you don't get a menu and sometimes if you do, you don't get what was listed. They do have alternatives you can request, but you have to let the kitchen know two hours ahead of time. In an interview on 07/13/2022 at 11:25 AM, Staff Z, Medication Assistant/Nursing Assistant, stated they believed the residents were given weekly menus and if they did not like what was being served, they needed to let staff know an hour or two in advance of the meal. At 11:55 AM that same day, Staff Q, Nursing Assistant, stated menus used to be given to the residents at the beginning of each week, but lately that was not being done. Staff Q stated if they were aware the resident did not like what was being served, they could request the alternative, but it needed to be done one to two hours before the meal was served. In an interview on 07/13/2022 at 4:14 PM, Staff E, Dietician, stated menus used to be kept at the nurse's station and if residents ask for a menu, one could be printed. When informed that several residents reported not being able to request the alternative meal due to not being provided menus, Staff E stated they believed the kitchen manager provided the menus, but they were not sure how that was coordinated. Review of Resident 73's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (when the heart muscle doesn't pump blood as well as it should). Review of the resident's 04/26/2022 Dietary Profile, showed Resident 73 disliked wheat bread, oatmeal, scrambled eggs, fish, pork, ravioli, rice, zucchini, and pasta. Review of the resident's 06/30/2022 quarterly assessment, showed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of Resident 73's undated diet card showed no listing of the resident's food preferences. During an interview with the resident on 07/11/2022 at 1:58 PM, they stated not liking tomato sauce or pasta and stated, The food used to be good, but now not much of it is inedible. Much of it (the food) is covered in tomato sauce. A lot of pasta and a lot of tomato sauce (is served), and I can't handle tomato sauce. Observation of Resident 73 in their room during meal service for lunch on 07/12/2022, between 12:36 PM and 12:45 PM, Staff F, Nursing Assistant, served the resident a room tray with chicken parmesan with tomato sauce and spaghetti noodles, garlic bread, and green beans. Staff F cut the resident's chicken into strips and told the resident what was on the plate. The resident stated, I don't like noodles, and Staff F stated, I know. Resident 73 then stated, I don't like tomato sauce. Staff F stated, There isn't too much tomato sauce on there. Staff F continued to cut the resident's chicken and prepare the meal, and then exited the room. The resident was not offered an alternative meal, or an alternative to the spaghetti or the tomato sauce. During an interview with Staff F on 07/12/2022 at 12:48 PM, they stated alternatives were available for residents who requested them. Staff F then stated, I don't know what the alternative (meal) is. I just cut up his chicken because he likes chicken. Staff F acknowledged not offering Resident 73 an alternative meal, after they stated not liking the noodles or tomato sauce. Staff F was not observed to approach the resident, to ask if they would like an alternative meal, even after the interview was conducted. During an interview with Staff I, Assistant Dietary Manager, and Staff J, District Dietary Manager, on 07/14/2022 at 2:00 PM, they stated Resident 73 was assessed for food preferences upon admission to the facility and then quarterly after that. They stated after each assessment, the resident's dietary preferences were updated in the facility's meal tracker system, to ensure they did not receive foods they disliked or had an allergy to. Staff I and J stated menus were printed daily, and posted on a wall outside of the facility dining room. They stated the nursing assistants were able to check the menus on the wall, and then tell each resident what the meal options were, prior to each meal service. They stated an Always Available Menu was also kept at the nurses station, and the nursing assistants were able to give that information to the residents, if requested. Staff J stated, It looks like egg noodles were put into the meal tracker instead of all noodles (related to Resident 73's disliked foods). Maybe there was a miscommunication. Staff J stated their expectation was that nursing assistants would come to the kitchen to request alternative meals if needed stating, We have sandwiches, salads, extra hamburgers and extra alternatives meals available if someone refuses or does not like what is being served. Reference: (WAC) 388-97-1160(1)(a)(b)

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 9 staff (M, I, F, S, T, O, U, P, V), when reviewing infection control practices. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. Findings included According to the CDC document, How to use Your N95 Respirator, dated 03/16/2022, N95 masks (a protective mask that is used to help prevent the spread of disease by filtering airborne particles) must form a seal to the face to work properly. The N95 should be placed under the chin, with the nose piece bar at the top. The top strap should be pulled over the head and placed near the crown, and the bottom strap should be placed at the back of the neck, below the ears. The straps should lay flat, untwisted, and not be crisscrossed. Per the 02/22/2022, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, published by the CDC, eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The facility's 03/2021 Infection Prevention and Control Program (ICPC) Policy, read, in part, Purpose: The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; and Standard Precautions: 1.Staff will use standard precautions when providing care to residents who do not require special precautions, and 3. The type of PPE [Personal Protective Equipment] used for resident contact will be dependent on the type and extent of blood, body fluid or pathogen exposure anticipated during the resident interaction. On 07/11/2022 at 2:41 PM, Staff M, Nursing Assistant, was observed wearing an N95 mask with both straps placed behind their neck. At 3:13 PM, Staff I, Assistant Dietary Manager, was observed wearing an N95 mask with one of the straps positioned in front of the mask. On 07/12/2022 at 12:42 PM, Staff F, Nursing Assistant, was observed wearing googles that were placed on top of their head, while passing resident meal trays. At 12:54 PM the same day, when asked when eye protection should be worn, Staff F stated it should be worn when in resident care areas. Staff F stated the googles were placed on the top of their head because they got fogged up when they were on, and it made it difficult to see. At 2:44 PM on 07/12/2022, Staff S, Nursing Assistant, was observed wearing an N95 with the mask straps positioned behind their neck. At 4:36 PM the same day, both Staff S and Staff T, Occupational Therapy Assistant, were observed sitting at the nursing station with their N95 straps placed behind their necks, and at 4:47 PM, Staff D, Nursing Assistant, was also observed with their N95 straps placed behind their neck. On 07/13/2022 at 9:34 AM, Staff O, Licensed Practical Nurse, was observed wearing an N95 placed around their chin. The mask was not covering the mouth or nose, as required. At 12:17 PM the same day, Staff U, Licensed Practical Nurse, was observed wearing an N95 with both mask straps placed on top of the head above their hair clip. When asked how the straps should be placed, Staff U felt the mask straps and stated the straps were moved so they could drink some water and they did not reposition them back afterwards. Staff U then repositioned the straps to place the bottom strap behind their neck. At 2:49 PM the same day, Staff P, Nursing Assistant was observed sitting at the nurse's station on the east unit without an N95 mask on. When asked when N95s should be worn, Staff P stated there had been training two weeks ago, and masks were to be worn when there was a resident on precautions for COVID-19. Staff P further stated the mask made it difficult to breath, and they sometimes needed to take it off for a few minutes. At 3:18 PM, Staff V, Nursing Assistant, was observed with both straps of their N95 positioned on the top of their head. When asked about the strap positions, Staff V stated it was important to have a good seal, and the straps were on top of their head because they get a good seal wearing the N95 mask in that manner. On 07/14/2022 at 8:48 AM, Staff S was again observed wearing an N95 with both straps placed around their neck. When asked, Staff S confirmed the straps were not placed properly and moved the top strap to the top of their head. In a combined interview on 07/14/2022 at 10:57 AM, with Staff B, Director of Nursing, and Staff C, Infection Preventionist, Staff B stated all staff should be wearing their PPE correctly and there, had been ongoing training and education about the proper use and wearing of PPE. Reference (WAC): 388-97-1320 (1)(a)