Based on interviews and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 sampled residents (Resident 1) reviewed for medication management. The failure placed residents at risk for adverse events related to missed medications.Findings included .<Resident 1>Review of Resident 1's care plan, dated 02/06/2025 showed they had a diagnosis of a shoulder fracture and chronic pain. The same care plan had interventions, dated 02/11/2025, that included: the resident's pain is alleviated/relieved by rest and medications and administer analgesia (pain medication) as per orders.Review of the resident's admit orders, dated 02/06/2025, showed the following narcotic pain medication:-Morphine 30 mg (milligram) immediate release (IR) (a short acting, strong narcotic pain medication): Take 1 tablet by mouth twice daily. Review of Resident 1's Medication Administration Record (MAR) for August 2025 showed an order dated 02/06/2025, for Morphine 30 mg to be given two times daily at 7:00 AM and 7:00 PM. On 08/07/2025 at 7:00 PM the MAR shows code OO (on order). On 08/08/2025 at 7:00 AM the MAR shows code 9 (other/see progress note). On 08/08/2025 at 7:00 PM the MAR shows code OO.Review of Resident 1's progress notes showed on 08/07/2025 at 9:20 PM, Staff D, Licensed Practical Nurse (LPN), wrote the residents Morphine 30 mg was on order from the pharmacy. On 08/08/2025 at 8:04 AM, Staff E, Registered Nurse (RN), wrote, med not available, pharmacy called and [stated] need new script provider called, waiting for script to be sent to pharmacy. Further review showed that on 08/08/2025 at 3:22 PM, Staff D, wrote, called pharmacy to check on status of Morphine order, was told that 60 tabs would arrive on the morning run. On 08/09/2025 at 2:41 PM Staff F, RN, wrote Pt endorsed withdrawal from morphine. Had missed 2 doses before MSER (morphine extended release) arrived from pharmacy on 8/9.Review of the medical provider communication book showed an untimed note dated 08/06/2025, that indicated Resident 1 needs MS (morphine) renewal order.Review of pharmacy records showed a prescription written by Staff C, Nurse Practitioner, on 08/06/2025 for Morphine 30 mg IR. A pharmacy communication was then returned to the facility at 1:52 PM which indicated Resident1's previous Morphine prescription had been for Morphine Extended Release (ER) and checking to see if the NP now wanted Morphine IR. A response was sent back to the pharmacy at 2:56 PM which stated the NP intention was to provide new rx (prescription) to continue same order. Void this rx for IR tab, [they] will send new surescript (electronic prescription) for ER formulation. The pharmacy responded on 08/06/2025 at 2:59 PM with dc' d (discontinued). The next pharmacy communication found was dated 08/08/2025, with a fax time at the top of the scanned page of 11:55 AM, marked urgent, for Resident 1's Morphine 30 mg ER, written by Staff C.Review of the Food and Drug Administration (FDA) package insert/prescribing information for Morphine ER showed under the heading Morphine ER dosage and Administration, provided direction Do not abruptly discontinue morphine sulfate extended-release tablets in physically dependent patient because rapid discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide.Review of the publication Pain Management in the Post-Acute and Long-Term Care Setting, Copyright 2021, indicates on page 63, that opioid dependence (i.e., the body's physical dependence on opioids to function normally) is common. A withdrawal syndrome can result from abrupt cessation, rapid dose reduction.During an interview with Resident 1 on 09/09/2025 at 11:50 PM, with their spouse also present in the room, Resident 1 stated that there was a day, last month, when I did not get my Morphine in the evening or the next day. They further stated that they had been on the same dose of Morphine for several years, related to chronic pain, and were dependent on the medication for pain relief. They stated that when they did not get the Morphine in the evening the nurse told them that the medication had not come from the pharmacy, and it would come the next day. On the next day it still did not come, and the nurse told them that they would get their as needed Hydrocodone (a narcotic mixed with Tylenol) until the Morphine arrived. They stated that they went through that day and experienced unrelieved pain and felt that they experienced withdrawal symptoms in the form of body aches and flu-like symptoms until the medication arrived from the pharmacy the next day. They further stated that they did not feel as if the nursing staff took the situation seriously and discounted their complaints of pain and withdrawal.In an interview on 09/09/2025 at 1:14 PM with Staff B, Resident Care Manager (RCM) and LPN, they stated that the facility policy for reordering medication was for the nurse to notify the pharmacy when there was a seven-day supply of the medication remaining. They further stated that if the floor nurse did not have an ordered medication for a resident, they should notify them so they could communicate with the medical provider. They further stated that they were the RCM responsible for oversight for Resident 1 and they had no knowledge of the resident missing their prescribed twice daily Morphine.In an interview with Staff A, Director of Nursing, on 09/09/2025 at 1:40 PM, they stated that the facility policy for reordering medications was for the nurse to notify the pharmacy when there was a three-day supply of the resident's medication remaining. They stated that if a medication was reordered too soon the pharmacy would not send it. They further stated that they had no awareness of Resident 1 having missed doses of their prescribed Morphine. In a later communication via email, on 09/11/2025 at 3:16 PM, Staff A stated that the nurse was to reorder the resident medication when the resident supply hit the blue line on the medication card, indicating the last seven doses of the medication were remaining.During an e-mail conversation with Staff C, Nurse Practitioner, on 09/11/2025 at 10:15 AM, they wrote that, this situation of not having the morphine was not planned or recommended. Later in the same email chain, at 10:31 AM, Staff C indicated that Resident 1 was very aware of [their] pain management and all of the medications included in [their] pain management plan. Staff C further stated that they did not speak with Resident 1 about their prescribed Morphine not being available nor had they written a progress note related to the situation.In an interview with Staff D, LPN, on 09/09/2024 at 2:48 PM, they stated that they had verbally spoken to the Medical Provider, Staff C, on the same day Resident 1 was out of their prescribed Morphine. They further stated that they had not noticed Resident 1 was almost out of their Morphine until the day before they ran out and Staff D thought they had communicated with Staff C then too but could not remember clearly. They stated that the medication should have been reordered when the remaining supply was at the blue line, with seven days of the medication remaining. They stated that during the time Resident 1's Morphine was not available that Resident 1 had asked them several times when it was coming from the pharmacy and indicated that they wanted the medication. Reference: (WAC) 388-97-1300 (1)(a)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 dependent residents (Resident 1 and 3), reviewed for Activities of Daily Living (ADL's), received the appropriate number of baths per week. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 1> Review of a facility assessment, dated 05/14/2025, showed the resident was admitted with diagnoses to include a stroke with one sided weakness. The resident had aphasia (affects the ability to produce spoken or written language, even though the individual may understand language). Resident #1 had difficulty making their needs known. The resident's care plan, dated 02/19/2025, showed the resident was to be showered twice a week. It was noted the resident preferred bed baths but staff should continue to offer for the resident to use the shower. Review of Resident 1's shower record from 05/09/2025 to 06/09/2025 showed the resident received a bed bath on 05/09/2025 and not again until 05/19/2025, 10 days later. The next bed bath was 7 days later on 05/26/2025 and an additional 7 days on 06/02/2025. On 06/09/2025 at 12:28 PM, Resident 1 was laying in bed. The resident had difficulty answering questions. When asked if they received bathing twice a week they shook their head no. When asked if they like showers, they nodded no and nodded yes they preferred bed baths in their room. <Resident 3> Review of a facility assessment, dated 05/06/2025, showed the resident was admitted with diagnoses to include dementia. The resident had difficulty making their needs known and required partial to moderate assistance for personal hygiene. Review of Resident 3's shower record from 05/09/2025 to 06/09/2025 showed the received a shower on 05/12/2025 and not again until 05/20/2025, 8 days later. On 06/09/2025 at 11:20 AM, Staff A, Nursing Assistant (CNA), stated they had a shower aide for the unit but they had called off for the day. Staff A was asked how showers were made up if there wasn't a shower aide and they replied they weren't sure. On 06/09/2025 at 12:22 PM, Staff B, CNA, stated they were a shower aide but had been taken off showers for the day to help on the floor. Staff B stated they would be pulled if too many CNA's called off sick. If Staff B couldn't do showers, they would try and make them up the next day they worked. On 06/09/2025 at 12:25 PM, Staff C, Resident Care Manager (RCM), stated if a shower aide was pulled onto the floor, they would make up the showers the following day. Staff C stated showers were to be given twice a week. On 06/09/2025 at 1:18 PM, Staff E, Director of Nursing (DNS), stated on occasion the shower aides would be pulled to the floor. If that was done, the floor staff should help get the showers done that had been missed. Reference WAC 388-97-1060(2)(ac)

Based on observation, interview and record review, the facility failed to maintain urinary catheters (a tube inserted into the bladder that drains urine into a collection bag) in a dignified manner for 2 of 3 sampled residents (Residents 36 and 154) reviewed for urinary catheter care. This failure placed the residents at risk for public visualization of their urine and possible embarrassment. Findings included . The December 2000 Evaluation for Indwelling Catheters facility policy documented residents admitted to the facility with an indwelling catheter were evaluated at admission and quarterly for catheter usage. The policy did not address concerns regarding a resident's dignity when catheters were required. <Resident 36> A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that caused slow, stiff movement, tremors and loss of balance) and kidney disease. The resident had an indwelling urinary catheter and required substantial assistance of staff for toileting. A further review of the record documented on 01/10/2025, Resident 36 reported feeling weak and out of breath and developed a high temperature of 102 degrees Fahrenheit. Blood work and a urinalysis and urine culture were ordered. The resident received one dose of ceftriaxone, an antibiotic, while waiting for the results of the urine culture to return. On 01/14/2025, the urine culture was positive and Resident 36 was ordered to receive a full course of ceftriaxone. On 01/15/2025 at 1:03 PM, Resident 36 was seated in their wheelchair and was positioned in the doorway of their room by Staff B, Director of Nursing. The urine collection bag was hanging on the frame of their wheelchair, was not covered in a dignity bag, and the bag and clamp were dragging on the floor. The collection bag was observed in the same position, uncovered and touching the floor at 1:17 PM. <Resident 154> A review of the 01/02/2025 admission assessment documented Resident 154 had diagnoses that included benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement) and urinary retention. The resident had an indwelling urinary catheter and was dependent on staff for toileting. The 12/23/2024 care plan documented Resident 154 had an indwelling catheter. Staff were instructed to position the urine collection bag and tubing below the level of the bladder and away from the door, check for a securement device (secured the tubing to the leg to prevent movement that caused irritation and risk for infection), monitor for signs or symptoms of a urinary tract infection and clean the catheter every shift. On 01/09/2025 at 8:56 AM, Resident 154 was observed lying in bed. The urine collection bag was hung on the bedframe visible from the doorway of the resident's room. The resident's bed was in a low position so that the collection bag and its clamp were resting on the floor. The collection bag was not covered for the resident's privacy (use of a plastic or cloth covering that kept a person's urine from view, also referred to as a dignity bag). On 01/09/2025 at 1:58 PM, Resident 154 was napping. The resident's urine collection bag was hung on the bedframe, part was bunched up on the floor, next to the wheels of the overbed table. There was no dignity bag on it and it was visible from the hall. On 01/13/2025 at 5:30 AM, Resident 154 was sleeping. A dignity bag was hanging on the bedframe on the side of the bed that faced the doorway.Their urine collection bag was lying on the floor on the other side of the bed away from the door. Additional observations of the resident's uncovered urine collection bag were made on 01/14/2025 at 9:57 AM, and on 01/15/2025 at 1:17 PM. During an interview at 01/16/2025 at 1:05 PM, Staff G, Nursing Assistant, observed Resident 154 with the surveyor from the hall. Resident 154 was resting in bed. Their urine collection bag was visible and not covered with a dignity bag. Staff G stated Resident 154 needed a dignity cover over their urine collection bag. Staff G stated it was probably still on the resident's wheelchair when the resident was out of bed earlier. They stated they would put the cover on. Staff G stated any resident's urine collection bag was never to be left touching the floor as doing so could contribute to infections. During an interview on 01/17/2025 at 5:24 PM, Staff B stated urine collection bags were to be kept off the floor, hanging below the level of the bladder to help the flow of urine, and covered in a dignity bag. Reference: WAC 388-97-0180(1-4)

Based on observation, interview, and record review the facility failed to implement the self-administration of medicaiton policy, ensure the interdisciplinary team (IDT) determined a residents could self-administer medications, ensure only provider approved medications were kept at the resident's bedside and/or safely and securely stored at the bedside for 1 of 3 sampled residents (Resident 24), reviewed for choices. This failure placed residents at risk of access to unsecured medications, potentially avoidable medication errors and/or accidents, and diminished quality of life. Findings included . Review of the facility policy titled, Self-Administration of Medication updated September 2017, showed if a resident desired to self-administer medications they would be evaluated using the self-medication evaluation assessment. If a resident was determined to self-administer medications provider orders that specified specific medications to self-administer would be obtained, a self-administration care plan would be implemented, a bedside self-administration record was to be implemented if medications were stored at bedside, and proper safety mechanisms for bedside medication storage would be implemented. The resident would be re-assessed quarterly and with any changes of condition. The policy further showed the IDT only reviewed when a resident was unable to self-administer medications, to determine if there were areas the resident could complete. According to the 11/16/2024 quarterly assessment, Resident 24 had diagnoses that included chronic obstructive pulmonary disease (COPD, lung disease that made it difficult to breathe), muscle weakness and reduced mobility. Resident 24 was cognitively intact and able to verbalize their needs. Review of the 05/25/2023 self-administration of medication evaluation showed Resident 24 continued to be appropriate for self-administration of saline [solution of salt and water] nasal spray, cough drops, and topicals [medication applied to the body such as creams, lotions, or ointments]. The evaluation further showed Resident 24 was to keep these items at bedside and could administer them per provider orders and no other medications of any kind was to be kept at beside or self-administered. Review of the fall risk care plan showed a 12/05/2023 intervention Resident 24 was approved to purchase and/or keep cough drops, saline nasal spray and topicals in their room for independent use and instructed staff to report any other items to nursing management staff immediately. Review of provider orders showed an 08/28/2024 order for Mentholatum (over-the-counter petroleum-based ointment used to soothe symptoms associated with the common cold) as needed to affected areas, a 03/22/2024 order for lidocaine cream every four hours as needed may keep at bedside and self-administer as able, steroid nasal spray into each nostril daily for allergies, and routine oxygen use to keep oxygen levels greater than 88%. Review of the 06/25/2024, 09/24/2024, and 12/16/2024 care conference assessments showed Resident 24's self-medication program was reviewed without changes made. During observation on 01/07/2025 at 2:35 PM, Resident 24 wore an oxygen nasal cannula in their nose and had Xylitol [natural occurring sweetener] nose sprays, a small opened green jar of Mentholatum ointment, a bag of cough drops, Lidocaine creams and roll on liquids unsecured at their bedside. Similar observations were made on 01/08/2025 at 9:42 AM, on 01/09/2025 at 8:11 AM and 12:20 PM, on 01/10/2025 at 8:18 AM and 11:31 AM. Further review of provider orders showed no provider orders for Resident 24's cough drops, Xylitol nasal spray or the liquid roll-on Lidocaine, observed at their bedside. The as needed Mentholatum order showed no documentation it had been approved for bedside storage. During an interview on 01/10/2025 at 11:31 AM, Resident 24 stated they applied the Mentholatum ointment right under their nose because their nasal passages got dry related to their use of oxygen. According to the National Institute of Health website, NIH.gov The use of petroleum-based products should be avoided when handling patients under oxygen therapy. Whenever a skin moisturizer is needed for lubrication or rehydration of dry nasal passages, the lips or nose when breathing oxygen, consider the use of oil-in water creams or water-based products. During observation and interview on 01/14/2024 at 8:32 AM, Resident 24 laid in their bed with their eyes closed with unsecured over-the-counter medications at bedside, as identified and described above. At 8:35 AM, a confused fellow resident wandered into Resident 24's room. At 8:36 AM, the confused resident approached Resident 24's bed. At 8:37 AM, the resident exited Resident 24's room. At 8:38 AM, Resident 24 identified the confused resident and stated the resident visited them often. In a follow-up interview on 01/15/2025 at 10:17 AM, Resident 24 stated they were not required to inform staff if, and/or when they used the medications stored in their room. In an interview on 01/15/2024 at 12:38 PM, Staff E, Registered Nurse, stated if/when a resident chose to self-administer medications they would have to be assessed, the order would indicate what medications were to be self-administered and/or allowed to be stored at the bedside, and care planned accordingly. Staff E further stated Resident 24 was not to have medications at the bedside but frequently ordered over-the-counter medications online and kept those items at their bedside. Staff E was unsure how residents were to secure medications at the bedside. In an interview on 01/15/2025 at 12:56 PM, Staff D, Resident Care Manager, stated the provider was to approve a resident to self-administer medications or store medications at the bedside. Staff D explained a resident had to be assessed for their ability to safely self-administer medications and/or store medications at the bedside, the order would indicate what medications were to be self-administered and/or allowed to be stored at the bedside, and care planned accordingly. Staff D stated medications stored at the bedside needed to be secured to prevent other residents from accessing the medications. Staff D reviewed Resident 24's medical record. Staff D acknowledged Resident 24's Mentholatum order did not indicate it was to be stored at the bedside or to be used to moisten dry nasal passages due to oxygen use. Staff D further stated using petroleum-based products while wearing oxygen was a potential safety issue. In an interview on 01/15/2025 at 2:11 PM, with Staff B, Director of Nursing, and Staff C, Assistant Director of Nursing, Staff B stated the provider would approve medications for self-administration and/or to store medications at the bedside which would be documented on the individual medication order. Staff B further stated residents would be assessed, educated, and care planned accordingly. Staff C stated bedside medication storage depended on the medication but was to be stored out of sight to prevent other residents from having unintended access to them and acknowledged it would be a safety concern if a confused resident wandered into a room with unsecured medications. Staff B stated Resident 24 was known to purchase over-the-counter medications online or at the local grocery store. Staff B acknowledged using petroleum-based products when wearing oxygen was a potential safety concern. In an interview on 01/15/2025 at 3:36 PM, Staff A, Administrator, stated they expected staff to ensure medications were safely secured when stored at the bedside. Reference WAC 388-97-0440, -1060 (3)(I)

Based on observation, interview and record review the facility failed to maintain a clean, comfortable, safe and homelike environment for 2 of 2 sampled residents (Resident 23 and 28), reviewed for environment. Specifically, Resident 23's personal refrigerator contained expired foods, and the facility failed to ensure an exit door was in good repair and Resident 28 had a large hole in the wall behind the door to their room. These failures placed Resident 23 at risk for a foodborne illness, and all residents at risk for injury and a diminished quality of life. Findings included . Review of the facility policy titled, Resident Personal Refrigerators And Foods Brought Into The Center By Family/Visitors dated August 2020, showed temperatures were to be monitored daily and perishable foods covered, labeled, dated and discarded following use by date guidelines on the Food Labeling Reference Guide. The policy further showed center staff may, at their discretion, discard food items that were not safe to eat nor labeled, after verbally notifying the resident and/or the responsible party. <Personal Refrigerator> During an observation and interview on 01/07/2025 at 11:56 AM, Resident 23 was sitting in their wheelchair in their room. They had a personal refrigerator that contained 3 containers of meat and stuffing that had no expiration date. Resident 23 stated their family had brought them the food. Subsequent observations of the containers of food without a date were made on 01/09/2025 at 12:26 PM, 01/10/2025 at 8:41 AM, 01/13/2025 at 7:07 AM, and 01/14/2025 at 10:49 AM. On 01/13/2025 a glass of tomato juice had been placed in the refrigerator without an expiration date. Per the January 2025 Medication Administration Record, the Licensed Nurse was to check and log the temperature of Resident 23's refrigerator and discard expired food every night shift. A review of the temperature logs in Resident 23's room showed multiple omissions for December 2024 and no temperatures for January 2025. In an interview on 01/15/2025 at 10:02 AM, Staff E, Registered Nurse, stated daily refrigerator temperatures needed to be obtained, and food monitored for expiration dates. Staff E stated this was important to prevent the food from spoiling. During an interview on 01/17/2025 at 4:31 PM, Staff B, Director of Nursing, stated the nursing assistants and nurses were responsible for labeling and dating food and the nurses were responsible for monitoring the temperature of the refrigerators. Staff B stated this was important to ensure the safety of the food was maintained. <Drywall Penetration> According to the 12/16/2024 quarterly assessment, Resident 28 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. During observation and interview on 01/09/2025 at 12:58 PM, a large hole was observed in the dry wall behind the door to Resident 28's room. The hole was the length and width of the surveyor's hand and was at door nob level. Resident 28 stated the hole in the drywall had been there a long time, as long as they could remember. Similar observations were made on 01/13/2025 at 7:56 AM, on 01/14/2025 at 8:33 AM, and on 01/15/2025 at 10:21 AM. During observation and interview on 01/15/2025 at 10:26 AM, Staff G, Nursing Assistant (NA), stated if staff noticed something was broken or in disrepair, they would write it down in the maintenance binder. Staff G observed the large hand size hole behind Resident 28's room door. Staff G stated they were unsure how long the hole had been there. During observation and interview on 01/15/2025 at 10:44 AM, Staff BB, Maintenance, stated they checked they maintenance request binder frequently throughout the day. Staff BB observed the large hand size hole behind Resident 28's room door. Staff BB stated they checked the facility for wall penetrations and/or dents that if left unaddressed could lead to potential penetrations monthly. Documentation of wall penetration rounding was requested from Staff BB. Staff BB stated they did not have any documentation. Staff BB further stated the hole in the drywall appeared to be caused by a hard pushing force and the elongated door nob penetrated the wall. Staff BB acknowledged the large hole in the drywall was a potential fire hazard and was not a homelike environment. <Exit Door> During observation on 01/10/2025 at 11:42 AM, the outside door leading to the foyer at the back of the building, outside of 100 hall, was offset, did not latch, and slammed on the outer portion of the door jamb. Similar observations were made on 01/13/2025 at 3:58 AM and on 01/15/2025 at 10:23 AM. During observation and interview on 01/15/2025 at 10:28 AM, Staff G, NA, observed the outside door leading to the foyer at the back of the building, outside of 100 hall, was offset, did not latch, and slammed on the outer portion of the door jamb. Staff G stated they knew the door had been slamming but never noticed the door was offset and did not latch. During observation and interview on 01/15/2025 at 10:44 AM, Staff BB observed the outside door leading to the foyer at the back of the building, outside of 100 hall. Staff BB stated they were unsure how long the door had been offset and did not latch. Staff BB acknowledged the offset door was a potential safety issue. In an interview on 01/15/2025 at 3:49 PM, Staff A, Administrator, stated they would defer to maintenance to determine if a wall penetration was a potential fire hazard or if things in disrepair were a potential safety issue. Reference WAC 388-97-0880

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 1 of 2 sampled residents (Resident 54), reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold, while they were hospitalized . Findings included Per the 12/23/2024 significant change in condition assessment, Resident 54 had diagnoses which included high blood pressure, diabetes, and dementia, and had severe cognitive impairments. Review of Resident 54's record showed a 12/12/2024 nursing progress note which documented the resident had a rapid heart rate and their oxygen level was 74 percent (the normal oxygen level is 90-100). The resident was assessed and was sent to the hospital for evaluation. Additional record review found no documentation that showed the resident had been provided a bed-hold notice until 12/16/2024, not within 24 hours as required. In an interview on 01/17/2025 at 8:57 AM, Staff K, Admissions Director, stated bed holds were offered upon admission and within 24 hours of a discharge to the hospital, unless it was on a Friday, then it would have been offered on a Monday. Staff B stated no one offered bed holds when they were gone and it was important to offer bed holds because some residents want to return to their same room. Reference WAC 388-97-0120 (4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 4 sampled residents (Resident 36) reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included . The Facility assessment dated [DATE] documented the facility offered cares to residents with various types of needs. Services for Mobility and Fall/Fall with injury Prevention included Restorative Nursing care among others in supporting the resident's independence in doing as many of these activities by him or herself. A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a central nervous system disorder that caused slow, stiff movements, tremors and balance difficulties) and muscle weakness. Resident 36 was cognitively intact, did not use assistive devices such as a walker or wheelchair, and required partial assistance from staff for bed mobility and bed to chair transfers and personal hygiene. The resident required substantial assistance for toileting, bathing/showering and dressing. The resident received six days of restorative walking and active range of motion during the look back period. The 09/24/2024 care plan documented Resident 36 had impaired mobility related to decreased strength, ambulation and transfer skills. Interventions included a Restorative (RNA) active range of motion and walking program to include sit to stand to a four-wheeled walker for two sets of three repetitions and to ambulate 50 feet with a four-wheeled walker with a wheelchair following behind. A review of the 12/04/2024 Occupational Therapy discharge summary documented Resident 36 was seen from 11/01/2024 to 12/04/2024. At the time of discharge, the resident required stand-by assistance with cueing to transfer from sitting to standing, met their goal for increased lower abdominal strength and maintained their standing balance. A restorative nursing (RNA) program was established at discharge on [DATE]. A report provided from the facility regarding RNA participation for Resident 36 documented the following participation for the following weeks: -12/01/2024 to 12/07/2024 Three 15-minute sessions -12/08/2024 to 12/14/2024 Three 15-minute sessions -12/15/2024 to 12/21/2024 One 15-minute session -12/22/2024 to 12/28/2024 None -12/29/2024 to 01/04/2025 None -01/05/2025 to 01/11/2025 Three 15-minute sessions. The resident refused RNA sessions on 01/13/2025 and 01/14/2025. The review of the resident's record documented that the resident had been ill with a urinary tract infection, had an elevated fever of 102 degrees Fahrenheit, and received antibiotics beginning 01/10/2025. A review of daily staffing sheets showed that beginning the week of 12/08/2024 through 01/14/2025, one of three of the Restorative Nursing Aide staff were pulled from their RNA duties and were assigned to direct resident care assignments 16 times on the following dates: -12/11/2024, 12/13/2024, 12/15/2024, 12/20/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/29/2024,12/30/2024 and 12/31/2024 in December and, -01/01/2025, 01/02/2025, 01/03/2025, 01/10/2025, and 01/14/2025 in January. A quarterly assessment submitted on 01/13/2025 documented Resident 36 had declined in their ability to perform their ADLs; the resident used assistive devices of a walker and a wheelchair, was dependent on staff for toileting assistance, dressing their upper and lower body, and they required substantial assistance for personal hygiene, bed mobility and bed to chair transfers. The resident received 2 days of restorative walking activity and 1 day of restorative active range of motion during the 7-day look-back period. During an interview on 01/08/2025 at 10:35 AM, Resident 36 stated they no longer received therapy as their insurance benefits ran out. Resident 36 was seated in a recliner, and a four-wheeled walker and wheelchair were positioned at the end of their bed by their closet just past the recliner. When asked what types of activities the resident preferred to participate in, Resident 36 stated they mainly stayed in their room. They stated they were supposed to get restorative therapy, but the restorative aides were usually pulled to direct care assignments. Resident 36 stated their restorative activity was important to them because they did not want to stiffen up. During an interview on 01/15/2025 at 10:46 AM, a staff member that wished to remain anonymous stated when a resident was discharged from therapy, physical therapy determined what restorative program was appropriate for a resident. They stated each RNA had 18-20 residents a piece. They tried to see each resident 4-5 times a week. If a resident refused, the RNA marked refused in their documentation. If the resident participated, but did an activity other than what was in their plan, such as walking instead of doing active range of motion, the RNA documented that the resident did not complete the plan as written with no but the resident still got RNA services. When a Resident was in their window for charting (the look back period for their comprehensive assessments), they were seen 6 times in the week. The staff member stated they worked often with Resident 36, and noticed the resident was not doing as much. They stated they notified therapy the resident was not doing as well. The staff member stated they were often given direct care assignments so were unable to complete RNA activities. Consistency was important for Resident 36 because they lost progress quickly without their restorative work. During an interview on 01/16/2025 at 1:14 PM, Staff L, Director of Rehabilitation, stated therapy created the restorative plan for a resident when their therapy program ended, but they were unsure how often a resident was seen by the RNA; the restorative program was a nursing program so nursing determined the frequency. Staff L stated they were notified that day, 01/16/2025, that Resident 36 had declined and had trouble transferring so they had done an evaluation and they would be providing therapy to the resident again. Staff L stated when Resident 36 was discharged from therapy services in December of 2024, they required contact guard assistance of one staff with their walker and could walk to their bathroom. During an interview on 01/17/2025 at 3:06 PM, Staff W, Registered Nurse, Minimum Data Set Coordinator, stated Resident 36 had been ill, and once their treatment had been completed, the resident was to be evaluated for a second area of decline to determine if there had been a significant change. Staff W stated restorative services were to be completed 6 days per week. Reference: WAC 388-97-1060(2)(a)(b) Refer to F725 for additional information.

Based on observation, interview, and record review the facility failed to provide adequate assistance during mealtimes for 1 of 4 sampled residents (Resident 90), reviewed for activities of daily living. This failure placed the resident at risk for decreased food and fluid intake, possible unintended weight loss and decreased quality of life. Findings included . Per the 12/17/2024 comprehensive assessment, Resident 90 had diagnoses which included traumatic brain injury (brain damage caused by a sudden forceful bump, blow, or jolt to the head), lack of coordination and muscle weakness. The assessment further documented Resident 90 had no range of motion impairment to their upper extremities, required set-up or clean-up assistance for eating and was cognitively intact for decision making. Review of the 12/09/2024 nutrition care plan showed Resident 90's assistance needs during meals varied from independent up to set -up assistance and instructed staff to refer to physical therapy (PT) and/or occupational therapy (OT) as appropriate. The 12/09/2024 limited physical ability care plan showed Resident 90 had a contracture to their left hand and instructed staff to provide PT/OT as ordered and/or as needed. Review of the 12/12/2024 nutrition evaluation form showed Resident 90 required set up assistance for meals, did not use adaptive equipment, and consumed 0-100% of each meal. Review of nursing progress notes showed Resident 90 was agreeable to therapy on 12/12/2024. During an observation on 01/09/2025 at 12:50 PM, Resident 90 was sitting in the dining room eating their lunch. Resident 90 had slow arm movements while feeding themselves and had difficulty grasping their utensils. Resident 90 used their fingers to eat pieces of cut-up chicken. Resident 90 took long breaks (approximately 5-10-minute intervals or more) between bites and consumed less than 25% of their meal. No staff were present. During an observation on 01/10/2025 at 8:25 AM, Resident 90 was sitting in the dining room eating breakfast. A staff member cut-up Resident 90's biscuit with jelly and then sat down with another resident across the room. Resident 90 was slowly eating using their fork and ultimately began to eat the scrambled eggs with their fingers. No staff was observed providing cues or assistance. During an observation on 01/13/2025 at 7:41 AM, Resident 90 was sitting in their wheelchair eating breakfast in their room. Resident 90 attempted to pick up a full cup of orange juice with their left hand while they simultaneously held a cup of coffee in their right hand. Resident 90 could not grasp the cup of orange juice and drank the coffee instead. Resident 90 did not attempt eating. At 8:16 AM, Resident 90 lightly held the full cup of orange juice with two hands, almost dropped it, and began to slowly drink from the edge of the cup. At 8:33 AM, Resident 90 still had their breakfast tray in front of them. No staff was observed assisting Resident 90 during their meal. During an observation on 01/14/2025 at 12:18 PM, Resident 90 was sitting up in their bed eating lunch extremely slow and showed difficulty manipulating their utensils to feed themselves. During an interview on 01/15/25 at 10:18 AM, Resident 90 stated that they would like to work with the therapy on grasping items with their hands, such as picking up a glass of water. Resident 90 further stated their hand impairment made them feel insecure and would ask for assistance during their meals, if staff was available. During an interview on 01/16/2024 at 4:05 PM, Staff L, Certified Occupational Therapist Assistant, stated nursing staff informed the therapy department Resident 90 was having increased difficulties at meals, on 01/09/2025, and was currently receiving OT to address their activities of daily living skills. Staff L explained Resident 90's gross motor skills (use of large muscle groups in the arms, legs and core to perform coordinated movements) were impaired . Staff L reviewed Resident 90's care plan. Staff L stated stand by assistance during meals was a more appropriate level of care for Resident 90 and the care plan should have been updated to reflect that. Reference WAC 388-97-1060 (2)(C ) This is a repeat deficianry from 01/24/2024.

Based on observation, interview, and record review the facility failed to consistently implement a resident's care plan and ensure appropriate treatment and services to restore as much normal bladder and bowel function as possible were received 1 of 3 sampled residents (Resident 81), reviewed accidents. These failures placed residents at risk for a decline in urinary and/or bowel function, embarrassment, and diminished quality of life. Findings included . Per the 11/14/2024 quarterly assessment, Resident 81 had diagnoses including stroke and hemiplegia (muscle weakness on one side of the body). The assessment further showed Resident 81 was dependent for transfers during toileting and was frequently incontinent of bowel and bladder. There was no bowel and bladder training program in place. Resident 81 had moderate cognitive impairment. Review of the 06/04/2024 self-care deficit care plan documented Resident 81 was dependent for toileting and instructed staff to only use a bedpan to use for toileting. The 08/27/2024 bowel incontinence care plan instructed staff to observe pattern of incontinence and initiate a toileting schedule if indicated. Review of the bowel records from 12/16/2024 through 01/14/2025, showed Resident 81 had bowel incontinence for 19 days, bowel continence for 4 days, and no bowel movements at all for 5 days. Review of the bladder records from 12/16/2024 through 01/14/2025, showed Resident 81 had urinary incontinence daily and was continent of urine for 4 days. During an observation on 01/09/2025 at 09:07 AM, staff transferred Resident 81 into bed using a full body lift, provided incontinence care but did not offer or provide Resident 81 with the bedpan, as care planned. Similar observations were made on 01/09/2025 at 1:06 PM and 01/10/2025 at 11:47 AM. In an interview on 01/15/2025 at 3:26 PM, Resident 81 stated they had not used a bed pan for toileting and would prefer to be continent. During an observation and interview on 01/15/2025 at 3:47 PM, Staff DD, Nursing Assistant, entered the resident's room and repositioned them in their wheelchair after the resident stated they were in pain. Resident 81 made a grunting sound, showed facial grimaces and stated they were in pain because they needed to have a bowel movement. Staff DD did not offer or provide Resident 81 with a bedpan. In an interview on 01/16/2025 at 1:49 PM, Staff E, Registered Nurse, stated Resident 81's toileting did not include the use of a bed pan and acknowledged nursing staff only checked and changed Resident 81's brief. In an interview on 01/16/2025 at 03:41 PM, Staff L, Certified Occupational Therapist Assistant, acknowledged a bed pan should be used with Resident 81 due safety during transfers and comfortability when voiding. In an interview on 01/17/2025 at 5:18 PM, Staff DD stated Resident 81 informed staff when they needed to have a bowel movement or be changed after incontinence episodes. Staff DD acknowledged they never used a bed pan with Resident 81 or seen a bedpan in the room. Staff DD stated using a bedpan would be better for the Resident 81's skin integrity and dignity, rather than using a brief. In an interview on 01/17/2025 at 06:05 PM, Staff B, Director of Nursing, reviewed Resident 81's care plan. Staff D acknowledged a bed pan should have been available and offered to the Resident 81 for toileting use, as care planned. Reference WAC 388-97-1060 (3)(c ) Refer to F725 for additional information.

Based on observation, interview and record review, the facility failed to ensure bi-level positive airway pressure (BIPAP, a machine that helped people breathe by delivering pressurized air into their lungs through their nose, or nose and mouth) was implemented as ordered by the physician for 1 of 3 sampled residents (Resident 81) reviewed for respiratory care. This failure placed the resident at risk for impaired sleep, unmet care needs, and a diminished quality of life. Findings included . The 11/14/2024 quarterly assessment documented Resident 81 was moderately cognitively impaired, was able to make their needs known, and had diagnoses which included stroke and impaired ability to move the upper and lower extremity on one side of their body. In addition, the assessment documented the resident was dependent on nursing staff to complete activities of daily living (ADLS) for getting dressed. Review of Resident 81's care plan showed a respiratory care plan was developed on 12/10/2024 to provide interventions to treat the resident's sleep apnea, a condition that caused breathing to stop during sleeping. The care plan informed nursing staff the resident had a BIPAP machine, and the licensed staff were to ensure the BIPAP was worn by the resident while sleeping, including naps as ordered. Observations of Resident 81 sleeping in bed and/or their wheelchair without the BIPAP being worn were made on the following: - 01/10/2025 at 11:34 AM, 11:42 AM, and 11:58 AM. - 01/13/2025 at 8:01 AM, and 10:41 AM; and 01/14/2025 at 8:34 AM. During the observation on 01/14/2025 at 8:34 AM of Resident 81 not wearing the BIPAP, the resident woke up and stated they didn't get much sleep yesterday. In an interview on 01/15/2025 at 3:38 PM, Resident 81's spouse stated it was important for the resident to wear the BIPAP anytime they were asleep due to the high risk for another stroke and decreased alertness from not sleeping well. In an interview on 01/17/2025 at 5:11 PM, Staff DD, Nursing Assistant, stated Resident 81 used a BIPAP at night, did not use it during the day when they nappped, just when they slept at night to help them breath. When asked how the nursing staff knew what the care needs were for residents, Staff DD, stated the resident's care plans provided information and instructions. In an interview on 01/17/2025 at 6:00 PM, Staff B, Director of Nursing, was informed of the multiple observations of Resident 81 not wearing the BIPAP while sleeping. After review of the residents' orders and record, Staff B confirmed the resident needed to wear the BIPAP whenever sleeping, including naps as ordered. Reference WAC: 388-97-1060(3)(j)(vi)

Based on interview and record review the facility failed to timely act upon the pharmacist's monthly medication regimen review recommendations for identified irregularities for 1 of 5 sampled residents (Resident 24), reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications, medication complications, and diminished quality of life. Findings included . Review of the facility policy titled, Medication Regimen Review published March 2019, showed a pharmacist reviewed the resident's medication regimen monthly and report irregularities to the attending physician, medical director, and Director of Nursing (DNS). The pharmacist was to exit with the DNS or designee prior to leaving the facility and email their report of any irregularities, at the end of their visit. The attending physician was to respond to pharmacist recommendations within 2-4 weeks and provide documentation pharmacy recommendations were reviewed. If a change was made, the facility notified the pharmacy and completed the order. According to the 11/16/2024 quarterly assessment, Resident 24 had diagnoses including high cholesterol. Resident 24 was cognitively intact and able to verbalize their needs. Review of provider orders showed Resident 24 had an active 03/22/2024 order for staff to administer a cholesterol lowering medication daily at bedtime. Review of the 07/31/2024 pharmacy medication review note to attending prescriber showed Resident 24 took a cholesterol lowering medication. The consultant pharmacist recommended obtaining baseline and yearly liver function test (LFT) and lipid panel blood work to monitor the therapeutic effects and side effects of the medication. The form included a handwritten note that indicated Resident 24's primary care physician was from outside the facility's provider group. A 08/22/2024 typed provider response showed LFTs were done on 05/09/2024 and instructed the facility to repeat the LFTs and fasting lipids next time lab rounds at the facility. Review of the 08/31/2024 pharmacy medication review note to the attending prescriber showed Resident 24 took a cholesterol lowering medication. The consultant pharmacist repeated their 07/31/2024 recommendation to obtain baseline and yearly LFTs and lipid panel blood work to monitor the therapeutic effects and side effects of the medication. No documentation of a provider response was found. Review of the 09/30/2024 pharmacy medication review note to attending prescriber showed Resident 24 took a cholesterol lowering medication. The consultant pharmacist made a recommendation for the third month in a row to obtain baseline and yearly LFTs and lipid panel blood work to monitor the therapeutic effects and side effects of the medication. No other documentation of a provider response was found. On 10/18/2024, Resident 24 had blood tests drawn by the lab that included liver function tests. A lipid panel, which was ordered on 08/22/2024, was not included in the blood work. On 10/31/2024 a pharmacy medication review note to the attending prescriber showed Resident 24 took a cholesterol lowering medication. The consultant pharmacist again recommended obtaining baseline and yearly LFTs and lipid panel blood work. The form included a handwritten provider response for the facility to obtain a fasting lipid panel and fax results to the outside provider's office. Review of 11/25/2024 blood test results showed results for a lipid panel, 95 days after it was originally ordered by Resident 24's provider. In an interview on 01/15/2025 at 12:37 PM, Staff E, Registered Nurse, stated they were unsure of the facility monthly pharmacy medication review process. In an interview on 01/15/2025 at 12:48 PM, Staff D, Resident Care Manager, stated they were unsure how an outside provider received and/or reviewed the pharmacist monthly medication review recommendations. Staff D acknowledged Resident 24's lipid panel was not obtained timely as recommended by the pharmacist. In an interview on 01/15/2025 at 1:48 PM, with Staff B, Director of Nursing, and Staff C, Assistant Director of Nursing, they explained the pharmacist monthly medication review process. Both Staff B and C expected the provider to respond to a pharmacy recommendation within two-four weeks and expected pharmacy recommendations to be completed by the end of the month. Staff C acknowledged Resident 24 had an outside primary care physician. Both staff B and C reviewed Resident 24's medical record. Staff C acknowledged Resident 24 had blood work obtained 10/17/2024 but a lipid panel was not obtained until 11/25/2024. In an interview on 01/15/2025 at 3:26 PM, Staff A, Administrator, reviewed Resident 24's medical record. Staff A acknowledged Resident 24's order to obtain fasting lipid blood work was entered into the medical record on 11/22/2024 with the blood work obtained on 11/25/2024, 95 days after it was originally ordered by Resident 24's provider. Staff A stated they expected staff to follow the facility monthly medication review process. Reference WAC 388-97-1300 (4)(c )

Based on record review and interview, the facility failed to ensure significant medication errors were prevented when medications ordered by the provider were not supplied and as administered for 1 of 5 sampled residents (Resident 156) reviewed for unneccesary medications. This failure put the resident at risk for a possible decline in their physical and mental well-being and decreased quality of life. Findings included . A review of the 01/01/2025 admission assessment documented Resident 156 had diagnoses including bone infection of the hip, ankylosing spondylosis (causes swelling, joint pain and fatigue), and depression. Resident 156 was cognitively intact, and took antidepressant, antianxiety, and opioid pain medications daily. The resident had a depression screening score of 6 (on a scale of 0 to 27, six indicating mild depression) related to poor appetite, feeling tired, feeling down and depressed, and little interest in doing things. The 12/26/2024 care plan documented Resident 156 used antidepressant medication. Staff were instructed to administer medications as ordered, educate the resident regarding the risks and benefits of the medication and possible side effects, monitor for effectiveness and report any side effects. The provider had given orders for Resident 156 to receive the following medications: -12/26/2024 amitriptyline 150 milligrams (mg) at bedtime for depression and -12/29/2024 Enbrel 50 mg/milliliter (ml), inject 1 ml weekly every Sunday for osteoarthritis (when flexible tissue at the end of bones wore down, caused pain, swelling and stiffness in the joints). A review of the medication administration records (MAR) for December 2024 and January 2025 showed Resident 156 did not receive Enbrel on 12/29/2024, 01/05/2025, and 01/12/2025. A code OO was entered on the MAR. The Resident also did not receive amitriptyline on 01/11/2025, 01/12/2025, and 01/15/2025 and the same code OO was entered on the MAR. The key on the MAR documented code OO indicated the medication was on order from the pharmacy. When reviewed, there were no progress notes related to the missed doses of the Enbrel and amitriptyline. During an interview on 01/17/2025 at 12:32 PM, Staff Y, Resident Care Manager, stated if a medication is not in the cart, staff were to look in the the overflow drawer on the cart and if not there, they were to see if it was available in the Cubex (a large medication storage unit that housed various medications staff were able to use until the regular ordered medications were received from the pharmacy.) If not in the Cubex, staff were to notify the pharmacy so the medication could be special delivered. Staff were also to notify the provider. Staff Y reviewed the Cubex Inventory report the facility provided to the surveyor, and neither the Enbrel nor amitriptyline were in the Cubex. Staff Y stated they would need to contact the pharmacy and would follow up. During a follow-up interview on 01/17/2025 at 3:56 PM, Staff Y stated the pharmacy had previously sent a fax requesting authorization for the Enbrel. A signature was required before it was to be dispensed because of the cost. Staff Y stated the amitriptyline would be delivered that afternoon. Staff Y stated it was possible the wrong administration code was entered on the MAR, and they would check with Staff Z, Licensed Practical Nurse, the nurse that administered the medications. During an interview on 01/17/2025 at 3:59 PM, Staff Z stated it had been passed on in their shift report that the amitriptyline had been ordered from the pharmacy. Staff Z stated it was difficult getting the medication from the pharmacy. They stated it might have been an insurance issue, but they had not entered the wrong code, they had not given the medication; it had not come from the pharmacy yet. During an interview on 01/17/2025 at 5:24 PM, Staff B, Director of Nursing, stated they had signed the authorization that day, 01/17/2025, for Resident 156's Enbrel. It was a policy that an authorization had to be signed for medications that cost over a certain amount. Staff B stated they usually received an email when an authroization was needed but did not remember getting one for the Enbrel. Staff D expected staff to call the pharmacy and notify the provider so medication doses were not missed. This is a repeat citation from the previous recertification survey conducted on 10/04/2023 and on 03/07/2024. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure the staff dated multi-dose vials of medications when first accessed or opened, monitored refrigerator temperatures to ensure vaccinations were adequately stored in 2 of 2 medication storage rooms, cleaned 1 of 2 medication carts reviewed for cleanliness, and ensured medications were secured in a resident's room. This failure placed residents at risk for receiving compromised or ineffective medication management. Findings included . <Expired Medications> An observation on 01/08/2025 at 2:08 PM with Staff PP, Licensed Practial Nurse (LPN), in the Oak Hall Medication Room identified an undated vial of Tuberculosis screening solution. The plastic cap on the vial's rubber stopper was removed and the vial had been accessed. The box where the vial was stored showed an instruction to the staff to discard the medication after 30 days from being opened.Staff PP stated the medication vial should have been dated when opend and needed to be discarded. This continued medication room observation on 01/08/2025 identified two bottles of mineral oil with an expiration date of 01/04/2025. Staff PP acknowledged the mineral oil was expired and should be discarded. An observation in the Transitional Care Unit (TCU) Hall Medication Room on 01/09/2025 at 10:35 AM showed two bottles of expired mineral oil dated 11/19/2024 and 01/04/2025. Staff QQ, Agency LPN, acknowledged they were expired and should be discarded. <Unmonitored Refrigerator Temperatures> Review of Temperature Log for Vaccines in the Oak Hall Medication Room with Staff PP on 01/08/2025 at 2:08 PM showed an instruction to the staff to check the temperature in both the freezer and the refrigerator compartments at least twice a day, each working day. The form also instructed the staff what to do in the case they identified unacceptable temperate ranges for the storage of the vaccines. Observation showed a vaccine inside the refrigerator for Resident 12 for respiratory syncytial virus (RSV, a contagious respiratory virus that infects the nose, throat, and lungs). The vaccine showed the pharmacy dispensed the vaccine on 11/2024. Review of the Oak Hall October, November, and December 2024 and January 2025 Temperature Log for Vaccines showed the staff only documented temperatures once a day for the refrigerator and did not document freezer temperatures. Additionally, the staff failed to document any temperatures on 12/23/2024, 12/27/2024, 12/30/2024, and 12/31/2024, and from 01/03/2025 to 01/07/025, or five consecutive days. An observation of the TCU Medication Room refrigerator with Staff QQ on 01/09/2025 at 2:08 PM identified a box with two influenza vaccines and another box that contained six influenza vaccines. Also present in the refrigerator were pneumonia and RSV vaccines for Residents 70 and 88. Review of the TCU October 2024 through January 2025 Temperature Log for Vaccines showed the staff only documented temperatures once a day for the refrigerator and did not document freezer temperatures. Additionally, the staff failed to document any temperatures on 01/01/2025, 01/04/2025, and 01/05/2025. The above findings were shared with Staff J, LPN and acting Infection Preventionist, on 01/09/2025 at 12:07 PM. Staff J acknowledged the omissions in temperature recordings. <Unsanitary Medication Cart> An observation of the Oak Hall Medication Cart 1 on 01/09/2025 at 10:08 AM showed extensive dry stains inside the medication cart drawers, to include the plastic storage bins in the top drawer that held eye drops and other medications. Staff RR, LPN, identified the stains as medication residue. Some of the stains ranged in color from opaque white to darker grey steaks.The medication cart was observed with run off stains to the outside, to include the attached garbage can. Staff RR stated the night shift was supposed to clean the medication carts weekly and acknowledged the medication cart required cleaning. <Drug Storage> An observation with Staff QQ on 01/09/2025 at 8:48 AM identified a tube of Triamcinolone acetonide cream on the Resident 70's bed and a bottle of ammonium lactate 12% lotion on their bedside table. Resident 70 stated that they applied it to their right foot at night and in the morning. Record review with Staff QQ on 01/09/2025 at 9:05 AM showed no orders for the medications found in the resident's room. Staff QQ stated that there should be an order for the application of the medications, and both an evaluation and an order to safely store at bedside. Reference: WAC 388-97-1300(2) Refer to F554 and WAC 1080 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dietary staff had the required training for 4 of 17 sampled dietary staff (Staff M, N, O and P) reviewed for credentialing. 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 Staff P had no Washington State Food Workers card. Staff P had an expired certificate that was not provided. Staff M, N, and O had a certificate from Food Handler Solutions for completing the food handler's course. Review of Food Handler Solutions website, foodhandlersolutions.com/[NAME]-food-handler-card/ showed, the Food Handler Solutions Program was not currently an approved credentialing program in the State of [NAME]. This program was only intended to be used for personal development and preparation for the State provided training. During an interview on 01/14/2025 at 2:24 PM, Staff Q, Dietary Manager, stated they were unaware the program did not meet credentialing requirements. Reference: WAC 388-97-1160

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident records were complete, accurate, readily accessible and resident records were safeguarded against loss, destruction, or unauthorized use for 1 of 4 sampled residents (Resident 98), reviewed for accidents. This failure placed residents at risk of having an incomplete medical record, unauthorized access to confidential health information, and diminished quality of life. Findings included . Review of the facility employee handbook related to use of business equipment showed company telephones, computers, tablets, handheld computers, copiers, supplies, and other equipment were to be used for business use. Employees were not allowed to use cell phones or smart phones in resident care areas. Direct care staff were prohibited from using or having their cell phones turned on while on duty and were only to use these items during their meal or break times in non-resident care areas. The handbook further showed all employees were expected to follow applicable state or federal law or regulations regarding the use of cell phones or smart phones at all times. According to the [DATE] admission assessment, Resident 98 admitted to the facility on [DATE] with diagnoses including muscle weakness, reduced mobility, lack of coordination, and chronic pain. Resident 98 required touch assistance to transfer onto the toilet and moderate staff assistance to perform toileting hygiene. Resident 98 had severe cognitive impairment. Review of the admission agreement, consent for medical treatment, showed the resident group authorizes the center to take photographs of the resident which are necessary for identification, medical purposes, or both, at any time during the resident's stay and the section on personal health information disclosure showed the center will not disclose the resident's personal health information, including the resident's medical record, without express written authorization except as permitted by law. The admission agreement further showed it was electronically signed by the severely cognitively impaired Resident 98, not their legal representative, on [DATE]. Review of a [DATE] facility incident report showed Resident 98 experienced an unanticipated death. Resident 98 was found slumped over on the toilet with a laceration above their left eyebrow. Review of [DATE] nursing progress notes showed Resident 98 required moderate assistance for toileting. On [DATE], Resident 98 was found sitting on the toilet unresponsive, staff called emergency medical services and initiated cardiopulmonary resuscitation (CPR) per Resident 98's wishes. Resident 98 expired and the medical examiner (ME) was notified of the laceration to the left upper eyebrow. The progress notes further showed the ME was sent pictures of Resident 98's facial laceration and Resident 98 would need to be picked up for further testing. Further review of Resident 98's medical record showed no pictures of Resident 98's facial laceration were found. The pictures of Resident 98's facial laceration sent to the ME on [DATE] were requested from Staff B, Director of Nursing, on [DATE] at 2:31 PM, and again on [DATE] at 1:41 PM, from Staff A, Administrator. In an interview on [DATE] at 2:16 PM, Staff KK, Corporate Licensed Nurse, stated the nurse who took the pictures of Resident 98 deleted the picture from their phone after they were sent to the ME. Staff KK acknowledged the pictures sent to the ME were not in Resident 98's medical record. In an interview on [DATE] at 9:35 AM, the ME stated they requested pictures of Resident 98's head injury to determine the severity of the head injury. The ME acknowledged they received two photographs of Resident 98's head injury via text messaging to the ME's work phone. In an interview on [DATE] at 11:05 AM, Staff GG, Nursing Assistant, stated staff were not allowed to photograph residents, especially by using a staff's personal electronic device. Staff GG explained the health unit coordinators (HUC) would photograph residents for an electronic medical record profile picture. In an interview on [DATE] at 11:21 AM, Staff LL, Licensed Practical Nurse, stated if a resident photograph was taken for medical purposes, then it should be in their medical record. Staff LL acknowledged staff should not use personal phones to take photographs of residents because it would violate HIPAA (Health Insurance Portability and Accountability Act, established standards that protect sensitive health information from disclosure without a patient's consent and protected one's privacy). In an interview on [DATE] at 11:57 AM, Staff Y, Resident Care Manager, stated they were unsure on the facility process for photographing residents. In an interview on [DATE] at 3:10 PM, Staff B, Director of Nursing, stated HUCs used the facility mobile device to obtain resident's profile pictures. Staff B acknowledged staff should not take resident pictures using their own personal cell phones because of HIPAA concerns. In an interview on [DATE] at 12:45 PM, Staff NN, HUC, stated they used the facility mobile tablet to take a resident's picture for their electronic medical record profile. Staff NN explained pictures taken with the facility's mobile tablet were automatically uploaded to the facility computer. Staff NN further sated they had not had to transmit resident photographs and was unsure of the process. Staff NN acknowledged staff were not to use any other devices besides the facility equipment to photograph residents. In an interview on [DATE] at 4:15 PM, Staff A, Administrator, acknowledged Resident 98's picture was taken using a staff's personal cell phone and transmitted to the ME via normal text messaging to a phone number provided by the ME. Review of additional information provided by the facility on [DATE] showed a handwritten statement dated [DATE] and signed by Staff MM, Licensed Practical Nurse. The statement acknowledged Staff MM used their personal mobile phone to take a picture of Resident 98, transmitted the photo to the ME as requested, and immediately deleted the picture from my phone. Reference WAC 388-97-1720 (1)(b), (5)(a)(b)

**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 in a form, manner, and/or language understood by the resident and/or their legal representative for 2 of 3 sampled residents (Residents 13 and 88) reviewed for arbitration. Failure to ensure residents had the cognitive ability to understand and enter into an arbitration agreement with the facility, and failure to ensure staff responsible for explaining the arbitration process and offering the arbitration agreement had adequate training, placed the residents at risk of being uninformed of their rights, losing legal protection, the right to pursue legal action, and a diminishd quality of life. Findings included . The facility policy, [NAME] Arbitration Agreement, last updated September 2022, stated the parties understood that any legal dispute, controversy, demand or claim that arose out of or related to the Resident admission Agreement, or any service or care provided by the Center to the Resident would be resolved exclusively by binding 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 have any claim decided in a court of law before a judge or jury, and that by signing the agreement, they fully understand the terms contained in the agreement. <Resident 13> The 12/26/2024 admission assessment documented Resident 13 admitted to the facility on [DATE], was severely cognitively impaired and had diagnoses which included non-Alzheimer's dementia. Review of Resident 13's record showed the facility's voluntary arbitration agreement was signed on 12/23/2024 by Resident 13 and not their legal representative. Review of the progress notes from 12/20/2024 through 01/15/2025 showed Resident 13 was cognitively impaired, had dementia, and was alert to self only, but able to make needs known. In an interview on 01/15/2025 at 12:20 PM, Staff GG, Nursing Assistant, stated Resident 13 was confused, was able to make needs known to staff, but decisions regarding their care was made by the resident's daughter. On 01/15/2025 at 12:28 PM, Resident 13 was observed sitting in the dayroom, being assisted with eating lunch. The resident smiled and stated yes when asked if they were doing well but was unable to state the date or where they were when asked. <Resident 88> The 12/24/2024 admission assessment documented Resident 88 admitted to the facility on [DATE] and had severe cognitive impairment. Review of Resident 88's record showed the facility's voluntary arbitration agreement was signed on 12/19/2024 by the Resident 88 and not their legal representative. An admission progress note on 12/18/2024 at 4:15 PM documented Resident 88 was confused and oriented to self only, and on 12/19/2024 at 11:49 AM, the day Resident 88 signed the arbitration agreement, Staff HH, Physician, documented Resident 88 was still confused. In an interview on 01/15/2025 at 12:23 PM, Staff GG stated Resident 88 was very confused, and decisions regarding their care were made by the resident's spouse. On 01/15/2025 at 12:33 PM, Resident 88 was observed in their room, lying in bed, visiting with their spouse. When Resident 88 and their spouse were asked if the facility's arbitration process had been explained to them, and if they had signed the arbitration agreement, the resident stated they knew nothing about that, and the spouse stated they were not aware of any arbitration process or agreement. When the spouse was asked if they were aware the resident had signed the arbitration agreement, they stated no. Resident 88 then asked for clarification about what they had signed when they were in high school. After the arbitration process was explained, Resident 88 stated, That is over my head, I know nothing. Do you have a business card? You can bring me a report when you finish. In an interview on 01/15/2025 at 12:05 PM, Staff K, admission Coordinator, provided a copy of the facility's arbitration agreement and stated the agreement was offered and explained to residents and/or family, representatives when the resident was admitted to the facility. In an interview with Staff K, admission Coordinator, and Staff II, admission Director, on 01/15/2025 at 2:51 PM, they were asked the facility had a process or assessment to determine if the resident was cognitively able and had the mental capacity to enter into and sign an arbitration agreement. Staff II stated Staff JJ, Nursing Assistant/Transportation driver, assisted with completing the arbitration agreements, and they would not be able to assess the resident. Staff II stated if a resident was cognitively impaired or unable to sign the agreement, it was offered to the resident's guardian, power of attorney, or next of kin. When informed both Residents 13 and 88 had severe cognitive impairment, and had signed the arbitration agreement, Staff II stated they would need to follow up with Staff JJ to find out if the resident's representative/family had been offered the agreement. When informed that no documentation had been found that showed either Resident 13 or 88's family and/or representative had been offered the agreement, and asked if the residents should have signed the arbitration agreement, Staff II stated they did not believe they should have. In an interview on 01/16/2025 from 11:04 to 11:20 AM, Staff JJ stated their main responsibility was as the transportation driver, but they assisted with completion of the admission paperwork and the arbitration agreements. Staff JJ stated they had received training on arbitration from the previous transportation driver and the agreements were offered when residents admitted to the facility. Staff JJ was unable to explain the arbitration process and when asked if the resident and/or representative gave up the right to go to court if they entered into an agreement, Staff JJ stated they did not believe they gave up the right. When the arbitration process and agreement was explained to Staff JJ, they stated they did not know the right to sue the facility was lost when the agreement was signed. In a follow up interview on 01/16/2025 at 3:54 PM with Staff H and Staff JJ, Staff JJ stated they understood the arbitration process and stated any issues/conflicts were resolved by a third party instead of going to court. When Staff H and Staff JJ were asked if the resident and/or family gave up the right to sue or take the facility to court if they entered into an arbitration agreement, Staff H stated, no, the resident and/or representative was still able to take the facility to court. No Associated WAC

Based on interview and record review the facility failed to ensure residents could file grievances without reprisal or fear of reprisal, report grievances consistent with alleged abuse to the State Survey Agency as required, and repeatedly promptly resolve grievances for 4 of 5 sampled residents (Resident 40, 31, 10, 24), reviewed for grievances. This failure placed residents at risk of feelings of powerlessness, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy title, Grievance Procedure revised November 2016, documented residents and resident representatives were informed of their right to voice a grievance orally, in writing, and anonymously regarding the care and treatment/lack of treatment, behavior of staff and of other residents, and other concerns during their stay. The policy further documented residents had the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. Grievances were to be resolved immediately, when possible. If a grievance involved an allegation of abuse, neglect, exploitation, or misappropriation of resident property the executive director was to be notified, an investigation started and the abuse prohibition procedure was to be followed. <Resident 40> According to the 11/02/2024 quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 40 filed the following grievances: -08/06/2024 the beef tips taste like sawdust with a 08/15/2024 resolution of facility returned to the previous food supplier. -08/06/2024 staff ignored call lights and played on their mobile phones. A 08/26/2024 resolution of staff was educated on leaving phones in lockers and notifying the nurse all resident cares were provided by the end of the shift. -09/03/2024 still having issues with staff ignoring call light never had any follow up from prior grievance in August and staff did not perform hand hygiene prior to handling resident items. A 09/10/2024 resolution of 1:1 staff education on hand hygiene. -12/03/2024 night shift staff using Oak activity room as break room and ignoring call lights. A 12/10/2024 resolution of staff education and signage posted on activity room staff were not to use the resident area as a breakroom. In an interview on 01/08/2025 at 10:38 AM, Resident 40 stated staff still had not answered call lights timely. Resident 40 further stated they received medications around 3:30 AM and often came out in search of the nurse to find staff using the Oak activity room as a breakroom while residents had call lights on in the halls. In a follow-up interview on 01/08/2025 at 11:11 AM, Resident 40 stated they felt staff retaliated against them when they previously voiced concerns. Resident 40 explained Staff F, Nursing Assistant (NA), approached them once and stated Why did you say that? You threw me under the bus and then would not talk to Resident 40 for a while. Resident 40 further stated they felt staff talked down to them and this made them feel they needed to move out. Resident 40 was unaware they could file a grievance anonymously and felt grievances were not addressed timely because they had the same concerns month after month. Review of additional grievances provided by the facility on 01/20/2025 showed: -06/04/2024 an identified nursing assistant (not Staff F, NA) wore their pants low with their underwear exposed. Resident 40 recommended the staff use a belt and staff responded, I don't have one, you are just looking at my **s. -06/10/2024 Resident 40 felt retaliated against when the staff identified in the 06/04/2024 grievance approached the resident and stated, I hope everyone can see that I am doing my job right. <Resident 31> According to the 11/19/2024 quarterly assessment, Resident 31 had diagnoses including chronic (occurring for long period of time or repeatedly) respiratory failure (lungs not working properly to get enough oxygen into the body) with hypoxia (low oxygen levels in body), chronic pulmonary embolism (blood clot that blocks blood flow to lungs), and muscle weakness. Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 31 filed the following grievances: -07/02/2024 the night NA was rude, rough and pinched Resident 31's skin when they assisted with a brief change. A 07/03/2024 resolution included staff education and verbal disciplinary action. The grievance did not describe what type of staff education was provided. Review of the July 2024 through December 2024 facility mandatory reporting log showed no entries for this allegation of potential abuse. -09/03/2024 the clam chowder smelled and tasted bad with a 09/04/2024 resolution switched out soup for replacement item. -11/05/2024 waited 45 minutes for staff to assist with personal hygiene after an episode of incontinence. A 11/12/2024 resolution included a staff reminder to answer call lights as soon as possible. In an interview on 01/08/2025 at 10:38 AM, Resident 31 stated staff were still not answering call lights timely. Resident 31 further stated they were not to be taking themselves to the bathroom but did because staff would not respond to their call light timely. Resident 31 explained they typically did not wear their oxygen when in the bathroom, last week they pressed their bathroom call light, after waiting 35 minutes without staff response, Resident 31 began to yell out because they needed their oxygen. Resident 31 stated they left the door to their room open, in case of emergencies, because staff did not response to call lights timely. In a follow-up interview on 01/08/2025 at 11:11 AM, Resident 31 stated they felt ignored, and staff talked down to them. Resident 31 further stated they did not know how to file a grievance until their child informed them how. <Resident 10> According to the 10/19/2024 annual assessment, Resident 10 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of the July 2024 through December 2024 grievance log showed Resident 10 filed the following grievances: -09/03/2024 Teriyaki beef was too tough with a 09/04/2024 resolution of staff were educated on roasting meat. In an interview on 01/08/2025 at 10:55 AM, Resident 10 stated they rarely ate meat served because they could not chew it. Resident 10 further stated the facility did not follow-up on grievances. <Resident 24> According to the 11/16/2024 quarterly assessment, Resident 24 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 24 filed the following grievances: -11/05/2024 waited one and a half hours for staff assistance with a 11/12/2024 resolution of staff re-education on call light response times. In an interview on 01/07/2025 at 2:43 PM, Resident 24 stated the facility did not have enough staff because they often had excessively long call light wait times. In an interview on 01/17/2025 at 9:09 AM, Staff G, Nursing Assistant, stated residents could submit grievances without fear of retaliation and informed residents about the Ombudsman (a person who investigated and resolved complaints, and advocated for resident's rights) if retaliation concerns arose. Staff G further stated staff were not to confront a resident as to why a concern was reported because that could be considered retaliation. In an interview on 01/17/2025 at 9:50 AM, Staff E, Registered Nurse, stated residents could file grievances without fear of retaliation. Staff E explained if they received a grievance that was a potential allegation of abuse, they followed the facility's abuse prohibition policy. Staff E acknowledged staff should not tell a resident they were thrown under the bus when a concern was voiced, that was unprofessional behavior that could potentially be considered retaliation or harassment. In an interview on 01/17/2025 at 10:26 AM, Staff T, Social Service Director, stated Staff A, Administrator was the grievance official. Staff T further stated residents should be able to submit grievances without fear of retaliation, staff should not approach a resident saying they were thrown under the bus as that could be considered retaliation. Staff T explained grievance information was confidential, and some details were not be shared with staff involved. Staff T further stated if they received a grievance that rose to the level of a potential abuse allegation, they followed the abuse prohibition policy. In an interview on 01/17/2025 at 11:33 AM, Staff B, Director of Nursing, stated residents could submit grievances without fear of retaliation and protected residents by not disclosing persons involved to maintain confidentiality. Staff B was unsure the time frame a grievance should be resolved by. Staff B further stated if a grievance sounded like a potential allegation of abuse, they followed the facility's abuse prohibition process. Staff B acknowledged staff should not approach a resident saying they were thrown under the bus when a concern was voiced because it could be considered retaliation that would need to be investigated. In an interview on 01/17/2025 at 3:56 PM, Staff A, Administrator, stated they reviewed grievances for potential allegation of abuse and followed the abuse policy if a grievance appeared to rise to the level of a potential allegation of abuse or neglect. Staff A further stated the facility attempted to resolve grievances within five days, but some grievances might take longer. Staff A acknowledged staff should not approach residents asking them why they were thrown under the bus as that could be considered potential retaliation. Reference WAC 388-97-0460 Refer to F607, F725, and F804 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its Abuse and Neglect Policy and Procedure to include the identification of potential allegations of abuse, responding to and reporting the allegation to the State Survey Agency (SA) as required, and thoroughly investigating allegations for 5 of 8 sampled residents (Resident 98, 10, 58, 40, and 31), reviewed for abuse. This failure placed residents at risk for abuse, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated [DATE], defined different forms of abuse. The policy defined mental abuse as the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The policy further showed new and existing staff would be trained regarding the facility's abuse policies to include identification of abuse and/or neglect, immediately report all suspected and/or allegations of abuse as required, and thoroughly investigate potential, suspected and/or allegations of abuse. <Resident 98> According to the [DATE] admission assessment, Resident 98 admitted to the facility on [DATE] with diagnoses including muscle weakness, reduced mobility, lack of coordination, and chronic pain. Resident 98 required touch assistance to transfer onto the toilet and moderate staff assistance to perform toileting hygiene. Resident 98 had severe cognitive impairment. Review of a [DATE] facility incident report showed Resident 98 experienced an unanticipated death. Resident 98 was found at 6:30 PM slumped over on the toilet with a laceration above their left eyebrow. The incident report further showed Resident 98 was last seen sitting on the edge of their bed at 5:25 PM, on hour and five minutes prior. The incident report only contained two staff interviews and no resident interviews. A [DATE] investigation summary showed Resident 98 had been compliant with use of their call light, but the call light was not on at the time Resident 98 was found on the toilet. The investigation summary did not rule out abuse and/neglect. Review of [DATE] nursing progress notes showed Resident 98 required moderate assistance for toileting. On [DATE] Resident 98 was found sitting on the toilet unresponsive, staff called emergency medical services and initiated cardiopulmonary resuscitation (CPR) per Resident 98's wishes. Resident 98 expired and the medical examiner (ME) was notified of the laceration to the left upper eyebrow. The progress notes further showed the ME was sent pictures of Resident 98's facial laceration and Resident 98 would need to be picked up for further testing. Further review of Resident 98's medical record showed no pictures of Resident 98's facial laceration were found. In an interview on [DATE] at 11:00 AM, Staff GG, Nursing Assistant (NA), stated they looked into resident rooms as they walked down the hall to check on residents. Staff GG further stated abuse and/or neglect was ruled out by management interviews of residents and staff interviews on the unit. In an interview on [DATE] at 11:16 AM, Staff LL, LPN, stated they constantly checked on residents as they walk down the hall. Staff LL explained incident investigations were completed by management, everyone filled out statements, and management ruled out abuse and/or neglect by reviewing staff and resident interviews conducted. In an interview on [DATE] at 11:53 AM, Staff Y, Resident Care Manager (RCM), explained investigations were completed by management staff depending on the allegation or incident. Staff Y further stated social service staff conducted interviews of residents in the general vicinity and staff, the interdisciplinary team (IDT) discussed the incident and ruled out abuse by asking questions. In an interview on [DATE] at 3:02 PM, Staff B, Director of Nursing (DNS), explained when an allegation of abuse was received, the staff receiving the report ensured resident safety and started the investigation process. The RCM and/or DNS would then interview staff and resident involved and social service staff would conduct extended interviews that included other resident in the area and staff working the unit at the time. Staff B further stated interviews were reviewed by the IDT to rule out abuse and/or neglect. In an interview on [DATE] at 4:17 PM, Staff A, Administrator, explained the facility ruled out abuse and/or neglect by interviewing residents and staff, if appropriate other staff beyond who was involved would be interviewed to try to get a clear picture of an incident. Staff A stated the facility ruled out abuse and/or neglect related to Resident 98's unanticipated death. Staff A was asked how abuse was ruled out if the investigation only contained two staff statements and no resident interviews. Staff A stated, no other residents were involved in that situation, so why would we interview other residents? <Resident 58> The [DATE] quarterly assessment documented Resident 58 had severe cognitive impairment but was able to understand others and make their needs known. On [DATE] at 8:14 AM, Resident 58 was observed lying in bed, waiting for breakfast. When asked about the care at the facility, the resident stated they did not care for Staff X, Licensed Practical Nurse (LPN). The resident stated Staff X was rude and not nice when they interacted with them. In a follow up interview at 1:14 PM that same day, Resident 58 stated that about two or three weeks ago, they had observed Staff X sleeping at the nurse's station, and when they had mentioned it to Staff X, they denied being asleep, and their manner was rude and condescending. Resident 58 further stated it made them feel terrible, and they would not feel comfortable in approaching Staff X if they needed assistance or had a medical concern. When Resident 58 was asked if they had told any of the other staff of their concern, Resident 58 stated they had kept quiet because they did not want to cause a ruckus and were afraid of retaliation. Resident 58 was then asked if they were comfortable with the surveyor informing the facility of their concerns regarding Staff X, and Resident 58 stated yes. In an interview on [DATE] at 2:16 PM, Staff A, Administrator, was informed of the conversation with Resident 58 and the resident's concerns regarding Staff X. On [DATE] a review of the State Agency incident reporting program, STARS, found no documentation that the facility had reported the allegation of possible abuse concerning Resident 58. A report was then made by the surveyor to the SA. An additional review of STARS on [DATE] at 11:49 AM, eight days after the facility was notified of the allegation, found no documentation to show the facility had reported the allegation to the SA as required. Review of the [DATE] facility grievance log which had been provided to the survey team on [DATE] found no entries related to Resident 58. On [DATE] at 12:00 PM, Staff A, Administrator was asked to provide the facility investigation related to Resident 58's allegation, an updated grievance log and the facility reporting log for [DATE]. On [DATE] at 2:38 PM, the updated facility reporting log for [DATE] was reviewed and no entries had been made regarding Resident 58. On [DATE] at 2:39 PM, review of the updated grievance log for [DATE] found an entry dated [DATE] was now present related to Resident 58 which documented the issue as a staff concern which was resolved on [DATE]. On [DATE] at 3:38 PM, a grievance form for Resident 58 was received via email correspondence from Staff A related to the staff concern on [DATE]. The form documented the nature of the concern was expressed by the surveyor and stated Staff X was mean. The form did not include all the information that had been reported to the facility. The form further documented the only steps taken to investigate were to interview the resident. No other documentation or a facility investigation was received. In an interview on [DATE] at 6:14 PM, Staff B, Director of Nursing, was asked if an investigation had been completed regarding the concerns expressed by Resident 58. Staff B stated it was their understanding that the concern was more how Staff X talked, and it was not identified as potential abuse. <Resident 40> According to the [DATE] quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of [DATE] through [DATE] grievance log showed Resident 40 filed the following grievances: -[DATE] staff ignored call lights and played on their mobile phones -[DATE] still having issues with staff ignoring call light never had any follow up from prior grievance in August and staff did not perform hand hygiene prior to handling resident items. -[DATE] night shift staff using Oak activity room as break room and ignoring call lights. In an interview on [DATE] at 10:38 AM, Resident 40 stated staff were still not answering call lights timely. Resident 40 further stated they received medications around 3:30 AM and often came out in search of the nurse to find Staff X, LPN, sleeping at the nurses' station and other staff using the Oak activity room as a breakroom, while residents had call lights on in the halls. In a follow-up interview on [DATE] at 11:11 AM, Resident 40 stated they felt staff retaliated against them when they previously voiced concerns. Resident 40 explained Staff F, NA, approached them once and stated Why did you say that? You threw me under the bus and then would not talk to Resident 40 for a while. Resident 40 further stated they felt staff talked down to them and this made them feel they needed to move out. In an interview on [DATE] at 12:03 PM, Staff A, Administrator, was informed Resident 40 voiced an allegation of potential abuse related to how staff communicated with them and how it made them feel. In an interview on [DATE] at 12:19 PM, Resident 40 was informed the surveyor reported their concerns about how staff communicated with them and how it made them feel to the facility because it was a potential allegation of abuse the facility needed to investigate. In a follow-up interview on [DATE] at 12:55 PM, Resident 40 stated social services spoke to them. Review of the State Survey Agency Secure Tracking And Reporting System, STARS, on [DATE], showed no entries for Resident 40's [DATE] allegation of potential abuse. The investigation for Resident 40's [DATE] allegation of potential abuse was requested from Staff A, administrator, on [DATE] at 12:00 PM. No documentation was provided. <Resident 10> According to the [DATE] annual assessment, Resident 10 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. In an interview on [DATE] at 11:11 AM, Resident 10 stated staff had poor social skills and ignored residents. Resident 10 explained this made them feel ignored and depressed. Review of the [DATE] depression screening assessment showed Resident 10 scored a one, indicating minimal depression symptoms. Review of the [DATE] depression screening assessment showed Resident 10 scored an eight, indicating mild depression symptoms. In an interview on [DATE] at 12:03 PM, Staff A, Administrator, was informed Resident 10 voiced an allegation of potential abuse related to how staff communicated with them and how it made them feel. In an interview on [DATE] at 12:19 PM, Resident 10 was informed the surveyor reported their concerns about how staff communicated with them and how it made them feel to the facility because it was a potential allegation of abuse the facility needed to investigate. The investigation for Resident 10's [DATE] allegation of potential abuse was requested from Staff A, administrator, on [DATE] at 12:00 PM. Review of the [DATE] facility incident report showed Resident 10 stated staff was mean and they wanted staff to make them feel like a human being. The investigation contained a [DATE] grievance filed by Resident 58 related to Staff X, LPN, being mean, no staff or other resident interviews were included. A [DATE] investigation summary showed abuse and/or neglect was ruled out through residents' interviews conducted by social services. <Resident 31> According to the [DATE] quarterly assessment, Resident 31 had diagnoses including chronic pulmonary embolism (blood clot that blocks blood flow to lungs) and muscle weakness. Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of [DATE] through [DATE] grievance log showed Resident 31 filed the following grievances: -[DATE] night NA was rude, rough and pinched Resident 31's skin when assisting with a brief change. A [DATE] resolution of staff education and verbal disciplinary action. The grievance did not describe what type of staff education was provided, did not include staff or resident interviews, and did not rule out abuse and/or neglect. Review of the [DATE] through [DATE] facility mandatory reporting log showed no entries for the [DATE] allegation of potential abuse. In an interview on [DATE] at 11:11 AM, Resident 31 stated they felt ignored by staff and staff talked down to them. In an interview on [DATE] at 12:03 PM, Staff A, Administrator, was informed Resident 31 voiced an allegation of potential abuse related to how staff communicated with them and how it made them feel. In an interview on [DATE] at 12:19 PM, Resident 31 was informed the surveyor reported their concerns about how staff communicated with them and how it made them feel to the facility because it was a potential allegation of abuse the facility needed to investigate. Review of the State Survey Agency Secure Tracking And Reporting System, STARS, on [DATE], showed no entries for Resident 31's [DATE] or [DATE] allegations of potential abuse. The investigation of Resident 31's [DATE] allegation of potential abuse was requested from Staff A, administrator, on [DATE] at 12:00 PM. Review of documentation provided showed a single piece of paper with Resident 31's vague interview. Resident 31's interview showed they could perform most cares independently, staff thought they did not need to help them but Resident 31 voiced they could use more staff assistance. Abuse and/or neglect was not ruled out. In an interview on [DATE] at 9:13 AM, Staff G, NA, stated if they received a report of a potential allegation of abuse, they would ensure resident safety then report the allegation to the nurse and up the chain of command so an investigation could be started. Staff G further stated a report of staff being rude and so rough they pinched a resident's skin, would be considered a grievance, not a potential allegation of abuse. In an interview on [DATE] at 9:54 AM, Staff E, Registered Nurse, stated if a resident reported staff was rude and so rough they pinched a resident's skin, Staff E would complete a skin assessment, speak with the identified staff 1:1, and notify management. Staff E further stated they would ask the resident if they would like to file a grievance with an incident resolution. In an interview on [DATE] at 10:32 AM, Staff T, Social Service Director, explained when an allegation of potential abuse was reported they would ensure resident safety by removing any identified staff from providing resident care, start an investigation, and rule out abuse and/or neglect by completing resident and staff interviews. Staff T acknowledged if a resident reported staff was rude, rough, and pinched their skin, it would be considered a potential allegation that needed to be reported to the State Survey Agency and all steps followed to investigate the potential allegation. In an interview on [DATE] at 11:38 AM, Staff B, Director of Nursing, stated all staff were mandatory reporters and should follow the appropriate steps when an allegation of abuse was received. Staff B acknowledged Resident 31's [DATE] grievance of rude staff with rough care and pinched skin should have been reported as an allegation of abuse and investigated as such. In an interview on [DATE] at 3:56 PM, Staff A, Administrator, stated they reviewed grievances for potential allegations of abuse and/or neglect. Staff A further stated if a grievance appeared as a potential allegation, then it would be reported and investigated following all the steps in the abuse policy. In a follow-up interview on [DATE] at 4:01 PM, Staff A, acknowledged if a resident reported staff was rough and pinched their skin, it would be considered an allegation of potential abuse. Reference WAC 388-97-0640 (2) Refer to F585, F730, and F842 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care according to the person-centered care plans and provider orders for 4 of 8 sampled residents (Residents 27, 36, 54 and 89 ) reviewed for quality of care. Specifically, Resident 27 was on a fluid restriction and their intake was not monitored or maintained, Resident 36's blood sugar monitoring equipment was broken by staff and was not replced timely, Resident 54 did not have their bowel management medications administered to prevent constipation, and Resident 89 had difficulty swallowing and a Speech Therapy evaluation was not completed timely. These failures placed residents at risk for unintended health consequences and decreased quality of life. Findings included . <Resident 36> A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a Central nervous system disease that caused stiffness, tremors and balance difficulty) and diabetes. The resident was cognitively intact and received insulin injections (treated high blood sugar) daily. On 08/07/2024, an order was given by the provider for staff to utilize a continuous glucose monitor (CGM, a sensor inserted under the skin that monitored blood sugar levels continuously and sent the information to a receiver or smartphone application) to monitor Resident 36's blood sugar level twice a day, no finger sticks. During an interview on 01/08/2025 at 11:11 AM, Resident 36 was in their room seated in their recliner. The resident stated they received insulin injections every day to manage their blood sugar. Resident 36 stated they had an implanted blood sugar monitor and it was observed on the back upper portion of the resident's left arm. The resident stated they had a receiver that was held up to their arm and their blood sugar level could be seen. Resident 36 stated their CGM had been broken over a week prior. The resident stated one of the nurses had been unable to get the CGM to work, had tried to replace a cartridge in the sensor and also broke the cartridge. The resident stated ever since, staff were pricking their fingers to obtain their blood sugar and their fingertips were sore. Resident 36 stated their family member had tried to order more cartridges but none had come in yet. Review of the January medication administration record (MAR) documented blood sugar results were obtained twice daily from Resident 36's CGM, with no omissions. There were no progress notes that documented that the CGM was broken, what the status was, or if the provider or other staff had been notified. During a follow up interview on 01/17/2025 at 9:10 AM, Resident 36 stated they were still having their blood sugar results obtained using finger sticks. They stated no one from the facility had talked with them regarding replacing their cartridges or if their family was able to obtain any supplies. During an interview on 01/17/2025 at 9:33 AM, Staff AA, Certified Medication Technician, stated they performed finger sticks to obtain Resident 36's blood sugar result. Staff AA viewed the order that instructed staff to use the monitor and not use finger sticks and stated the resident's CGM was not working and had been broken for several weeks. Staff AA was not sure if the provider had been notified, or if the Resident Care Manager knew the CGM was broken. During an interview on 01/17/2025 at 1:18 PM, Staff D, Resident Care Manager, stated they had not been notified that Resident 36's CGM was not working. The resident's family had been providing the supplies for the monitor. Staff D stated they expected staff to notify the provider so other arrangements or orders for blood sugar monitoring could be obtained, and they expected staff to follow-up and also write a progress note. CONSTIPATION <Resident 54> Review of the March 2018 facility bowel protocol, documented residents who were at risk of constipation would have a care plan implemented. A licensed nurse reviewed the bowel monitor daily, and if a resident did not have a bowel movement (BM) for three days, the nurse administered the physician ordered bowel program. Per the 12/23/2024 significant change in condition assessment, Resident 54 was unable to make decisions regarding cares, and needed total assistance from staff for activities of daily living, such as toileting. Review of the 04/27/2023 care plan showed there was no care plan for constipation. Review of the December 2024 MAR documented on 12/17/2024, the physician had ordered a laxative (Milk of Magnesia) to be given on day four of no BM as needed, a suppository was to be given the next shift if no BM and an enema the next shift if no results had occurred. Review of the bowel records from 12/12/2024 through 01/08/2025, documented Resident 54 had no BMs from 12/20/2024 through 12/24/2024 (five days). Additional review of the MARS for December 2024, 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 01/16/2024 at 3:14 PM, Staff B, Director of Nursing, stated the expectation was for bowel medication to be given as ordered and this was important to prevent constipation which could cause pain, discomfort and an obstruction. FLUID RESTRICTION <Resident 27> According to the 12/19/2024 quarterly assessment, Resident 27 admitted to the facility on [DATE] with diagnoses including heart failure (HF, heart is not strong enough to pump blood well enough to meet the body's needs), atrial fibrillation (irregular and abnormal heartbeat) and malnutrition. Resident 27 had moderate cognitive impairment and was able to verbalize their needs. Review of the 09/24/2024 nutrition care plan showed Resident 27 had nutritional risks and instructed staff to provide diet per provider orders, provide 120 milliliters (mls) of a house supplement with meals, obtain weights per facility protocol, and follow a 1500 ml/24 hours (hrs) fluid restriction per provider orders. Review of provider orders showed a 12/02/2024 order Resident 27 was on a 1500 ml fluid restriction. The provider order broke down the fluids as dietary was to provide 960 mls/24 hrs with meals and nursing was to provide 540 mls/24 hrs, (180 mls each shift in addition to fluid provided by dietary). A 12/02/2024 order instructed night shift to add all fluids provided by the dietary and nursing departments nightly. Review of the December 2024 through January 2025 MAR showed Resident 27 was provided the following fluids by nursing: -12/02/2024 540 mls on evening shift -12/08/2024 240 mls on day shift -12/12/2024 540 mls on night shift -12/15/2024 360 mls on day, evening, and night shifts -01/01/2025 360 mls on day shift and evening shift -01/08/2025 320 mls on evening shift These amounts exceeded the 180 mls allowed per shift. The January 2025 MAR further showed Resident 27 received 1620 mls fluid total on 01/07/2025 and 2480 mls fluid total on 01/08/2025. Review of the December 2024 through January 2025 fluid intake at meals showed Resident 27 was provided: -12/23/2024 488 mls with breakfast, 440 mls with lunch, and 240 mls with dinner (1168 mls) -12/12/2024 360 mls with breakfast, 240 mls with lunch, and 480 mls with dinner (1080 mls) -01/06/2025 420 mls with breakfast and lunch, 240 mls with dinner (1080 mls) During observation on 01/07/2025 at 9:15 AM, Resident 27 sat in their room with a Fluid Restriction 1500mls, NO water at bedside sign posted above their bed. Resident 27 had a large clear cup of ice water with a straw on their bedside table. Similar observations were made on 01/07/2025 at 12:13 PM, on 01/09/2025 at 8:14 AM and 12:13 PM, on 01/13/2025 at 7:44 AM, and 01/15/2025 at 10:05 AM. In an interview on 01/09/2025 at 1:25 PM, Staff R, Nursing Assistant (NA), stated floor staff passed ice water at least twice daily. Staff R was unsure what size the large clear cups used to pass ice water to the residents were. In an interview on 01/14/2025 at 10:13 AM, Resident 27 stated they could get all the juice, coffee, or other fluids they wanted but sometimes staff limited their water. Resident 27 explained staff removed water from the bedside at night. In a follow-up interview on 01/15/2025 at 12:12 PM, Staff R, NA, stated staff could reference a resident's care plan to see what interventions were implemented for the resident, including a fluid restriction. Staff R further stated fluid restrictions were typically in place related to heart issues and not following a fluid restriction could potentially cause increased swelling and medical complications. During observation and interview on 01/15/2025 at 12:25 PM, Staff E, Registered Nurse, explained when a resident was on a fluid restriction, the daily fluid allotment would be divided up into fluids provided by dietary for meals and fluids provided by nursing throughout the day. Staff E stated fluids consumed would be documented in the resident's medical record. Staff E further stated residents were typically on fluid restrictions related to HF and could fill up with fluid if the restriction was not followed. Staff E stated Resident 27 was on a fluid restriction and had signage posted at the bedside to notify staff. Staff E walked into Resident 27's room to point out the fluid restriction sign that read Fluid Restriction 1500mls, NO water at bedside. Staff E removed a large clear cup of water off the bedside table and acknowledged Resident 27 should not have water at their bedside. Staff E reviewed Resident 27's medical record. Staff E stated Resident 27 was on a fluid restriction because they had HF. In an interview on 01/15/2025 at 1:07 PM, Staff D, Resident Care Manager, explained when a resident was on a fluid restriction, the daily fluid allotment would be divided up into fluids provided by dietary for meals and fluids provided by nursing throughout the day. Staff D stated a resident on a fluid restriction should not receive extra water and typically had signage posted at the bedside for staff to follow. Staff D reviewed Resident 27's medical record. Staff D acknowledged Resident 27 was on a fluid restriction because of their HF. In an interview on 01/15/2025 at 2:22 PM, with Staff B, Director of Nursing, and Staff C, Assistant Director of Nursing, they explained when a resident was on a fluid restriction, the daily fluid allotment would be divided up into fluids provided by dietary for meals and fluids provided by nursing throughout the day. Staff B stated the facility typically posted signage at the bedside when a resident was on a fluid restriction and staff should ask the resident's nurse for approval on fluids prior to providing them to a resident on a fluid restriction. The provider should be notified if a resident took in more fluids than ordered. Both Staff B and C stated if a fluid restriction was not followed it could cause fluid overload and/or a potential flare up of the medical condition the fluid restriction was managing. Both Staff B and Staff C were unsure what size the large clear plastic cups used to pass ice water to the residents were. Staff B reviewed Resident 27's medical record. Staff B acknowledged Resident 27 was on a fluid restriction for HF. In an interview on 01/15/2025 at 3:44 PM, Staff A, Administrator, was unsure what size the large clear plastic cups used to pass ice water to the residents were. Staff A stated they expected staff to read signage posted in a resident's room and follow fluid restrictions when implemented. In an interview on 01/17/2025 at 3:28 PM, Staff S, Registered Dietician, was unsure what size the large clear water cups used to pass ice water to the residents were. Staff S further stated they were not aware staff were not following Resident 27's fluid restriction and were concerned. Reference WAC 388-97-1060 (1) This is a repeat deficiency from 11/13/2024 and 05/13/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement interventions timely to prevent weight loss for 2 of 7 sampled residents (Resident 54 and 77) reviewed for nutrition. This failure placed the residents at risk for further weight loss and a decline in their health. Findings included . <Resident 77> According to the 11/09/2024 annual assessment, Resident 77 admitted to the facility on [DATE] with diagnoses including dysphagia and muscle weakness. The assessment further showed Resident 77 showed no signs and/or symptoms of a swallowing disorder. Resident 77's weight was 159 lbs within the last 30 days. Resident 77 was cognitively intact and able to clearly verbalize their needs. Review of the 01/05/2024 initial nutrition evaluation by the Registered Dietician showed Resident 77's weight was 181.6 lbs on 01/04/2024. The assessment further showed Resident 77 was on a regular texture diet with thin liquids and nourishment supplement ordered at bedtime. Resident 77 consumed 75-100% of all three meals. Nutritional interventions were listed as monitoring with a goal weight of 180 lbs, plus or minus 5%. Review of a 05/01/2024 nutrition hydration skin committee review form showed Resident 77 was reviewed related to weight loss. Resident 77's weight was 165.8 lbs on 04/30/2024 with a 5% weigh loss in the last month from 174.9 lbs on 03/29/2024. Resident 77's average meal intake was 26-100%. An interdisciplinary team evaluation summary showed Resident 77 had an 11 lbs significant weight loss in April 2024 unrelated to intake, no recommendations were made at that time. Review of a 08/22/2024 nutrition hydration skin committee review form showed Resident 77 was reviewed related to weight loss. Resident 77's weight was 158.8 lbs on 08/22/2024 with a 7.5% weight loss in the last three months from 169.2 on 05/09/2024 and a 10% weight loss in the last six months from 179.9 on 02/16/2024. Resident 77's average meal intake was 51-100%. An interdisciplinary team evaluation summary showed Resident 77 had documented weights indicating weight loss, weight were obtained sitting, standing, and in wheelchair and recommended consistent weighing method be used. Review of a 08/23/2024 nutrition note showed Resident 77's body mass index (BMI, calculated weight relative to height) was at the lower end of normal for their age and a calorie dense supplement was added twice daily for calorie and protein support. Review of provider orders showed Resident 77 was ordered a nutritionally enhanced meals (NEM, extra calories added through use of butter, brown sugar and gravy for example) on 08/22/2024 and a calorie dense supplement twice daily on 08/23/2024. Review of the nutrition care plan revised 08/23/2024 instructed staff to provide Resident 77 a diet and calorie dense supplement as ordered, offer liquids between meals, obtain weights per facility protocol, and offer a meal substitute or supplement if 50% or less of a meal was consumed. Review of a 09/24/2024 provider progress note showed Resident 77 was concerned about their weight loss. The note further showed Resident 77 had a 15 lbs weight loss in the last six months, moderate protein-calorie malnutrition with muscle wasting in their abdomen, thighs, and face. Resident 77 stated the food is horrible. Review of the 11/06/2024 annual nutrition evaluation form showed Resident 77's weight was 159.2 lbs on 11/04/2024 and their desired body weight was between 170-180 lbs. The assessment further showed Resident 77 was on regular texture NEM diet with thin liquids and calorie dense supplement twice daily. Resident 77 consumed 26-100% of their meals. The dietician evaluation summary showed between 08/14/2024 through 11/04/2024, Resident 77's weights had been stable between 154 and 160 lbs. Review of a 12/04/2024 provider note showed Resident 77 was seen for follow-up on their protein calorie malnutrition. Resident 77 was on nutritional supplements and their weight had stabilized between 157-158 lbs for the last three months. Resident 77 attributed their weight loss to disliking the facility food. In an interview on 01/07/2025 at 2:53 PM, Resident 77 stated the facility food was terrible. Resident 77 further stated they had lost 30 lbs, from 180 lbs down to 160 lbs, and it bothers me. Resident 77 explained they had lost so much weight they could now pull their pants down without having to undo their belt. In a follow-up interview on 01/17/2025 at 9:04 AM, Resident 77 stated their preferred weight was being in the 180 lbs range. Resident 77 again stated their pants were loose and was concerned they had lost so much weight. In an interview on 01/16/2025 at 1:43 PM, Staff G, NA, explained the facility process for obtaining weights. Staff G explained if a weight showed a potential weight loss, a reweigh would be obtained and they would notify the nurse and resident care manager. Staff G was unsure if Resident 77 had weight loss. In an interview on 01/16/2025 at 1:53 PM, Staff E, Registered Nurse, stated if a resident refused a meal or consumed less than 50% of a meal, they would offer them an alternative like a sandwich or pudding. Staff E further stated if potential weigh loss was identified the provider and RD would be notified. Staff E reviewed Resident 77's medical record. Staff E stated Resident 77's weight upon admission was 182 lbs on 12/29/2023, was not on a prescribed weight loss regimen and had weight loss in the facility, Resident 77's lowest weight was 154.8 lbs on 10/01/2024. Staff E further stated Resident 77 was started on a calorie dense supplement on 08/23/2024 after a 23.2 lbs weight loss. Staff E acknowledged Resident 77's stopped losing weight, their weight stabilized, and they started gaining a few pounds after the supplement was added and increased. In an interview on 01/16/2025 at 2:18 PM, Staff Y, Resident Care Manager, reviewed Resident 77's medical record. Staff Y stated Resident 77's weight upon admission was 182 on 12/29/2023, they lost 23 lbs since at the facility, Resident 77's weight was 159 lbs on 01/10/2025. Staff Y stated Resident 77 was ordered calorie dense supplements on 08/23/2024. Staff Y acknowledged if supplements were ordered sooner, it could have potentially prevented Resident 77 from losing so much weight. In an interview on 01/16/2025 at 2:40 PM, Staff B, Director of Nursing, reviewed Resident 77's medical record. Staff B stated Resident 77's admission weight was on 12/29/2023 and had significant weight loss in May 2024, five months after their admission. Staff B stated Resident 77 was started on a NEM diet and calorie dense supplements in August 2024, after their weight loss. In an interview on 01/17/2025 at 3:03 PM, Staff S, RD, reviewed Resident 77's medical record. Staff S stated Resident 77 began to be followed by the facility nutrition/hydration committee 05/01/2024 for identified weight loss, 165.8 lbs on 04/30/2024, a 16.2 lbs weight loss. Staff S further stated a NEM diet and calorie dense supplements were ordered in August 2024, then their weight stabilized. Staff S reviewed the 09/24/2024 provider progress note that showed Resident 77 had protein calorie malnutrition after a 15 lbs weight loss in six months with muscle wasting. Staff S acknowledged Resident 77's protein calorie malnutrition diagnoses was new during their stay at the facility. In an interview on 01/17/2025 at 4:11 PM, Staff A, Administrator, stated the facility implemented interventions when weight loss was identified, not prior to weight loss. <Resident 54> Per the 12/23/2024 significant change assessment, Resident 54 had diagnoses which included diabetes, high blood pressure, dementia and had severe cognitive impairments. The assessment further showed the resident held food in their mouth or residual food in their mouth after meals, coughed or choked during meals and had no weight loss or gain. A 12/23/2024 physician's order prescribed Resident 54 mildly thickened liquids, supervision for all intake and was to have aspiration precautions [sitting upright at a 90-degree angle, taking small bites and chewing well before swallowing, and eating and drinking slowly] for dysphagia (difficulty swallowing). The order also stated sippy cups (a cup with two handles and a lid that prevented excessive flow of fluids) for all drinks. The 04/24/2024 care plan stated Resident 54 would have no unplanned significant avoidable weight loss or gain, was at risk related to an aspiration event, dysphagia and was on a mechanically altered diet. The interventions included a two handled cup, aspiration precautions, no straws, supervision, refer to the dietician as appropriate and two ounces of no sugar added shakes with lunch and dinner that was added on 12/23/2024. A 10/01/2024 nutritional evaluation by the Registered Dietician showed Resident 54 had a downward trend in weight, lost 10 lbs in the last year but was not significant and food preferences were updated. A 12/23/2024 nutritional evaluation by the Registered Dietician showed Resident 54's weight on 06/12/2024 was 172.4 pounds (lbs), 09/04/2024 170.4 lbs, 11/05/2024 163.2 lbs, and 12/18/2024 157.5 lbs. The resident's average intake was 58 %, current body mass index was 22.6, underweight, and a no sugar added shake was added to meals. Review of Resident 54's record from August 2024 through January 2025 showed a 9.1% weight loss in six months, a 6.57% loss in three months and a 2.3% loss over the past month. During an observation on 01/10/2025 at 12:11 PM, Resident 54 sat alone in their room consuming fluids and eating independently (no supervision as ordered). Subsequent observations of the resident without supervision during the meal service were made on 01/10/2025 at 12:31 PM, 01/13/2025 at 7:23 AM, 7:44 AM, 7:55 AM, 01/15/2025 at 12:28 PM, 12:32 PM, 12:37 PM, and 12:45 PM. In an observation on 01/10/2025 at 12:36 PM, Resident 54 had some regular cups and had consumed fluids from them (not all cups were sippy cups as ordered). In a similar observation on 01/13/2025 at 7:05 AM, the resident had a regular cup, and one cup of the fluids contained ice cubes (resident was prescribed thickened liquids). At 7:55 AM, the resident had three cups of fluids, and none were in a sippy cup. On 01/15/2025 at 12:33 PM and 01/16/2025 at 7:58 AM, the resident had consumed fluids out of a regular cup. In an interview on 01/15/2025 at 1:39 PM, Staff OO, Nursing Assistant, stated supervision for meals meant sitting with the resident but they did not have enough staff to do so when the residents ate in their rooms. Staff OO stated they looked at the resident's care plan or meal tickets to know if they needed adaptive equipment for meals. When asked why it was important for the resident to have a sippy cup, Staff OO stated to prevent choking. Staff OO stated any resident that received thickened liquids should not have had ice in their fluids as they could choke or aspirate. During an interview on 01/16/2025 at 2:19 PM, Staff B, Director of Nursing, stated Resident 54 had not triggered for weight loss, but had lost 15 lbs. Staff B added interventions would be placed prior to weight loss. Staff B stated a resident that requires sippy cups should have them for all liquids and this was important to control the flow of the liquids and stated residents on thickened liquids should not have ice cubes unless they have signed a risk/benefit form, and this could cause aspiration. In an interview on 01/17/2025 at 2:41 PM, Staff S, Registered Dietician, stated Resident 54 had a downward trend in their weight. When asked what interventions were put in place for the resident over the past six months, Staff S stated they had a downgrade in their diet, change in adaptive equipment and aspiration precautions. Staff S added house supplement had been added on 12/23/2024. When asked if interventions should have been placed prior to December 2024, Staff S stated it possibly could have helped to start the house supplement sooner or to have increased it. Staff S acknowledged Resident 54 was diabetic and added they did not have sugar free house supplement in stock, and it had to be ordered when needed. Reference: WAC 388-97-1060 (3)(h) Refer to F804 for additional information.

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 1 of 5 sampled staff (Staff F), 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 Staff F, Nursing Assistant, personnel file showed they were hired on 11/03/2022. The personnel file included a 01/10/2023 verbal warning for not completing training as required and a 07/29/2024 written warning for a verbal altercation with a peer which included use of profanity and threatening language at the nurse's station. No documentation of a performance evaluation was found. In an interview on 01/17/2025 at 12:28 PM, Staff G, Nursing Assistant, stated staff evaluations were done yearly. In an interview on 01/17/2025 at 12:52 PM, Staff E, Registered Nurse, stated staff evaluations were done yearly. In an interview on 01/17/2025 at 12:59 PM, Staff D, Resident Care Manager, stated staff evaluations were supposed to be completed yearly. Staff D stated resident care was a priority and acknowledged staff evaluations were not completed yearly as required. In an interview on 01/17/2025 at 1:46 PM, Staff B, Director of Nursing, stated staff evaluations were to be completed yearly. Staff B acknowledged the facility was behind on completing staff evaluations yearly as required. Reference WAC 388-97-1680 (1), (2)(a-c) Refer to F585 for additional information.

Based on observation, interview and record review, the facility failed to prepare palatable (acceptable/appetizing) meals for 7 of 10 residents (Residents 10, 28, 31, 35, 40, 50 and 77), reviewed for food palatability.This failure placed the residents at risk for a diminished dining experience, dissatisfaction with food served and a potential for less than adequate nutritional intake leading to weight loss. Findings included . <Resident 77> According to the 11/09/2024 annual assessment, Resident 77 was cognitively intact and able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 77 filed the following grievances: -09/03/2024 the clam chowder smelled and tasted bad with a 09/04/2024 resolution that the facility switched out soup for a replacement item. Review of a 09/24/2024 provider progress note showed Resident 77 was concerned about their weight loss. The note further showed Resident 77 had a 15-pound (lbs) weight loss in the last six months, moderate protein-calorie malnutrition with muscle wasting in their abdomen, thighs, and face. Resident 77 stated the food is horrible. Review of a 12/04/2024 provider note showed Resident 77 was seen for follow-up on their protein calorie malnutrition. Resident 77 was on nutritional supplements and their weight had stabilized between 157-158 lbs for the last three months. Resident 77 attributed their weight loss to disliking the facility food. In an interview on 01/07/2025 at 2:53 PM, Resident 77 stated the facility food was terrible, if I didn't have to eat, I would not eat here. Resident 77 explained the food consisted of tough pork, turkey, chicken, and beef so tough it was like rubber and they were unable to chew. Resident 77 further stated they had lost 30 lbs, from 180 lbs down to 160 lbs, and it bothered them. In a follow-up interview on 01/07/2025 at 3:24 PM, Resident 77 stated they had chicken for lunch that day. Resident 77 explained the chicken was so dry they were unable to cut or chew it and had to place it on their fork and try to gnaw at it. <Resident 28> According to the 12/16/2024 quarterly assessment, Resident 28 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. In an interview on 01/07/2025 at 11:27 AM, Resident 28 stated the hot food was typically lukewarm, they had cold eggs for breakfast and a cold hamburger for lunch that day. Resident 28 further stated they could not tolerate when their food was cold. In a follow-up interview on 01/09/2025 at 12:14 PM, Resident 28 stated they had a big lump of turkey for lunch that day, it was dry and hard and they could not cut or chew it. Resident 28 stated they refused to eat their food and were not offered an alternative meal or nutritional supplement. <Resident 40> According to the 11/02/2024 quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 40 filed the following grievance: -08/06/2024 the beef tips tasted like sawdust. In an interview on 01/08/2025 at 11:31 AM, Resident 40 stated the soup was gross, flavorless, it tasted like flour and water. <Resident 31> According to the 11/19/2024 quarterly assessment, Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 31 filed the following grievance: -09/03/2024 the clam chowder smelled and tasted bad. In an interview on 01/08/2025 at 11:31 AM, Resident 31 agreed with Resident 40 and stated the soup was gross, flavorless, it tasted like flour and water. <Resident 10> According to the 10/19/2024 annual assessment, Resident 10 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 10 filed the following grievance: -09/03/2024 Teriyaki beef was too tough. In an interview on 01/08/2025 at 10:55 AM, Resident 10 stated they rarely ate the facility meat because they could not chew it. <Additional Food Concerns> In an interview on 01/07/2025 at 2:35 PM, Resident 50 stated the food was overcooked and was not good. Resident 50 stated they picked and chose what they were going to eat. In an interview on 01/07/2025 at 3:15 PM, Resident 35 stated for the most part the food was bad and had no flavor. On 01/14/2025 at 12:44 PM, a test tray was received which contained crab pasta, carrots, peach crisp, milk and water. The crab pasta did not taste like crab, the sauce was bland, tasted like flour and had no appetizing flavor. The peach crisp tasted like plain unsweetened oatmeal topped with chocolate syrup. During an interview on 01/14/2025 at 1:56 PM, Staff Q, Dietary Manager, stated the food was under seasoned and they had received complaints about the food. Staff Q explained some residents were not allowed to have salt and recently they had a resident allergic to black pepper. Staff Q added, the residents were tired of the food because the menu had not been changed in years. Reference WAC 388-97-1100 (1), (2) Refer to F585 and F692 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform hand hygiene when indicated and follow transmission-based precautions (TBP) when implemented for 1 of 3 sampled residents (Resident 61), reviewed for infection control. This failure placed residents at risk of acquiring communicable diseases and diminished quality of life Findings included . TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled, Transmission-Based Precautions (Isolation) revised March 2024, showed TBP were used whenever measures more stringent than standard precautions were needed to prevent or control the spread of infection. There were three types of TBP (airborne, contact, and droplet). Contact precautions were implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy listed infections, including Shingles (viral infection that caused a painful blistery rash), that would require contact precautions be implemented. The policy instructed persons entering a contact precaution room to wear gloves and a disposable gown upon entering the room, adequately clean and disinfect commonly used items between residents if unable to use or dedicate equipment to a resident on contact precautions. According to the Center for Disease Control website CDC.gov - with regard to TBP showed, Use contact precautions for patient with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning [applying] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. <Resident 61> According to the 01/08/2025 annual assessment, Resident 61 had moderate cognitive impairment and was able to clearly verbalize their needs. Review of the 01/02/2025 care plan showed Resident 61 had shingles and instructed staff to maintain contact precautions, administer antiviral medication per provider orders, and pregnant woman should not provide cares. Review of provider orders showed a 01/02/2025 order for Resident 61 to be on Contact precautions as recommended for residents known or suspected to be infected with infectious agents transmitted person to person via the direct/indirect contact route for shingles. Review of 01/09/2025 provider progress note showed Resident 61 had shingles and was on isolation precautions. During observation on 01/07/2025 at 8:59 AM, a contact precaution sign was posted on the wall outside of Resident 61's room. The sign instructed staff to perform hand hygiene and wear a gown and gloves prior to entering the room. The sign also instructed staff to clean and disinfect shared equipment. Similar observations were made on 01/07/2025 at 11:12 AM, on 01/08/2025 at 1:34 PM, on 01/09/2025 at 8:04 AM, and on 01/10/2025 at 8:14 AM. In an interview on 01/08/2025 at 10:38 AM, Resident 61's roommate stated staff did not clean the toilet after Resident 61 used it. Resident 61's roommate further stated the garbage in the room often overflowed with used and soiled gloves and they often emptied it because staff did not. During observation on 01/08/2025 at 1:34 PM, Staff R, Nursing Assistant, entered Resident 61's room without performing hand hygiene or putting on a gown or gloves. Staff R walked half way into the room, adjusted the privacy curtain, shut the call light off, and exited the room. During interview on 01/08/2025 at 1:35 PM, Resident 61's roommate stated staff only had to put a gown and gloves on when they worked with Resident 61 but not when they worked with them. Resident 61's roommate explained to Resident 61 staff had to wear the gown and gloves because of the rash on their leg. Resident 61 stated Oh yeah, that rash is driving me nuts, and lifted their blankets to show a blistery rash to their right groin/inner upper thigh. In an interview on 01/17/2025 at 9:20 AM, Staff EE, Housekeeper, stated housekeeping was responsible for emptying out the garbage, cleaned and disinfected transmission-based precaution rooms but typically waited to until the end of the day to clean TBP rooms. Staff EE explained housekeeping only worked on day shift, but housekeeping would round in the morning and empty out garbage in TBP rooms if it was full. Staff EE acknowledge garbage in TBP rooms got full from evening/night shifts and needed emptied in the morning. Staff EE further stated residents in TBP rooms should not empty out the garbage because it was a potential infection control issue. In an interview on 01/17/2025 at 9:33 AM, Staff G, Nursing Assistant (NA), was unable to state what contact precautions were. In an interview on 01/17/2025 at 9:37 AM, Staff FF, NA, explained everyone should put a gown and gloves on prior to entering a room with a contact precautions sign posted. Staff FF further stated staff should always clean/disinfect the bathroom between roommates. Staff FF stated residents should not empty out garbage in TBP rooms because it was not their job. Staff FF acknowledged TBP should always be followed when implemented to prevent the spread of germs. In an interview on 01/17/2025 at 9:45 AM, Staff E, Registered Nurse, stated staff were to disinfect the toilet between residents and empty garbage in TBP rooms, not the residents, because of potential infection control issues. Staff E further stated staff should follow TBP when implemented to prevent the spread of infections. In an interview on 01/17/2025 at 10:47 AM, Staff J, acting Infection Preventionist, explained any staff who entered a room to provide care to a resident on contact precautions needed to put a gown and gloves on prior to crossing the threshold of the room. This was different than enhanced barrier precautions which allowed persons to cross the threshold of the room without putting PPE on unless they were going to assist with high contact care activities. Staff J further stated trash in TBP rooms should be emptied by staff, not residents. Staff J expected staff to follow TBP when implemented to prevent the spread of germs and infections. In an interview on 01/17/2025 at 11:28 AM, Staff B, Director of Nursing, explained a gown and gloves should be placed prior to crossing the threshold of a room on contact precautions. Staff B stated they expected staff to follow the posted TBP signage. In an interview on 01/17/2025 at 3:54 PM, Staff A, Administrator, stated they expected staff to follow TBP when implemented. Staff A further stated staff should empty the garbage in TBP rooms but they could not stop residents from doing it. HAND HYGIENE Review of the facility policy titled, Handwashing/Hand Hygiene updated March 2018, showed hand hygiene was the primary means to prevent the spread of infections. Hand hygiene could be performed by use of alcohol-based hand rub (ABHR) or washing hands with soap and water. The policy showed hand hygiene should be performed before and after direct contact with residents, after contact with a resident's intact skin, after contact with objects in the immediate vicinity of a resident and after glove removal, before and after entering an isolation precaution setting, and before and after assisting a resident with meals. According to the website CDC.gov - with regard to hand hygiene showed, hand hygiene protects both healthcare personnel and patients. Hand hygiene means handwashing with water and soap or antiseptic hand rub (alcohol-based foam or gel hand sanitizer). Recommendations for hand hygiene in healthcare settings are immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. During observation on 01/07/2025 at 12:00 PM, Staff R, NA, did not perform hand hygiene and delivered a lunch tray to room [ROOM NUMBER], set up the tray, and exited the room without performing hand hygiene. Staff R obtained another lunch tray, delivered it to room [ROOM NUMBER], and exited the room without performing hand hygiene. Staff R obtained another lunch tray, delivered it to room [ROOM NUMBER], and exited the room without performing hand hygiene. During observation on 01/07/2025 at 12:02 PM, Staff DD, NA, did not perform hand hygiene, delivered a lunch tray to room [ROOM NUMBER], and exited the room without performing hand hygiene. During observation on 01/15/2025 at 11:54 AM, Staff R, NA, did not perform hand hygiene, delivered a lunch tray to room [ROOM NUMBER], and exited room without performing hand hygiene. Staff R obtained another try, delivered it to room [ROOM NUMBER], and exited the room without performing hand hygiene. In an interview on 01/15/2025 at 12:15 PM, Staff R, stated hand hygiene was washing their hands but there was no way to do it when passing trays. In an interview on 01/15/2025 at 1:16 PM, Staff D, Resident Care Manager, explained hand hygiene included using ABHR or washing hands with soap and water. Staff D stated hand hygiene was to be performed when entering or exiting a resident room, before serving meals, between residents, before and after cares. Staff D further stated if hand hygiene was not performed when indicated it could spread germs and expected staff to perform hand hygiene when indicated. In an interview on 01/17/2025 at 10:40 AM, Staff J, acting Infection Preventionist, stated hand hygiene was using ABHR or washing hands with soap and water. Staff J explained if hand hygiene was not performed when indicated it could potentially spread germs. Staff J stated they expected staff to perform hand hygiene when indicated. In an interview on 01/17/2025 at 11:25 AM, Staff B, DNS, stated hand hygiene was using ABHR or washing hands with soap and water. Staff B stated they expected staff to perform hand hygiene when indicated, including during meal service when passing different resident meal trays. In an interview on 01/17/2025 at 3:53 PM, Staff A, Administrator, stated they expected staff to perform hand hygiene when indicated. Reference WAC 388-97-1320 (1)(c ), (2)(b)

**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 5 of 9 sampled resident's (Resident 40, 31, 27, 24 and 28), 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 reviewed 08/15/2024, showed staffing levels were determined at the facility level to ensure there were enough staff with appropriate competencies and skill set necessary to care for the residents' needs as identified through resident assessments and plans of care. The facility would consider staffing needs for each shift and would adjust as necessary based on any changes to its resident population. The assessment further showed the facility average daily census was 105 over the last six months with an average of 70 long term care and 35 short term/rehabilitation residents. The facility reviewed resident acuity levels to understand potential implications regarding the intensity and complexity of care and services needed. The assessment showed the facility contingency staffing plan included the use of on-call managers who would come into the building to provided coverage as needed and the use of staffing agencies for immediate and long-term staffing needs when needed. <Resident 40> According to the 11/02/2024 quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 40 filed the following grievances: -08/06/2024 staff ignored call lights and played on their mobile phones. -09/03/2024 still having issues with staff ignoring call light never had any follow up from prior grievance in August. -12/03/2024 night shift staff using Oak activity room as break room and ignoring call lights. In an interview on 01/08/2025 at 10:38 AM, Resident 40 stated staff were still not answering call lights timely. Resident 40 further stated they received medications around 3:30 AM and would often come out in search of the nurse to find staff using the Oak activity room as a breakroom while residents had call lights on in the halls. <Resident 31> According to the 11/19/2024 quarterly assessment, Resident 31 had diagnoses including chronic (occurring for long period of time or repeatedly) respiratory failure (lungs not working properly to get enough oxygen into the body) with hypoxia (low oxygen levels in body), chronic pulmonary embolism (blood clot that blocks blood flow to lungs), and muscle weakness. Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of the 04/17/2024 self-care performance deficit care plan showed Resident 31 required extensive assistance of staff to perform most activities of daily living (ADLs) including toileting hygiene. A 04/17/2024 fall risk care plan showed Resident 31 was at risk for falls and instructed staff to encourage call light use, ensure appropriate footwear was worn, keep the bed at an appropriate transfer level, and anticipate Resident 31's needs. A 04/17/2024 respiratory care plan showed Resident 31 had difficulty breathing and instructed staff to elevate the head of the bed and provide oxygen therapy per provider order, changing from an oxygen mask to a nasal cannula during meals. Review of July 2024 through December 2024 grievance log showed Resident 31 filed the following grievances: -07/02/2024 the night Nursing Assistant was rude, rough and pinched Resident 31's skin when they assisted with a brief change. -11/05/2024 they waited 45 minutes for staff to assist with personal hygiene after an episode of incontinence. In an interview on 01/08/2025 at 10:38 AM, Resident 31 stated staff were still not answering call lights timely. Resident 31 further stated they should not be taking themselves to the bathroom but did because staff would not respond to their call light timely. Resident 31 explained they typically did not wear their oxygen when in the bathroom, last week they pressed their bathroom call light, after waiting 35 minutes without staff response, Resident 31 began to yell out because they needed their oxygen. Resident 31 stated they left the door to their room open, in case of emergencies, because staff did not response to call lights timely. <Resident 27> According to the 12/19/2024 quarterly assessment, Resident 27 admitted to the facility on [DATE] with diagnoses including muscle weakness. Resident 27 required substantial staff assist to transfer onto the toilet and was dependent of staff for toileting hygiene. The assessment further showed Resident 27 did not sustain any falls prior to admission and sustained three falls after their admission. Resident 27 had moderate cognitive impairment and was able to verbalize their needs. Review of the 11/18/2024 self-care deficit care plan showed Resident 27 required extensive assistance of one to two staff to use a mechanical lift for transfers. A 11/18/2024 care plan showed Resident 27 was a risk at risk for falls related to being legally blind and instructed staff to anticipate Resident 27's needs, encourage call light usage, keep bed at a safe transfer level, offer toileting with each interaction, and not to leave Resident 27 unattended on the toilet. Review of the November 2024 through December 2024 facility incident log showed Resident 27 sustained falls on 11/12/2024, 11/17/2024, 12/05/2024, and 12/28/2024. Review of the 11/17/2024 fall incident report showed Resident 27 was found sitting on the floor in the bathroom. A 11/19/2024 incident summary showed Resident 27 was left on the toilet unattended and attempted to self-transfer back into their wheelchair. Review of the 12/05/2024 fall incident report showed Resident 27 was found lying on the bathroom floor holding the back of their bleeding head. A 12/06/2024 incident summary showed Resident 27 recently had their diuretic (medication that helps the body get rid of excess fluid) increased and fell when they attempted to transfer onto the toilet independently. During observation on 01/10/2025 at 11:51 AM, the call light above Resident 27's room came on. A visitor stuck their head out of the room and said Where is an aide at? [Resident 27] needs to go to the bathroom, last time [Resident 27] fell, [staff] better get down here, we will see how long this takes. At 11:52 AM, Resident 27 now sat in the doorway to their room with the call light still on. At 11:53 AM, the visitor flagged staff down and informed them Resident 27 needed to go to the bathroom. In an interview on 01/14/2025 at 10:10 AM, Resident 27's family friend stated residents had excessively long call light wait times, and they reported their concern to nursing. Resident 27's friend explained they had seen multiple call lights on with no staff around. The friend continued to explain Resident 27 had weakness in their legs and had their diuretic increased which caused Resident 27 to urinate more often. Resident 27's friend further stated Resident 27 attempted to self-transfer because they waited too long for staff to answer their call light. In an interview on 01/14/2025 at 10:13 AM, Resident 27 stated they sustained at least three falls in the facility. Resident 27 explained they took themselves into the bathroom because they did not want to have incontinence accidents while waiting for staff to answer their call light. Resident 27 further stated there was not enough help because they had excessive call light wait times. <Resident 24> According to the 11/16/2024 quarterly assessment, Resident 24 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of the functional abilities care plan revised 12/05/2023 showed Resident 24 required substantial up to dependent staff assistance to perform most ADLs and instructed staff not to rush Resident 24 during ADL cares. Review of July 2024 through December 2024 grievance log showed Resident 24 filed the following grievances: -11/05/2024 the resident waited one and a half hours for staff assistance. In an interview on 01/07/2025 at 2:43 PM, Resident 24 stated the facility did not have enough staff because they often had excessively long call light waiting times. <Resident 28> According to the 12/16/2024 quarterly assessment, Resident 28 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. In an interview on 01/07/2025 at 11:29 AM, Resident 28 explained they approached the nurses' station after waiting 50 minutes for their call light to be answered and observed staff sitting around while call lights were going off. In an interview on 01/17/2025 at 12:28 PM, Staff G, Nursing Assistant (NA), stated they were unsure how the facility determined staffing levels. Staff G explained when a NA called in the facility pulled staff from another unit or placed the restorative staff on the floor. Staff G acknowledged residents had excessively long call light wait times when not enough staff. In an interview on 01/17/2025 at 12:52 PM, Staff E, Registered Nurse, stated they were unsure how the facility determined staffing levels. Staff E explained when a nurse called in, sometimes the resident care manager (RCM) came in to help. When a NA called in staff would be pulled from another unit or from the restorative nursing program. Staff E stated restorative nursing staff wore dual hats sometimes they were restorative aides and other times they were a floor aide. Staff E further stated the restorative program did not have a big pool of staff to pull from, only 2 or 3 restorative aides, but pulling from restorative staff was the last resort because that staff was not replaced when pulled to the floor. Staff E acknowledged residents had to wait a long time to get help when there was not enough staff. In an interview on 01/17/2025 at 12:59 PM, Staff D, RCM, stated in theory staffing should be based on census and acutely level. Staff D explained when staff called in, they were to call the facility to get the on-call managers number and call the on-call manager. The on-call manager was to attempt to call staff in and if unable to fill the vacancy, the facility would pull the shower aides to the floor or place restorative nursing staff on the floor. Staff D explained if the bathe aide was pulled to the floor each NA would be responsible for completing their own bathes, if the restorative aide was pulled to the floor, no staff replaced restorative because they did not have the training, there was no restorative program. A tracking log of attempts to fill call ins was requested from Staff D. Staff D acknowledged the facility had no tracking log of who was called in an attempt to fill staffing call ins when they occurred. Staff D was asked about facility acuity. Staff D explained Oak hall was long-term care residents, rooms 101 through 120 had lighter care needs while rooms 128 through 146 had heavier care needs with higher use of full body lifts for dependent residents. Staff D explained as the resident care manager they had attempted to readjust the NA section assignments based on resident acuity, but floor staff did not honor managements changes and readjust the assignments. Staff D acknowledged some residents had excessively long call light wait times, especially the back of Oak hall, rooms 128 through 146. During interview and record review on 01/17/2025 at 1:20 PM, Staff U, Staffing Coordinator, explained they followed a handwritten staffing guide. Staff U provided a copy. Review of the form provided by Staff U showed staffing assignments for Oak hall for staffing from three up to eight direct care staff and instructed nurses to adjust assignments based on resident behaviors and use of transfer lifts. Staff U explained Oak hall was long-term care, residents in the front part of Oak required less assistance than the residents toward the back of Oak hall. Staff U stated staff assigned to the front of Oak sometimes cared for more residents because they required less assistance, but that was not consistent. Staff U acknowledged staff who worked the back of Oak hall had voiced concerns about needing more staff in that area. In an interview on 01/17/2025 at 1:46 PM, Staff B, Director of Nursing, stated staffing was based on calculations according to the company guidance that determined how many direct care staff were needed based on census. Staff B further stated management also attempted to keep the facility acuity into consideration. Staff B acknowledged residents on the back part of Oak hall were heavier care and attempted to adjust section assignments accordingly. In a confidential interview on 01/17/2025 at 2:00 PM, an anonymous staff stated the back part of Oak hall was heavy care related to a high use of transfer lifts, it was too much for one person to handle. The anonymous staff further stated they had informed management, but nothing had been done yet; the section assignments did not get adjusted. The staff added sometimes it took them 20 minutes to find a peer to assist them with full body mechanical lift transfers because those should not be done with only one staff for safety. In an interview on 01/17/2025 at 4:07 PM, Staff A, Administrator, stated staffing levels were determined based on the facility population. Staff A further stated section assignments were readjusted based on resident acuity nightly. Reference WAC 388-97-1080 (1), -1090 (1) Refer to F585, F676, and F727 for additional information.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, expired foods were not discarded for 1 of 2 refrigerators, 1 of 1 dry storage areas, and food items in the refrigerator and freezer were not dated when opened. The facility further failed to maintain a clean cooking environment. These failures placed residents at risk for food-borne illnesses. Findings included . <Expired/undated food> During an initial tour of the kitchen on 01/07/2025 at 8:47 AM, the dry storage area revealed a container of French salad dressing and two containers of Caesar salad dressing with no received or expiration date, six cartons of thickened cranberry cocktail that expired November 2024, a bag of coconut that expired November 21, 2024, and twelve containers of a vanilla nutritional drink that expired on 12/28/2024. The refrigerator in the main kitchen contained a bag of brown, wilted salad, two bags of brown wilted lettuce and a bag of spinach that was brown that had no received or expiration dates. The freezer contained a bag of ham with a use by date of 09/22/2024, a bag of tortillas with a use by date of 11/06/2024, a bag of zucchini with a use by date of 12/11/2024, two pecan pies with a use by date of 12/30/2024, three bags of meatballs that expired on 01/03/2025, a bag of opened egg rolls and chicken breasts with no open or expiration date, and an opened bag of beef fritters and uncovered wheat rolls that were freezer burned. During an interview on 01/07/2025 at 9:34 AM, Staff S, Registered Dietician, stated there needed to be a date on all food items and it was important for quality, safety and to prevent food borne illnesses. <Food Temperatures> During observation of a lunch tray line on 01/14/2025 at 11:19 AM, Staff Q, Dietary Manager, had checked the temperatures of the cold items.The salad was 52.1 degrees Fahrenheit (F), cottage cheese was 44 degrees F, and the Jello was 64.6 degrees F., all above the recommended food temperature of 41 degrees. Staff Q placed the cottage cheese, salads, and sandwiches on an ice bath. At 11:39 AM, Staff Q served the items from the ice bath, no further temperatures of the food were obtained. At 11:58 AM, Staff Q served a chicken breast from a warmer and no temperature was obtained. At 12:02 PM, Staff Q served a sandwich from the refrigerator and no temperature was obtained. At 12:19 PM, Staff Q served another chicken breast and no temperature was obtained. In an interview on 01/14/2025 at 12:21 PM, Staff Q stated they were not sure if the items from the ice bath were at an appropriate temperature because they had not rechecked them. Staff Q stated it was important to check the temperatures of the food to prevent food borne illnesses. <Sanitary Environment> During an observation on 01/07/2025 at 10:03 AM, the oven was unclean with food debris on the outside of the oven and thick burned food debris covered the bottom of the inside of the oven. The food warmer was unclean with food debris. Staff Q initially stated it was from spilled food and the outside of the oven was cleaned once a month and the inside every three months. Staff S stated the oven warmer, and oven needed to be cleaned, and Staff Q stated the outside of them gets cleaned every evening. Staff S stated the oven and oven warmer needed to be kept clean to ensure safety. During a second observation of the kitchen seven days later on 01/14/2025 at 1:25 PM, the thick layer of burned food debris remained on the bottom of the oven and the outside of the warmer and oven were unclean. Reference: WAC 388-97-1100 (3), 2980

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff were offered the COVID-19 vaccine (COVID-19, a viral illness that caused fever, difficult breathing, and other viral symptoms that included possible hospitalization or even death), were provided education regarding the risks/benefits and potential side effects of the vaccine, and maintained documentation related to vaccine education, declination,or administration of the vaccine as required for 3 of 3 sampled staff (Staff G, H, and I) reviewed. This failure placed residents and staff at risk of illness or exposure to the COVID-19 virus and potential unintended health consequences. Findings included . The Centers for Disease Control and Prevention (CDC) Recommended Adult Immunization Schedule 2025 for ages 19 years or older retrieved from www.cdc.gov/acip-recs/hcp/vaccine-specific/ documented adults age [AGE]-64 years or adults age [AGE] or older who were unvaccinated for COVID-19 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of COVID-19 vaccine unless contraindicated. Those previously vaccinated before 2024-2025 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of 2024-2025 COVID-19 vaccine unless contraindicated. On 01/15/2025 at 12:58 PM, room [ROOM NUMBER] on Evergreen Unit was observed to have a new aerosol precaution sign (signage that notified staff of important measures to implement prior to entering a resident room such as donning personal protective equipment, PPE, or performing hand hygiene, for example) on their door and the door was closed. A bin of PPE was positioned at the doorway, and Staff F, Nursing Assistant, NA, was observed putting on a disposable gown, gloves and a respirator-type mask. When interviewed, Staff F stated the resident in room [ROOM NUMBER] had been at the facility for 6 days and had just tested positive for COVID-19 that morning when they developed symptoms of respiratory illness. During an interview on 01/17/2025 at 9:27 AM, Staff G, NA, stated they had been vaccinated for COVID-19 probably two years prior when the vaccine first came out and was unaware there were additional COVID-19 vaccines available. Staff G stated they had never received any education regarding the vaccine and had not been offered one recently. During an interview on 01/17/2025 at 10:33 AM, Staff H, NA, stated they did not remember being offered a COVID-19 vaccine recently unless it was offered as part of their initial employment onboarding paperwork. A review of staff COVID-19 vaccinations documented the following: -Staff G received two doses of the COVID-19 vaccine on 05/07/2021 and 06/08/2021 and signed a declination for an additional vaccine on 07/26/2023. -Staff H received two doses of the COVID-19 vaccine on 09/12/2021 and 10/11/2021. -A third staff, Staff I, NA, was added to the review and had received two doses of COVID-19 vaccine on 08/25/2021 and 09/16/2021. During an interview on 01/17/2025 at 1:13 PM, Staff J, Licensed Practical Nurse and temporary acting Infection Prevention Nurse, stated the facility did not offer COVID-19 vaccines to staff. They encouraged the staff to see their primary care provider or pharmacies that offered discounted vaccinations and bring in their proof of vaccination. Staff J was uncertain when the facility stopped offering COVID-19 vaccines. They stated if staff did not bring in evidence of their vaccine, the facility had no documentation. Staff J stated they did not keep track of staff education or who had received or declined the COVID-19 vaccine. Reference: WAC 388-97-1320

Based on interview and record review, the facility failed to prevent the development of a pressure ulcer for 1 of 3 sampled residents (Resident 3), reviewed for pressure ulcers. Resident 3 was at an increased risk for skin breakdown and developed an unstageable pressure ulcer that was not identified while at the facility. This failure placed the resident at risk for worsening pressure ulcer and a diminished quality of life. Findings included . Review of the facility admission assessment, dated 06/16/2024, showed Resident 3 was admitted with diagnoses which included Diabetes and paraplegia (paralysis of the legs and lower body). The resident was moderately impaired with decision making. Resident 3 required maximum assistance with bed mobility. The assessment showed the resident was at risk for pressure ulcers, did not currently have a pressure ulcer but had MASD (Moisture Associated Skin Damage which is inflammation of the skin caused by prolonged exposure of moisture which includes urine or stool). Review of the resident's care plan, dated 06/10/2024, showed Resident 3 was at risk for pressure ulcer development related to immobility, Diabetes, and paraplegia. Staff were to float the resident's heels, frequently reposition the resident, and inspect the skin when providing care. Review of nursing notes from 06/10/2024 - 06/23/2024 showed there was no documentation related to the resident's skin, which included the MASD that was identified on the facility admission assessment. Review of hospital records, dated 06/23/2024, showed the resident was admitted from the facility due to a change in condition. The resident was identified with an unstageable (base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure ulcer. During an interview on 08/02/2024 at 1:27 PM, Staff E, Resident Care Manager (RCM), stated when a resident was admitted , two different nurses evaluate the resident's skin, on admission and then the next day. The nurses also do weekly skin checks. The shower aides have skin sheets they document on as to whether a resident has skin impairments. If there is a skin issue, the shower aide will give one copy to the floor nurse and one copy to the RCM. The nurse or RCM will then go in and evaluate the area. This is a newer process started after the facility was made aware Resident 3 had a pressure ulcer when sent to the hospital. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to provide care in a manner that promoted resident dignity for 1 of 2 sample residents (Resident 1), reviewed for dignity. The facility failed to dress Resident 1 in appropriate attire before going to an appointment in the community. This failure placed Resident 1 and other residents at risk for embarrassment and diminished self-worth. Findings included . According to the 03/10/2024 facility assessment, Resident 1 had diagnoses which included blindness, a fracture and dementia. The resident was moderately impaired with decision making. Resident 1 required moderate assistance for dressing their upper body, and dependent on staff to dress their lower body. On 04/30/2024 at 09:45 AM, a State Agency representative stated they had received information Resident 1 was not dressed appropriately when they went out for an appointment. The person they spoke to was very upset and stated Resident 1 was in a night gown and had a saturated brief. On 04/30/2024 at 10:15 AM, a Collateral Contact (CC) was interviewed. The CC stated they went to meet Resident 1 at their appointment and found Resident 1 wandering, dressed in a large night gown (stating it didn't belong to the resident), no undergarments or socks on, and was wearing a sweater. The CC stated in addition, the resident was blind, did not have their hearing aides in and their hair had not been combed and was matted to their head. On 05/13/2024 at 2:28 PM, Staff C, Resident Care Manager (RCM), stated Resident 1 was very particular about their clothing and appearance, as well as the family. The day the resident went out to their appointment, Staff B, RCM, was working and saw the resident. Staff C stated the resident had refused to change clothing at times, but this was not their norm. Staff were expected to tell the nurse if a resident refused to be changed and re-approach. With Resident 1, Staff C stated they would have called the resident's family, who was very involved with the resident's care, to see if they could talk to the resident about changing clothes. On 05/13/2024 at 12:56 PM, Staff A, Social Services Director (SSD), stated they had gotten a call about how the resident went to their appointment. The resident's hair wasn't combed and they had another resident's gown on. Staff A stated they had received concerns prior to this when the resident would go out of the facility to visit or have dinner and they wouldn't be dressed appropriately. On 05/13/2024 at 2:44 PM, Staff D, Nursing Assistant (NAC), stated when a resident had an appointment, they were told by the nurse when the resident needed to be ready. If the resident had inappropriate clothing on for an appointment, Staff D would talk with the resident about being changed to go out of the facility. If the resident continued to refuse, the nurse would be notified. Staff D went on to say sometimes it took another staff member to approach a resident and they would be more receptive to them. If a resident continued to refuse to change, Staff D would let the nurse know. On 05/14/2024 1:35 PM, Staff B stated they worked the morning of Resident 1's appointment. Staff had brought Resident 1 out of their room with a gown on with a jacket over it and their hair was not combed. Staff B explained to the staff the resident could not go out to an appointment dressed they way they were and to take the back into the room to be dressed appropriately. Staff B did not hear anything after talking to staff and didn't see the resident until they came back to the facility from the appointment. The resident was dressed in the same way as they had seen prior to the appointment. Staff B stated they would expect staff to re-approach a resident if they refused to be changed and if they continued to refuse, talk to the RCM. REFERENCE: WAC 388-97-0180(1-4). .

Based on interview and record review, the facility failed to provide notification to the resident's representative of a change in condition for 1 of 3 sample residents (Resident 2), reviewed for notification of change. This failure prevented the resident's representative from being informed of Resident 2's worsening condition until the resident was being sent to the hospital. Findings included . The 03/04/2024 assessment showed Resident 2 had a spinal cord dysfunction and inability to move their lower extremities. Resident 2 was able to make their needs known. During an interview on 04/08/2024 at 1:50 PM, a Collateral Contact (CC) stated the resident's representative attended a care conference 03/19/2024 and was told Resident 2 was doing well. The CC stated the representative would get several phone calls a day from Resident 2 and those calls stopped, which was a concern. The CC went in to visit the resident and described the resident as listless (lack of energy). The CC stated no one had called and told them the change in the resident. The CC asked staff to have Staff F, facility physician, call them about the resident's condition. The CC did not receive a call until three days later when they were informed the resident was being transferred to the hospital. The CC stated, why didn't anyone call us to inform us [Resident 2] was sick prior to them going to the hospital? Progress notes were reviewed which showed a note on 04/04/2024 documenting the resident was nauseated and had not felt like eating the past few days. There was no documentation to show the resident's representative and/or family was notified of a change in condition until 04/08/2024, the day the resident was sent to the hospital. Review of Staff F's notes, dated 04/08/2024, showed the resident was seen for follow-up related to nausea. The resident had been having intermittent nausea and refused some meals. When the provider went in to see the resident, the resident was described as lethargic (fatigue and low energy) and was not able to respond well to Staff F's questions. The resident's family member was called and agreed for the resident to be sent to the hospital. During an interview on 05/13/2024 at 2:10 PM, Staff E, Director of Nursing, stated the facility didn't have a specific policy for a change in condition but used the standards of care. Staff would notify the provider and family at the time of the change, the resident would be placed on alert and monitored. Reference (WAC) 388-97-0320

Based on interview and record review, the facility failed to consistently monitor and document a condition change for 1 of 3 residents (Resident 2), reviewed for change in condition. This failure placed residents at risk for worsening medical conditions and unmet care needs. Findings included . Review of a facility assessment, dated 03/04/2024, showed Resident 2 had a spinal cord dysfunction and was unable to move their lower legs. The resident was able to make their needs known and was dependent on staff for mobility in and out of bed. Review of nursing progress notes from 04/04/2024 through 04/08/2024 showed a note on 04/04/2024 related to the resident being nauseated and had not felt like eating the past few days. There was no further documentation of the resident's condition until 04/08/2024, when the resident was seen by Staff F, physician, and sent to the hospital. Review of a progress note by Staff F dated 04/08/2024, showed the resident was seen for follow-up related to nausea. When the provider went in to see the resident, the resident was lethargic (fatigue and low energy) and was not able to respond well to Staff F's questions. The resident's family member was called and agreed for Resident 2 to be sent to the hospital. On 05/13/2024 at 2:49 PM, Staff G, Licensed Nurse (LN), stated when a resident had a change in condition they would go and assess the resident. The provider would be called and any orders given would be followed. The family would be notified as well. The resident would then be put on alert charting and any changes would be placed in the nurse progress notes. During an interview on 05/13/2024 at 2:28 PM, Staff C, Resident Care Manager (RCM), stated if a resident had a change in condition the nurse would notify the provider, RCM, and Director of Nursing (DON). The resident would be on alert charting and documentation would be found in the nurses progress notes. The family would also be notified of any change in the resident. Staff C had been approached by nursing on 04/04/2024 and stated Resident 2 had been having nausea and not eating well. Staff C stated they were off a few days and when they returned on 04/08/2024, Resident 2 was sent to the hospital by Staff F. During an interview on 05/13/2024 at 2:10 PM, Staff E, DON, stated the facility didn't have a specific policy for a change in condition but used the standards of care. Staff would notify the provider and family at the time of the change, the resident would be placed on alert charting, monitored for any changes, and documentation would be in the progress notes. Additional information was requested related to the resident's change in condition and nothing further was provided. Reference: WAC 388-97-1060(1)

Based on interview and record review, the facility failed to notify a resident and their representative of a missed medication for 1 of 2 sampled residents (1) reviewed for medication errors. This failure placed the resident and representative at risk of not being fully informed to make decisions about Resident 1's clinical condition and necessary care. Findings included . Per the 02/25/2024 significant change in condition assessment, Resident 1 was cognitively impaired, and had a family member who was involved in their care. Review of a facility investigation, dated 02/13/2024, showed the resident had had not received their Apixaban (a medication used to reduce the risk of blood clots) as ordered. The investigation further showed the resident's family member was not notified of the incident. During an interview on 03/04/2024 at 1:40 PM, Resident 1 and their family member who was Power of Attorney, stated they were unaware that a medication error had occurred. Review of Resident 1's medical record showed no documentation that the resident or their representative was notified of the medication error. During an interview on 03/04/2024 at 2:00 PM, Staff C, Resident Care Manager stated when an incident occurred, the family, doctor, nurse manager and director of nursing were all notified. During an interview on 03/04/2024 at 2:06 PM, Staff A, Director of Nursing confirmed that the resident and their representative should have been notified of the medication error. Reference: (WAC) 388-97-0300 (3)(a) .

Based on observation, interview and record review, the facility failed to ensure medications were given as ordered for 1 of 2 sampled residents (1) reviewed for medication administration. This failure placed Resident 1 at risk for worsening of a deep vein thrombosis (DVT, a blood clot in a deep vein) and adverse health consequences when they missed doses of their medications. Findings included . Per the 01/28/2024 admission assessment, Resident 1 had diagnoses including a right ankle fracture. A review of the hospital admissions records documented Resident 1 was found to have a left lower extremity DVT on 01/31/2024 and had been started on Apixaban at that time. A review of Resident 1's hospital orders dated 02/07/2024, documented Resident 1 was to have Apixaban (a medication used to reduce the risk of blood clots) 10 milligrams (mg) twice daily for 7 doses, then Apixaban 5mg twice daily for 360 doses and the 5mg needed to start on 02/09/2024. A review of Resident 1's order summary documented Resident 1 was to receive Apixaban 10mg twice daily for 7 administrations, then give Apixaban 5mg starting 02/13/2024. A review of the February 2024 medication administration record (MAR) revealed omitted entries (blank spaces) for Resident 1's Apixaban on 12/11/24 and 12/12/24. A progress note dated 02/13/2024 at 4:50 PM, documented Resident 1 was admitted for surgical repair of right ankle fracture with a DVT and the order was entered incorrectly into the computer upon admission. During an interview on 03/04/2024 at 11:45 AM, Staff B, Doctor, stated if Apixaban was not received, it could have increased the risk of getting a DVT. Staff C stated Resident 1 was previously diagnosed with the DVT to their right lower extremity and that the documentation stating the left lower extremity was incorrect. Staff C added it was not good to have missed the medication for the DVT. Staff C stated the missed medication did not relate to Resident 1's hospitalization and pulmonary concerns. Staff C stated the resident did not have co-morbidities related to missing the medication, however, it was considered a significant medication error. During an interview on 03/04/2024 at 1:33 PM, Staff A, Director of Nursing stated the missed medication could have resulted in a DVT and the error was significant. Reference: WAC 388-07-1069(3)(k)(iii)

Based on interview and record review, the facility failed to consistently provide showers for 4 of 5 dependent sampled residents (Resident 2, 3, 4, 5), reviewed for bathing. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 2> Review of a facility assessment, dated 01/11/2024, showed Resident 2 had diagnoses which included a stroke. The resident was alert and able to make their needs known. According to Resident 2's care plan, revised on 08/07/2023, Resident 2 required extensive assistance of one person with showers. The resident was to receive two showers a week. A review of the resident's shower records from 12/19/2024 through 01/25/2024 showed Resident 2 had a shower on 12/19/2023 and 12 days later on 01/01/2024. The resident received a shower on 01/05/2024 and bed bath 7 days later on 01/12/2024. On 01/15/2024 Resident 2 had a bed bath, refused a shower 01/18/2024 and didn't receive a shower until 01/25/2024, 10 days later. During an interview on 01/26/2024 at 12:32 PM, Resident 2 stated they didn't consistently receive showers twice a week. Resident 2 stated they would ask staff for a wash cloth in order to clean up by themselves. <Resident 3 > Review of a facility assessment, dated 11/08/2023, showed Resident 3 had diagnoses to include lung disease. Resident 3 was able to make their needs known. According to the resident's care plan, dated 06/05/2023, Resident 3 needed assistance of one person and was to have two showers a week. Review of Resident 3's shower records from 12/26/2023 through 01/22/2024 showed Resident 3 had a shower on 12/26/2024 and on 01/02/2024, 7 days later. Resident 3 had a shower on 01/03/2024 and 6 days later on 01/09/2024. On 01/11/2024 a shower was given and then 01/18/2024, 7 days later. <Resident 4> Review of a facility assessment, dated 01/05/2024, showed Resident 4 had diagnoses which included a stroke and dementia. The resident was moderately impaired with decision making. According to Resident 4's care plan, revised on 08/09/2023, Resident 4 required extensive assistance of one person for showers. The resident was to receive two showers a week. A review of the resident's shower records from 12/22/2023 through 01/22/2024 showed Resident 4 had a shower 12/27/23, refused a shower on 01/03/2024 and had a bed bath on 01/09/2024, 13 days without a shower. Resident 4 went from 01/09/2023 until 01/22/2024, another 13 days without a shower. <Resident 5> Review of a facility assessment, dated 11/29/2023, showed Resident 5 had diagnoses which included dementia. Resident 5 was able to make their needs known. According to the Resident 5's care plan, dated 04/13/2021, Resident 5 required one person assistance with showering. Resident 5 was to receive two showers a week. A review of Resident 5's shower records from 12/18/2023 through 01/23/2024 showed Resident 5 had a shower on 12/18/2023 and the next one was 12/26/2023, 8 days later. A shower was done on 12/29/2023 and the next one was 7 days later on 01/05/2024. A shower was done on 01/05/2024 the resident refused one on 01/09/2024 and was showered again on 01/12/2024, 7 days later. After the 01/12/2024 shower the resident did not receive another shower until 11 days later on 01/23/2024. On 01/26/2024 at 11:09 AM, Staff A, Shower Aide, stated they were pulled to the floor when their wasn't enough staff. Staff A stated the showers that weren't done on the day they were pulled were difficult to make up. Staff A stated they were the only shower aide on that unit so would try and do the residents that were missed, first. On 01/26/2024 at 2:30 PM, Staff F, Administrator, stated they sometimes pulled shower aides in the mornings for a few hours when they didn't have enough floor staff. Staff F stated the shower aides would then circle back to the residents that didn't have a shower and offer them one first. Reference: WAC 388-97-1060(2)(a)(i)

Based on observation and interview, the facility failed to ensure personal protection equipment (PPE's) was used in accordance with Centers for Disease Control (CDC) guidelines by 5 staff (A, B, C, D, E), when reviewing infection control practices. This failure placed the 103 residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. Findings included . At the beginning of the complaint investigation on 01/25/2024 at 1:00 PM, there were 15 residents that were in isolation for COVID-19. The residents were spread through out the facility on different units. According to the 05/16/2023 CDC publication, How to use your N95 Respirator, N95 masks (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 should be placed under the chin, with the nose piece bar at the top, with the top strap pulled over the head and placed near the crown, and the bottom strap at the back of the neck, below the ears. The straps should lay flat, be untwisted, and not crisscrossed. The document showed facial hair can cause gaps between your face and edge of the respirator and would not allow for a tight-fitting seal. On 01/25/2024 at 11:36 PM, Staff E, Licensed Practical Nurse (LPN) was gowning and putting on gloves to go into a resident room to answer the call light. The resident was on COVID-19 precautions. Staff E already had a N95 mask on and face shield. Staff E was observed exiting the room. Staff E had removed their gown and gloves in the room. Staff E used hand sanitizer and left the area, not changing their N95 or face shield. At 11:48 PM, Staff E was asked what PPE's they were to remove and/or change when exiting a room. Staff E stated they don't change their mask or shield, only remove their gown and gloves prior to leaving the room. On 01/25/2024 at 11:58 PM, Staff E stated the N95's and face shields should be changed after leaving an isolation room. On 01/26/2024 at 10:40 AM, Staff D, Nursing Assistant, was observed entering Oak unit with no shield and N95 down below their chin. Staff D walked through the unit until reaching their hallway and properly placed the N95 on their face and put on a face shield. On 01/26/2024 at 11:09 AM, Staff A, Shower Aide, was observed with both N95 bands on their neck. When asked about strap placement, Staff A stated one strap should be on the top of their head but it pulled their hair. Staff A placed the strap on the top of their head. On 01/26/2024 at 11:15 PM, Staff B, Dietary Aide, was observed with both N95 straps on their neck which appeared to be pulling the mask off their nose. When asked about strap placement, Staff B stated one should be on the top of their head. On 01/26/2024 at 11:33 PM, Staff C, Certified Medication Aide (MAC), walked by with both N95 straps on their neck. At 11:35 PM Staff C had one strap on the top of their head and one strap on their neck. Staff C was observed with facial hair. Staff C was asked about the facial hair and stated they were suppose to have a shaven face but returned to work after some days off and forgot. On 01/26/2024 at 11:36 AM, Staff D was observed to have their N95 mask and face shield on properly. Staff D stated N95 masks should be placed with one strap on the top of the head and one on the neck and shields needed to be worn. On 01/26/2024 at 2:30 PM, Staff F, Administrator, stated staff were expected to place their N95 and face shields on when they entered the building. Staff F stated they kept a large supply of both at the entrance of the facility. Staff F stated staff were to remove their N95 and face shields when leaving a room in isolation for COVID-19 and put on new ones. When Staff F was told about the observations of N95's not being properly place, they stated they had to continually educate staff on the proper use of PPE's. Reference: WAC 388-97-1320(2)(b)

Based on interview and record review, the facility failed to identify an incident as potential neglect and initial an investigation as required for 1 of 2 sampled residents (Resident 289) reviewed for abuse. These failures placed the residents at risk of further neglect, and unmet care needs. Findings included . The facility's Grievance Procedure, last updated November 2016, instructed staff if the grievance involved abuse, neglect, exploitation, or misappropriation of resident property, the Executive Director was to be notified immediately, and an investigation started. Review of the facility's Abuse Identification and Investigation polices, last revised October 2022, stated activities that constituted abuse, neglect, exploitation, and misappropriation of resident property, were to be reported to the Executive Director and an investigation which included the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegation, was to be completed. The 06/19/2023 admission assessment showed Resident 289 was able to make their needs known, and needed extensive assistance from nursing staff to complete activities of daily living, such as using the bathroom. A grievance form dated 07/27/2023 documented when nursing staff arrived that morning to start their shift, several resident call lights were on. When Staff R, Nursing Assistant, was asked to answer the call lights, Staff R stated the residents were not theirs, and refused to answer the lights. The grievance further stated that Staff R often refused to assist residents, used a rude tone of voice when speaking to residents, and on the day of the grievance, Resident 289 had reported Staff R refused to assist them to the bathroom. Additional review of the form showed the grievance was discussed with Staff R and education related to customer service and teamwork was provided, and the grievance was marked as resolved. The remainder of the form was blank, no documentation was made to show what investigation/actions were done, what the findings were, who was notified, or whether the resident had been interviewed. Review of the facility incident log from 07/01/2023 through 08/31/2023 found no entry had been made related to the incident. Review of Resident 289's record showed the resident discharged from the facility on 08/04/2023. No documentation related to the incident was found in the resident's record. In addition, no documentation was found to show the facility had initiated an investigation into the resident's complaint of not being provided with assistance. In an interview on 09/29/2023 at 2:55 PM, Staff A, Administrator, was asked for the facility investigation related to the concerns expressed on the grievance regarding Staff R's demeanor and refusal to provide care. Staff A stated the grievance was staff complaining about another staff member and an investigation had not been completed. Reference (WAC): 399-97-0640 (6)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Palm Guards (protective devices to prevent or assist with contractures and skin breakdown) were being used as directed in accordance with the comprehensive care plan for 2 of 2 sampled residents (Resident 21 and 29) reviewed for quality of care. This failure placed residents at risk of skin injuries, worsening contractures, the shortening or tightening of tissues that reduces movement, and a decreased quality of life. Findings included . <Resident 21> According to Resident 21's quarterly assessment dated [DATE], Resident 21 had severe cognitive impairments and diagnoses included contractures to the right and left hand. Review of Resident 21's care plan, dated 04/11/2022, showed the resident needed to wear bilateral palm guards at rest, and removed for discomfort or functional use of hands related to being at risk for skin tears. A physician's order, dated 09/09/2022, stated bilateral palm guards donned at rest and removed per resident discomfort or functional use of hands, check skin to palms upon removal daily every shift for comfort. On 09/27/2023 at 9:19 AM, Resident 21 was observed sitting in their wheelchair with no palm guards on bilateral hands. Additional observations of Resident 21 not wearing their palms guards were made on 09/27/2023 at 10:04 AM, 09/27/2023 at 10:55 AM, 09/27/2023 at 1:46 PM, 09/27/2023 at 3:12 PM, 09/28/2023 at 7:41 AM, 09/28/2023 at 10:02 AM and 09/28/2023 at 11:22 AM. During an interview on 10/02/2023 at 10:31 AM, Staff L, Nursing Assistant, stated Resident 21 had palm guards that were not worn related to pain and dementia. Staff L added Resident 21 had pain when opening their hand. During an interview on 10/02/2023 at 10:56 AM, Staff P, Licensed Practical Nurse stated if a resident refused a device, it would be charted in the Medication Administration Record or the Treatment Administration Record. Review of the records showed Resident 21 did not refuse their palm guards. During an interview on 10/03/2023 at 10:18 AM, Staff S, Therapy Director, stated they needed to be made aware if a resident was having pain, as a new assessment would be completed. Staff S assessed Resident 21 and stated they would request an order for contracture management. <Resident 29> According to Resident 29's quarterly assessment dated [DATE], Resident 29 had severe cognitive impairments and diagnoses including a right-hand contracture. Review of Resident 29's care plan, dated 11/23/2022, showed resident's right palm guard was to be worn continuously, with exception to remove for discomfort and to reapply in one hour. Resident 29's Individual Service Plan (a document that instructs the nursing assistants on what care to provide) stated palm guard to the right hand to be worn at all times, check skin for breakdown and perform hand hygiene, if resident complains of discomfort, remove for one hour and reapply. On 09/26/2023 at 10:12 AM, Resident 29 was observed sitting in their wheelchair with no palm guard on the right hand. Additional observations of Resident 29 not wearing their palms guards were made on 09/26/2023 at 11:05 AM, 09/27/2023 at 10:01 AM, 09/27/2023 at 1:41 PM, 09/28/2023 at 7:22 AM and 09/28/2023 at 11:22 AM. During an interview on 10/03/2023 at 2:45 PM, Staff D, Resident Care Manager, stated Resident 29's palm guard could prevent their contracture from worsening. During an interview on 10/04/2023 at 1:53 PM, Staff U, Registered Nurse stated Resident 29 should be wearing the palm guard as care planned. During an interview on 10/04/2023 at 2:23 PM, Staff C, Director of Nursing stated Resident 29 should wear the palm guard as care planned and that it may be removed for one hour. 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 2 of 2 residents (Resident 29 and 83), reviewed for respiratory care and treatment, received appropriate oxygen services. This failure placed the residents at risk to receive inappropriate care. Findings included . According to the facility's oxygen administration policy dated December 2017, Oxygen is administered by a physician order. Oxygen may be administered in the absence of a physician order in emergency situations . Oxygen liter flow is set by a licensed nurse in accordance with physician's orders . <Resident 83> According to an admission assessment, dated 05/19/2023, Resident 83 had diagnoses of COPD (lung disease that blocks airflow and make it difficult to breathe) and CHF (a chronic condition in which the heart does not pump blood as well as it should, which may cause difficulty breathing.) The resident was not using oxygen therapy at that time of their admission. On 09/27/2023 at 09:26 AM, 10/02/2023 at 10:34 AM, 10/03/2023 at 08:40 AM and 09:41 AM, and 10/04/2023 at 10:10 AM, Resident 83 was observed wearing oxygen via a nasal cannula. A review of the resident's orders showed no active/current orders for oxygen therapy. A review of the resident record showed a previous order, dated 06/13/2023, for Oxygen 1-4 liters per minute to keep sats (a reading of the oxygen saturation of the blood, measured by an oximeter) greater than 88% , and to wean off oxygen as tolerated. This order was discontinued the same day. A further review of Resident 83's record showed an order, dated 07/08/2023, to wean off the oxygen. This order showed as completed the following day. A review of Resident 83's O2 Sats Summary, showed readings of oxygen saturation levels labeled as either on room air (without supplemental oxygen) or with oxygen via nasal cannula. From 05/12/2023 through 05/20/2023 all readings were all checked on room air. The readings since 06/14/2023 through 10/04/2023, 80% were checked on oxygen (104 readings) and 20% (26 readings) were checked on room air. During an interview on 10/04/2023 at 10:55 AM, Staff F, Registered Nurse, was unable to find a current oxygen order in the computer. They stated the resident should have an order for the oxygen, they weren't sure what happened and they would call the MD and get an order right away. During an interview on 10/04/2023 at 11:10 AM, Staff C, Director of Nursing, stated that in an emergency, staff can start oxygen, then they need to get an order right after. During a follow-up interview on 10/04/2023 at 11:49 AM, Staff C acknowledged there was not a current order for the oxygen. Staff C further stated staff should have obtained an order and the error should have been caught sooner. <Resident 29> According to Resident 29's quarterly assessment dated [DATE], Resident 29 had severe cognitive impairments, had diagnoses including hypertension (high blood pressure), stroke and morbid obesity, and had not received oxygen therapy. Review of the resident's physician orders, printed 09/26/2023, revealed there were no orders for oxygen included in the resident's medication regimen. Review of Resident 29's care plan, initiated 05/09/2018, last revised 09/13/2023 showed the resident had no care plan for oxygen usage. A nursing note dated 07/18/2023 at 1:27 PM, showed Resident 29's oxygen saturation was 85%, and was immediately provided with supplemental oxygen. The note further stated the saturations increased to 94% on two liters per minute (lpm) of oxygen. The note did not specify whether the nurse considered this an emergency situation in which oxygen should be applied without a physician's order, or how the nurse determined the appropriate level of oxygen to apply. Further, if the situation was an emergency which warranted application of oxygen without a physician's order, it did not show that a provider was notified of the resident's emergent need for oxygen and overall condition. Additional progress notes from 07/18/2023 through 08/18/2023 showed Resident 29 was provided with oxygen without a physician's order. Observations made on 09/25/2023 at 10:41 AM, 09/26/2023 at 8:48 AM, 11:05 AM, 09/27/2023 at 10:01 AM, 1:34 PM, 3:14 PM showed Resident 29 was administered oxygen. During an interview on 10/02/2023 at 11:03 AM, Staff P, Licensed Practical Nurse, stated if a resident needed continuing oxygen after an emergent situation, you would need a physician's order. During an interview on 10/03/2023 at 10:59 AM, Staff C, Director of Nursing, stated a physician's order is needed, with the number of liters to administer oxygen. Reference: (WAC) 388-97-1060(3)(j)(vi)

Based on observation and interview, the facility failed to implement a consistent process to ensure 1 of 2 observed potentially hazardous areas (housekeeping closet) was secured. This failure placed cognitively impaired residents at risk of injury. Findings included . Observation on 09/25/2023 at 10:04 AM showed a housekeeping closet at the end of Oak Hall was unlocked, and able to be opened. The room contained chemicals that were harmful if swallowed or contacted the skin or eyes. No residents were wandering by the room. Additional observations of the housekeeping closet with the door left unlocked, without facility staff nearby and directly supervising the area were made at the following dates and times: 09/27/2023 at 9:08 AM and 09/27/2023 at 11:07 AM. In an interview on 09/27/2023 at 11:03 AM, Staff L, Nursing Assistant, stated when they have seen a resident wandering, they redirect them by offering activities. In an interview on 09/27/2023 at 11:07 AM, Staff K, Housekeeper, stated the housekeeping closet must remained locked because the chemicals that are kept in there are harmful. In an interview on 09/27/2023 at 11:20 AM, Staff A, Administrator, stated if harmful chemicals are kept in the housekeeping closet, the door should be locked. Staff A was informed of the surveyor's observations of the housekeeping room accessible to residents, without staff supervision. Reference: WAC 388-97-3220 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviewand record review, the facility failed to honor the shower preferences for 3 of 4 sampled residents (Residents 45, 48, and 84), reviewed for activities of daily living (ADLs). This failure placed the residents at risk for skin integrity concerns and decreased quality of life. Findings included . The Centers for Disease Control and Prevention (CDC) updated 05/08/2023, Interim Infection Prevention and Control for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. At the time of the entrance to the facility on [DATE], there were 8 residents isolated and positive for COVID-19 (a viral illness that caused difficult breathing, cough or other symptoms consistent with viral illnesses). Two residents were removed from isolation the same morning of 09/25/23. Five remaining positive residents were housed on the transitional care unit (TCU), and one resident was housed on the Evergreen Unit. The Oak unit had no further COVID positive residents housed there and contained the majority (68 of 92) residents. <Resident 45> A review of the record showed Resident 45 diagnoses included right below the knee amputation and need for assistance with personal care. The 07/27/2023 quarterly assessment documented the resident was cognitively intact and required physical assistance of one staff for bathing support. The 02/07/2022 care plan showed Resident 45 had a self-care deficit related to their right lower leg amputation. Resident 45 required extensive assistance of one staff for bathing/showering and preferred showers twice weekly. The Care Card record (documentation of cares provided by the nursing assistants) retrieved 09/27/2023 showed bathing was provided for Resident 45 on 09/18/2023. There were no other entries for bathing during the month of September. On 09/25/2023 at 10:09 AM, Resident 45 was observed dressed and groomed and was seated in their wheelchair in the hall on the Oak Unit. Resident 45 stated they had not had a shower for 4 weeks and staff had told them it was because there was COVID-19 in the building. Resident 45 stated the shower aide used to clean the shower room thoroughly between residents so they did not understand why they could not have showers. Resident 45 stated they were able to wash their hair at the sink in their room but because of how they had to position themselves at the sink, the water ran down their back and got their clothes wet. Resident 45 stated they preferred to shower and prior to the COVID outbreak was showered twice a week. <Resident 48> Resident 48 had diagnoses including a long term (chronic) ulcer to their right heel and pressure ulcers. A quarterly assessment completed on 09/06/2023 documented Resident 48 was cognitively intact, required supervision for personal hygiene and bathing did not occur. The 06/29/2023 care plan showed Resident 48 had a potential self-care deficit. Resident 48 required extensive assist of one staff for bathing/showering and was to have showers twice a week and as needed. The Care Card record showed the resident was showered on 09/18/2023 and bathed on 09/21, 09/25 and 09/28/2023. On 09/28/23 at 10:06 AM, Resident 48 was observed resting in their bed and resided on the Oak Unit. They were groomed and wearing clean clothes. Resident 48 asked the surveyor if there was a rule regarding no showers because of COVID; they were told they could not have showers by facility staff. Resident 48 stated when able, the nursing assistants came around and helped them with a spit bath, but it was not like getting a shower and Resident 48 had not had a shower in 2 ½ weeks. <Resident 84> Resident 84 diagnoses included above the knee amputation of the left leg. A 08/16/2023 quarterly assessment documented Resident 84 was cognitively intact, required extensive assistance of two staff for personal hygiene and was totally dependent on staff for bathing. The 07/19/2023 revised care plan showed Resident 84 had a potential self-care deficit. They required extensive assistance of one with showers twice a week and as needed. The Care Card report showed Resident 84 was showered on 09/01/2023 and received a bed bath on 09/19/2023. On 09/25/2023 at 3:15 PM, Resident 84 was observed in their room on the Oak Unit seated in their wheelchair. Resident 84 stated they had not had a shower in over two weeks. During an interview on 09/28/2023 at 8:52 AM, Staff M, Nursing Assistant (NA)/Transport, stated staff were giving bed baths in resident rooms because of the COVID outbreak. They had not been giving showers for several weeks. Staff M stated they were told residents were not to be out of their rooms and they were just doing what the Administrator instructed. At the time of the interview, three residents were observed scooting in the hall in their wheelchairs. Additionally, one resident was seated in front of the nurse's station with an overbed table in front of them that had drawing materials and personal items on it. During an interview on 10/03/2023 at 9:08 AM, Staff O, NA/Shower Aide, stated they had many residents complaining to them that they were not getting their showers; the residents were in the halls already. Staff O stated they were told that as long as there was COVID, there would be no showers. The shower room was observed, and Staff O demonstrated how they disinfected the shower walls and the shower chair with a cleaner that contained bleach. Staff O stated the overhead ventilation fan came on when the lights were on, and the cleaning products were allowed to remain on the surfaces in order to kill any viruses. On 10/03/2023 at 10:28 AM, Resident 45 was observed in the day room on the Oak unit scooting in their wheelchair. Resident 45 stated they still had not been showered and showers were preferred to bed baths. Resident 45 stated their skin itched and showers made the itching better. During a telephone interview on 10/04/2023 at 3:05 PM, the Infection Prevention Specialist at the regional county health jurisdiction stated the facility reported their outbreak as required. The Infection Prevention Specialist stated the health jurisdiction did not make recommendations to stop communal dining or showering residents unless it was for a specific unit, and not on a facility wide basis. They stated there were ways to provide those services with the appropriate infection control measures and planning. During an interview on 10/04/2023 at 4:53 PM, Staff Q, Registered Nurse, Infection Prevention, stated they were not included in the decision to suspend showers and communal dining; they had been on vacation. Facility management were waiting for the outbreak to be over. Staff Q stated residents could develop skin concerns if showers were not given. During an interview on 10/04/2023 at 5:33 PM with Staff A, Administrator, Staff B, Regional Director of Operations, and Staff C, Director of Nursing Services, Staff A stated they planned to revisit the decision to stop resident showers after the facility had gone 14 days with no new cases of COVID-19 and they had not had any new cases since 09/26/2023. Staff A stated only one resident had complained to them regarding not receiving a shower. Staff B stated guidance from the CDC was not always accurate. Staff C stated the regional county health jurisdiction had instructed them to stop the resident showers and they would review their email correspondence to verify this. Reference: WAC 388-97-0180(1-4)

Based on observation, interview and record review, the facility failed to ensure pharmacy services and medication administrations met professional standards when medications were not able to be re-ordered timely and residents missed multiple doses of their medications for 31 of 41 sampled residents (Residents 3, 5, 7, 9, 10, 18, 22, 34, 35, 37, 39, 41, 42, 45, 48, 50, 52, 53, 59, 65, 69, 71, 73, 77, 78, 80, 81, 83, 85, 86, and 212) reviewed for significant medication errors. This failure placed the 96 residents at risk for complications in their medical conditions, and decreased quality of life. Findings included . Record reviews completed on 09/27/2023 and 09/28/2023 showed that Residents 45, 48 and 71 had not received doses of medications to treat irritable bowel syndrome, blood pressure, viral illness, and mood disorders as the medications were documented as on order from pharmacy. A review of the 07/2023 Incident and Accident (A&I) logs showed that two residents (Residents 3 and 50) had also missed doses of their medications that treated depression. The medications were listed as on order from pharmacy. Further record reviews showed the facility identified on 09/18/2023 that Residents 5, 7, 9, 10, 18, 22, 34, 35, 37, 39, 41, 42, 52, 53, 59, 65, 69, 73, 77, 78, 80, 81, 83, 85, 86 and 212 had missed doses of their medications that were identified as on order from pharmacy and not delivered yet. Review of the medication administration records (MAR) for 08/2023 and 09/2023 identified additional missed doses of medications that had not been identified by the facility for Residents 7, 9, 10, 34, 35, 37, 39, 41, 53, 59, 65, 69, 73, 77, 78, 80, 81, 83, 86 and 212. The cause and outcomes for the residents, if any, of those missed doses had not been investigated by the facility. On 09/28/2023 at 9:50 AM, an inventory list of the facility Cubex (a large storage system of frequently used medications staff were able to access in the event a medication was not available through the usual ordering system) showed the medications available and was dated 05/14/2021. During an interview on 09/28/2023 at 9:05 AM, Staff T, Registered Nurse (RN), stated the number of doses of medications sent from the pharmacy varied, sometimes 7 days' worth, sometimes 14 days' worth. Staff T stated at other times, the pharmacy notified the facility via fax that additional documents were needed before certain medications were delivered. Staff T stated they were able to look in the Cubex for medications they needed, Otherwise, their pharmacy, which was not local, had to receive a request for the medication which was then forwarded to a local pharmacy, and the local pharmacy delivered it. Staff T stated it was difficult to reach their pharmacy by phone. They stated at times they were put on hold for over an hour, then received a prompt to leave a message with now ere to leave a message, then received a message that all representatives were busy and were put back into a holding cue. During an interview on 09/28/2023 at 9:31 AM, Staff II, RN, stated they were to reorder medications when there were 7-10 doses left. If the medications were not received, they had to make follow-up phone calls or send faxes to their pharmacy. Staff II stated there had been problems getting medications from the pharmacy for a long time, even before the facility changed owners. Staff II stated if medication were not delivered, they could check the Cubex and get it from there, but many of the medications needed were not in the Cubex. Staff II stated they had to call the pharmacy at least one or two times a week to follow-up on medications that had been ordered but not received. During an interview on 09/29/2023 at 10:14 AM with Staff A, Administrator, Staff B, Regional Director of Operations and Staff C, Director of Nursing, Staff C stated the facility had difficulty receiving medications from their pharmacy when the facility changed owners 09/01/2023. Resident information did not get transferred into the pharmacy system under the new ownership; that had to be done by the pharmacy. Staff C stated because of that, when nurses attempted to re-order medications into the electronic documentation system, it showed the medications were reordered, but the orders did not show in the pharmacy system for processing. Staff A and Staff B stated they were unable to explain medication doses that had been missed in 07/2023 and 08/2023 prior to the change in ownership. Staff A and Staff C stated they had made requests for their pharmacy distributor to come to the facility and review files to help determine the cause of the missed medications and as of 09/29/2023 at 10:40 AM had not received a response. During a telephone interview on 10/04/2023 at 11:51 AM, Staff LL, consultant Pharmacist, stated on 09/01/2023, some resident crossed over to the new system and some did not. Those that did not showed as inactive and needed re-entered into a new profile. In addition, Staff LL stated they used an outside data entry service, and they discovered the data entry service entered medications reorders incorrectly. These showed as already filled orders, but the orders had not been filled and delivered yet and this was another reason the facility missed doses of medications. Staff LL stated the facility had not reached out to them until the week of 09/18/2023. Prior to that, the pharmacy was unaware there was a problem receiving medications. Staff LL stated they were aware of the trouble staff had getting in touch with them. It had been going on for months. Staff LL stated they were going to begin to use a cloud-based computer service (a way of storing and retrieving computer data information) to help rectify the problem. Staff LL stated they were on a different computer server network than the facility. Staff LL stated their server had been hacked in 03/2023 and the software and telephones were affected and there had been a lot of instability in the network since then. Staff LL stated the pharmacy was also able to run reports on the medications that had been withdrawn from the Cubex, but the inventory of the Cubex had not been re-evaluated since August of 2021. (Refer to F760 regarding significant medication errors.) Reference: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents did not miss multiple doses of their ordered medications, investigate the causes of the missed doses timely, and educate the staff regarding the medication ordering process for 31 of 41 sampled residents (Residents 3, 5, 7, 9, 10, 18, 22, 34, 35, 37, 39, 41, 42, 45, 48, 50, 52, 53, 59, 65, 69, 71, 73, 77, 78, 80, 81, 83, 85, 86 and 212) reviewed for significant medication errors. The lack of ensuring the medication system was in place prior to change. This failure placed the residents at risk for complications in their medical conditions, and decreased quality of life. The facility had identified the issues and was in the process of correcting them. Findings included . The 06/2017 revised Medication Administration facility policy documented the nurse was to re-order medications prior to running out of the medication supply. If a medication was not available, the nurse was to document the medication was not available in the medication administration record (MAR) and check with the pharmacy to see how soon the medication was going to be available at the facility. The nurse was to notify the physician and check the ER (not defined) kit for like medications and follow physician orders for substitution or omission. <Resident 48> Per the [DATE] quarterly assessment, Resident 48 diagnoses included depression and anxiety and was cognitively intact. Resident 48 tested positive for COVID-19 (a viral illness that caused symptoms such as difficult breathing, fever, and cough.) A review of the 09/2023 MAR showed that Resident 48 did not receive 6 doses of nirmatrelvir (medication that lessened symptoms and decreased duration of COVID-19) from [DATE] to [DATE] and missed two doses of nortriptyline (medication to treat depression) on [DATE] and [DATE]. The MAR documented the missed doses were on order from the pharmacy. During an interview on [DATE] at 10:06 AM, Resident 48 stated facility staff had inquired if they wanted to take a medication to treat COVID-19 and Resident 48 decided to take it. Resident 48 stated they thought they were given it for about 5 days. Resident 48 stated they were made aware they had missed their depression medication and stated it was missed when the dose was changed, and the medication was changed to one that was less expensive. <Resident 71> Per the [DATE] quarterly assessment, Resident 71 diagnoses included dementia, hallucinations, and pain. Resident 71 was mildly cognitively impaired, received a pain medication regimen and an antipsychotic medication (a class of drugs used to treat psychotic symptoms that might include as hallucinations or delusions). The [DATE] quarterly pain evaluation showed Resident 71 had pain that affected their function and mobility. They used tramadol, acetaminophen, and a pain-relieving gel named Biofreeze, all for pain relief and they were satisfied with the pain relief they received from the medications. A review of the 08/2023 and 09/2023 MARs showed Resident 71 did not receive 5 doses of Seroquel (an antipsychotic medication) from [DATE] to [DATE]. Additionally, Resident 71 did not receive one dose of apixaban (medication that prevented blood clots) on [DATE], two doses of metoprolol (medication that treated high blood pressure) on 09/12 and [DATE], and Biofreeze gel (pain relieving gel) on 9/7, 9/10, 9/13, 9/14, 9/15, 9/16 and [DATE]. The MAR documented the medications were on order from pharmacy. <Resident 45> Per the [DATE] quarterly assessment, Resident 45 diagnoses included gastro-intestinal bleeding and constipation and was cognitively intact. The [DATE] comprehensive care plan showed Resident 45 had nausea and vomiting related to their disease processes. Interventions included to administer anti-nausea medications as ordered and monitor for aggravating or alleviating factors. A review of the provider orders showed in [DATE], Resident 45 was started on dicyclomine 10 milligrams (mg) four times daily for irritable bowel syndrome (IBS, changes in bowel movements which can be constipation or diarrhea or both). A review of Resident 45's MARs for 08/2023 and 09/2023 showed that on [DATE], the resident missed a dose of levothyroxine (to treat low thyroid levels) and furosemide (to treat fluid build-up.) On [DATE] Resident 45 also missed one dose of omeprazole (treated acid reflux) and from [DATE] to [DATE] they missed 27 doses of dicyclomine. A code 00 was entered on the MAR that was defined as on order from pharmacy. During an interview on [DATE] at 3:00 PM, Resident 45 stated they had missed several doses of dicyclomine about a week ago. Resident 45 stated they started on the medication a long time ago when they had a bad infection and had lost their leg. They stated everything at that time made them nauseated or gave them diarrhea and they lost a lot of weight. Resident 45 stated they had no nausea or diarrhea as a result of missing their medication. On [DATE] at 3:15 PM, the Physician Communication Binder (a document used by staff to communicate resident information to the providers when making their rounds) was reviewed. There was an entry on [DATE] that documented Resident 45 had not received refills for their furosemide and dicyclomine. A notation stated the pharmacy rejected the orders as they were expired. The entry was crossed out, signifying the provider had noted the entry. There were no entries in the Communication Binder regarding the medications Resident 71 had not received. There was, however, an additional entry on [DATE] that an additional resident, Resident 10, had not received rivaroxaban (a medication that prevents blood clots) since [DATE]. A notation showed the pharmacy and the unit manager came in the facility on [DATE] after being notified that Resident 10 had gone without their medication for a week. <Resident 10> A review of Resident 10's 09/2023 MAR showed that Resident 10 missed 7 doses of rivaroxaban; the medicine was on order from the pharmacy. In addition, the resident also missed 2 doses escitalopram (used to treat depression) on [DATE] and [DATE], and 4 doses of an albuterol nebulizer (used to open airways and ease the work of breathing) beginning on [DATE]. The missed doses of escitalopram and albuterol were not listed in the Physician Communication binder. A review of the facility 07/2023, 08/2023 and 09/2023 Accidents and Investigations (A&I) logs showed that the facility had entered 5 occurrences of medication errors. The sample of residents being reviewed for medication omissions was expanded and two residents, Residents 3 and 50, were randomly selected from the facility's incident log and reviewed for medication errors. <Resident 50> A review of the [DATE] quarterly assessment showed Resident 50's diagnoses included dementia and manic depression (a mental health condition that causes extreme emotional high or low moods) and was cognitively intact. A review of the [DATE] A&I investigation report showed that the nurse practitioner notified the nurse Resident Care Manager (RCM) that they had identified that Resident 50 had missed 21 doses of escitalopram, Medication they took for derpression. The investigation determined that the medication had not been reordered correctly from the pharmacy, staff had not notified the provider, and there were no progress notes made to indicate the resident had missed the doses of their medication. Additionally, the investigation determined that staff had not checked in the cubex (a large medication storage bin that held extra doses of commonly prescribed medications for staff to access in the event a medication had not been received from the pharmacy, for example.) The medication had been available in the cubex and staff had not utilized it. According to the investigation, staff were re-educated on accessing the cubex, and writing progress notes if a medication was unavailable. The incident investigation documented that the facility notified Resident 50's family contact and notified them of the missed medication. The family member noted that it made sense; they noticed an increase in weepiness and sadness in conversation with Resident 50. During a telephone interview on [DATE] 10:03 AM, Resident 50's family member stated they had been notified by the facility when Resident 50 had missed doses of their anti-depressant medication. They noticed a slight change in Resident 50 when they called them to visit Resident 50 was more emotional and weepier over things that seemed simple. Or when it was time to end the call Resident 50 was more tearful. The family member stated the resident normally went through periods like that though, so they were unsure if it was caused by missing the medication. <Resident 3> The quarterly assessment completed on [DATE] showed Resident 3's diagnoses included dementia, anxiety and depression and was cognitively intact. A review of the [DATE] A&I investigation report showed that the RCM was notified that the resident had missed many doses of Cymbalta (medication used to treat depression.) The investigation showed the resident missed 15 doses beginning [DATE]. The nurse practitioner discovered the omissions when they had come to assess Resident 3 because they were having increased confusion and delusions. The nurse practitioner determined the changes had to be related to a medication issue as they had not found any medical reason for the change. It was determined that the medication needed a prior authorization as it was non-formulary, so the pharmacy had not delivered it. The appropriate paperwork was completed, and the medication was sent. According to the investigation, staff were re-educated to notify the RCM and the provider each time a medication dose was missed. During an interview on [DATE] at 10:47 AM, Staff HH, Medical Director, stated Resident 3 was weaned off an anti-psychotic medication close to the time their Cymbalta doses were missed, and it was hard to point to the missed Cymbalta as the reason for the changes in Resident 3. Staff HH stated they would have expected to see withdrawal symptoms more like nausea or vomiting, not delusions. Staff HH stated they were aware the nurses had been having a difficult time getting in touch with their pharmacy. During an interview on [DATE] at 9:05 AM, Staff T, Registered Nurse (RN), stated at times they were sent 7 days of medications or 14 days' worth from the pharmacy. It depended on the medication. Some medications required manager approval and the pharmacy sent a fax requesting that. Staff T stated if they had to wait on the approval process, they gave the medication if it was in their cubex. If not, the medication was satellited to a local pharmacy and the local pharmacy delivered it. Staff T stated if a dose was missed, they got in touch with the provider to get an order for a substitute medication if needed. They stated they did not have trouble getting in touch with their providers, but they had trouble getting a hold of someone at the pharmacy. They would get put in an automated cue to leave a message but then could not get a prompt to leave the message or would be put in a cue where they might wait on hold for over an hour. When asked if there was a log kept of the missed doses, Staff T stated they did not know. They were unsure if missed doses of medications were considered medication errors. During an interview on [DATE] at 9:31 AM, Staff II, RN, stated medications were to be re-ordered when there were 7-10 doses left. The label was pulled and faxed to the pharmacy. If the medication was not received, then a follow up fax and phone call was done. Staff II stated there had been a problem getting medications from the pharmacy for a long time. If medication was not delivered, then they could check the cubex, but the medications needed were often not in the cubex either. Staff II stated they had to call the pharmacy at least once or twice a week to follow up on medication orders and it was a challenge. On [DATE] at 9:55 AM, the in-service education binders at the nursing unit desk were observed. An undated in-service was observed that stated staff were not to write that medications were not available from pharmacy in the MAR. Staff were to look in all medication rooms, carts, and in central supply or call the manager. Staff were also to check the cubex for the missing medication, contact the pharmacy if not in the cubex and request the medication be satellited to the facility. Staff were to notify the provider and document all efforts to obtain the medication. Six staff members had signed the in-service attendance sheet. A review of the staff roster showed there were 37 medication technicians, LPNs and RNs. This count did not include RCMs. During an interview on [DATE] at 10:01 AM, Staff D, LPN, RCM was asked when the in-service regarding medications was put in the in-service book. Staff D stated when they had that whole bunch of med errors happen. Staff D thought it was on [DATE]. A copy of the medication errors Staff D referenced was requested. During a follow-up interview on [DATE] at 2:46 PM, Staff D stated in-services were usually just posted on the unit where the concern was identified, and again was unable to state if there was a time frame that staff were expected have them completed. Staff D stated they depended on the cart nurses to let them know they were out of medications. Staff D stated that as evidenced by all the medication errors, staff were not notifying them each time a dose was missed. Staff D was unaware if any audits regarding medications were being completed. Staff D stated the facility changed owners and resident medications had to be re-entered under the new system, which went live on [DATE]. However, the change to the new system was not completed, so as residents began to run out of medications, they were not showing in the new pharmacy system for renewals and the facility identified this around the middle of September and had worked to correct the problem. Incident investigations dated [DATE] were provided that showed an additional 33 residents had missed doses of medications. A review of the incident reports showed the facility identified the following resident missed doses of medications on order from the pharmacy: -Resident 5 missed two doses of potassium supplement on [DATE] and [DATE]. -Resident 22 missed 4 doses of citalopram (treats depression) on [DATE], [DATE], [DATE] and [DATE]; two doses of alendronate (treats osteoporosis) on [DATE] and [DATE]; and one dose of spironolactone on [DATE]. -Resident 42 missed 5 doses of a probiotic (promotes good bacteria in the intestines) from [DATE] to [DATE]. The facility did not carry the probiotic, and the provider wrote orders for an equivalent substitution. Resident 42 also missed one dose of omeprazole (reduces stomach acid) on [DATE]. This was a floor stock medication and the facility supply had been depleted. -Resident 52 missed 3 doses of apixaban (prevents blood clots) on 09/12, [DATE] and [DATE]. -Resident 85 missed 8 doses of spironolactone on [DATE], [DATE], [DATE], and [DATE]. In addition, incident investigations dated [DATE] also identified the following residents had missed doses of their medications in 09/2023 on order from the pharmacy and not received. However, further record review showed that these residents had also missed additional medications in 09/2023, and also in 08/2023 prior to the change of ownership and system changes that the facility audit failed to identify, and thus had not been investigated or reported to the provider: -Resident 7 missed one dose of mirabegron (treated bladder spasms) on [DATE]. Resident 7 also did not receive their mirabegron from [DATE] to [DATE], and [DATE] and [DATE] that was not identified. -Resident 9 missed one does of memantine (treated dementia) on [DATE]. Additionally, Resident 9 missed one dose of citalopram on [DATE] and 4 doses of acyclovir (treated viral infections such as shingles) on [DATE] the facility had not identified. -Resident 18 missed two doses of furosemide on [DATE] and [DATE]. There were also two doses of atorvastatin (treated high cholesterol) missed on [DATE] and [DATE] that were not identified by the facility. -Resident 34 missed 6 doses of proair (an inhaler that eased breathing) on [DATE] and [DATE] to [DATE]. They also missed fluticasone nasal spray from [DATE] to [DATE], tizanidine (treated muscle spasms) [DATE] to [DATE], metoprolol [DATE] and hydrocodone (pain medication) on [DATE] that had not been identified. -Resident 35 missed one dose of ergocalciferol (supplement) on [DATE]. They also did not receive their eye drops (treated glaucoma) on [DATE], [DATE] and [DATE], and atenolol (treated blood pressure) on [DATE] that had not been identified. -Resident 37 missed 5 doses of allopurinol (treated gout) on [DATE] to [DATE] and [DATE] to [DATE]. They also did not receive Eliquis (prevented blood clots) on [DATE] and [DATE] that had not been identified. -Resident 39 missed 10 doses of CoQ10 (a supplement) from [DATE] to [DATE] and the provider discontinued it. They also missed linaclotide (treated abdominal pain) from [DATE] to [DATE] and clobetasol cream (treated psoriasis) on [DATE] and the facility had not identified these missed doses. -Resident 41missed 3doses of Biofreeze from [DATE] to [DATE]. Resident 41 missed one dose of atenolol on [DATE] that had not been identified. -Resident 53 missed levothyroxine on [DATE] to [DATE]. They also did not receive atorvastatin on [DATE] and [DATE], furosemide on [DATE], digoxin (treated fast heart rate) on [DATE], metoprolol on [DATE], and phenobarbital (treated seizures) from [DATE] to [DATE] that the facility had not identified. -Resident 59 missed one dose of omeprazole on [DATE] when the facility's floor stock was depleted. They also did not receive ropinirole (treated restless legs) on [DATE], [DATE] and [DATE] that the facility had not identified. -Resident 65 received extra doses of hydralazine due to a transcription error. The medication was to be given for 10 days for edema but the medication had not been discontinued after the 10 days. Resident 65 missed two doses of buspirone (treated anxiety) on [DATE] to [DATE] that the facility had not identified. -Resident 69 did not receive Biofreeze for multiple doses from 09/07-[DATE]. The resident also missed doses of furosemide on [DATE], [DATE] and [DATE], one Lidoderm patch (treated pain) on [DATE], apixaban on [DATE], [DATE], [DATE] and [DATE] and one dose of Cymbalta on [DATE] that the facility had not identified. -Resident 73 missed 4 doses of fluoxetine and 2 doses of atenolol from [DATE] to [DATE]. They also missed 4 doses of oral vancomycin (treated contagious diarrhea) on [DATE] to [DATE] and one dose of meclizine (treated dizziness) on [DATE] that the facility had not identified. -Resident 77 missed one dose of metronidazole (antibiotic) on [DATE]. They also missed one dose of rivaroxaban on [DATE] that the facility had not identified. -Resident 78 missed one dose of omeprazole on [DATE] when the facility depleted their supply of floor stock. Resident 78 also missed atorvastatin on [DATE], and potassium supplement on [DATE] and [DATE] the facility had not identified. -Resident 80 missed 2 doses of molnupiravir (treated COVID-19) on [DATE] and [DATE]. The resident also missed one dose of dexamethasone (steroid to ease breathing) on [DATE], one dose of insulin on [DATE], and rosuvastatin (treated high cholesterol) on [DATE] and [DATE]. -Resident 81 missed 2 doses of diclofenac gel on [DATE] that the facility did not identify. -Resident 83 missed Bactrim (antibiotic) on [DATE] and [DATE], and wixela (treats asthma) on [DATE] and [DATE]. The facility did not identify that Resident 83 missed Bactrim on [DATE] and [DATE], and wixela on [DATE]. -Resident 86 did not receive diclofenac gel from [DATE] to [DATE]. They also missed one dose of carvedilol (treated blood pressure) on [DATE], pravastatin on [DATE], and CoQ10 supplement from [DATE] to [DATE] that the facility had not identified. -Resident 212 did not receive Omega-3 (supplement) on [DATE], valacyclovir on [DATE], ezetimibe (treated high cholesterol) on [DATE] and CoQ10 from [DATE] to [DATE]. The CoQ10 was discontinued by the provider. The Omega-3 was available in the facility floor stock and was put on the medication cart. The resident also missed one dose of valacyclovir on [DATE] that the facility had not identified. On [DATE] at 10:10 AM, an interview was conducted with Staff A, Administrator, Staff B, Regional Director of Operations, and Staff C, Director of Nursing. Staff C stated there had been issues getting medications when the facility changed owners. Resident profiles had not been entered into the new system, so when a medication was re-ordered in the new system, the order did not recognize the resident, so the order just sat there. This occurred over a weekend, so when staff did not receive medications and attempted to contact the pharmacy, they were on hold for inordinate amounts of time. The provider was supposed to be notified if a resident missed doses of their medication. When the problem was discovered, Staff C stated they and Staff B had done 1:1 re-education but this was not documented. RCMs were responsible to follow-up with any staff that had not completed the education. Staff B stated prior to [DATE], the facility had not reached out to the pharmacy regarding receiving medications timely. Staff A and Staff B stated they were not aware there had been a problem prior to [DATE]. The staff had not informed them they had issues obtaining medications. Staff C stated after that, they had made a request for their pharmacy to come to the facility to determine the cause of the issue but had not received a response yet. During an interview on [DATE] at 10:37 AM, Staff KK, Consultant Pharmacist, stated when they conducted a monthly medication review, they reviewed each line of the MAR to ensure dosages were correct or there were no drug interactions. They met with the facility monthly, or they called the facility if an issue was identified. Staff KK stated they had not been seeing the missed doses with the code OO, on order from pharmacy as much as they should be. They had told the facility to call them with any service issues so they could advocate for the facility, but they had nothing to do with medication dispensing. That was completed by a pharmacy that was not in the area and that pharmacy had been hacked in 03/2023, and it was still disrupting services and phones. During an interview on [DATE] at 12:32 PM, Staff A stated they had provided 5 additional in-services regarding missed doses and staff that had not completed the education were not to be allowed to work until completed. They had also started a daily medication audit that day, [DATE], and had identified 10 more missed medication doses. Staff A stated they were not aware there had been a problem until [DATE]. Reference: WAC 388-97-1060(3)(k)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** < Suprapubic Catheter care and Wound care> According to a 09/08/2023 comprehensive assessment, Resident 83 had diagnoses of Peripheral Vascular Disease, (a condition where narrowed blood vessels reduced blood flow to and from the limbs) and had surgery to treat poor blood flow to his left leg. In addition, the resident had a suprapubic urinary catheter (a tube that goes through the abdomen directly into the bladder, to drain urine into a bag.) The resident required daily care to the insertion site for the suprapubic catheter and dressing changes to their left foot wounds. During an observation of Resident 83's care at 10/03/2023 at 09:41 AM, Staff G went to the residents sink and removed paper towels from the dispenser. They sprayed the wound cleanser around the opening for the resident's supra-pubic catheter then used the paper towels to wipe off the excess. Staff G completed the catheter care, performed hand hygiene, and changed their gloves. Staff G went back to the resident's sink, and removed more paper towels from the dispenser, returned to the bedside, then removed the soiled dressings and cleaned the wounds using wound cleanser and paper towels. Staff G did not change their soiled gloves or perform hand hygiene before they opened the new dressings and redressed the wounds. Staff G adjusted the pillows and pulled up their blankets with the same soiled gloves used to clean the wounds, before discarding them and leaving the room. On 10/03/2023 at 10:00AM, during an interview immediately following the observation, Staff G stated that they forgot to bring in gauze for cleaning wounds, as they should have, instead of using paper towels. They further acknowledged that they should have changed their soiled gloves before putting on the new wound dressings, and these practices could increase the risk of infection. Reference (WAC): 388-97-1320 (1)(a)(c) 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 15 staff (G, I, M, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG), when reviewing infection control practices. This failure placed the 96 residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus. In addition, the facility's failure to nursing staff performed hand hygiene during wound care for 1 of 5 sample residents (Resident 83) reviewed. this failure placed the resident at further risk of infection and medical complications. Findings included At the time of the entrance to the facility on [DATE] at 8:37 AM, there were 8 residents isolated and positive for COVID-19. Two residents were removed from isolation that morning. Five remaining positive residents were housed on the transitional care unit (TCU), and one resident was housed on the Evergreen Unit. The Oak unit had no further COVID positive residents housed there and contained the majority (68 of 92) residents. <Mask Placement> According to the 03/16/2022 CDC publication, How to use Your N95 Respirator, N95 masks (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 should be placed under the chin, with the nose piece bar at the top, with the top strap pulled over the head and placed near the crown, and the bottom strap at the back of the neck, below the ears. The straps should lay flat, be untwisted, and not be crisscrossed. The Facial Hairstyles and Filtering Facepiece Respirators guide published by the CDC in 2017 showed a beard does not allow for a tight-fitting seal for a respirator type mask (such as an N95). The Washington State Department of Health's Respiratory Protection Program Training Template for Long Term Care N95 User, published June 2023, stated wearing an N95 over glasses or head coverings can cause the seal to break and result in exposure to contaminated air. Slide 30 of the presentation showed the N95 straps must be placed on the hair and not on any head coverings when worn. On 09/25/2023 at 9:45 AM Staff V, housekeeping, was observed wearing an N95 mask with both straps placed on the top of their head, above the ears. On 09/25/2023 at 11:57 AM, Staff G, Certified Medication Aide, was observed with facial hair wearing an N95 mask with both straps behind the neck and a surgical mask placed over the N95. In an interview at 12:22 AM, Staff G stated they didn't have time to shave, and added the surgical mask when they realized the N95 was slipping because of their facial hair. Staff G acknowledged that their facial hair was longer than it should be. On 09/25/2023 at 3:13 PM, Staff FF, Licensed Practical Nurse, was observed wearing an N95 mask with both straps placed on the top of their head, above the ears. On 09/26/2023 at 9:11 AM Staff W, Central Supply, was observed wearing an N95 mask with both straps placed behind the neck. On 09/26/2023 at 9:16 AM, Staff X, Nursing Assistant, was observed wearing an N95 mask and a face shield upon exiting the room (323) of a resident that had COVID-19. A small portable cart containing PPE supplies (N95 masks, gowns, face shields and gloves) was located next to the entrance door of the room. Upon leaving the room, Staff X did not change their N95 or face shield for a clean one from the cart. It was unknown at that time if PPE supplies were in the room that would have enabled Staff X to change their N95 and face shield prior to exiting. On 09/26/2023 at 9:26 AM, Staff Y, Licensed Practical Nurse, was observed sitting at the Maple unit nursing station wearing an N95 with both mask straps placed on top of their head. On 09/26/2023 at 9:28 AM, Staff V, was again observed wearing an N95 mask with both straps on the top of the head, above the ears. When asked about the strap placement, Staff V stated the bottom strap should be placed behind the neck, but it made their neck hurt, so they placed it on top of their head. On 09/26/2023 at 9:57 AM, during an interview with the resident in room [ROOM NUMBER], it was observed that no PPE supplies aside from gloves were in the room, which confirmed Staff X had not changed their N95 mask or face shield as observed in the previous observation at 9:16 AM. On 09/26/2023 at 1:24 PM, Staff Y, Licensed Practical Nurse, was again observed wearing their N95 mask with both straps placed on top of their head. On 09/26/2023 at 1:38 PM, Staff G, was observed wearing an N95 mask with both straps behind the neck. On 09/27/2023 at 9:15 AM, Staff Z, Activity Assistant, was observed wearing an N95 mask with both straps placed on top of their head. On 09/27/2023 at 9:27 AM, Staff W, was again observed wearing an N95 with both straps placed behind the neck. On 09/27/2023 at 9:35 AM, Staff EE, Restorative Aide, was observed walking with a resident in the hallway. Staff EE was wearing an N95 mask with both straps behind the neck. On 09/27/2023 at 9:39 AM, Staff M, Nursing Assistant was observed wearing an N95 mask with both straps behind the neck as they were entering a non-covid positive resident's room. On 09/27/2023 at 9:41 AM, Staff GG, Nursing Assistant, was observed wearing an N95 with both straps behind the neck. When asked about the strap placement, Staff GG stated the top strap should be above their head and then preceded to reposition the strap to the correct position. On 09/27/2023 at 9:42 AM Staff Z, was observed going to resident's rooms to offer reading material while wearing an N95 with both mask straps placed above their ears. When asked about the placement of the mask straps, Staff Z reached up, checked the strap placement, stated the straps were in the wrong position, and they would go into the restroom and readjust them. On 09/27/2023 at 11:21 AM, Staff AA, Nursing Assistant Registered, was observed wearing an N95 with both straps behind the neck. When asked about the placement of the straps, Staff AA repositioned the top strap and stated the top strap should be on top of the head and bottom strap behind the neck. On 09/27/2023 at 1:39 PM, Staff BB, Nursing Assistant Registered, was observed wearing a head covering and an N95 mask. The strap placements were correct, but the straps were placed over the head covering, and not under as required. A similar observation was made at 1:54 PM, and when asked if the straps should be worn over the head covering, Staff BB stated they had been employed by the facility for two to three months, had been wearing the straps like that since employed, and nobody had said anything. On 09/27/2023 at 3:19 PM, Staff FF, was observed wearing an N95 mask with both straps behind the neck. When asked about the placement of the straps, Staff FF adjusted the straps to the correct placement and stated one should be upon the head and one behind the neck. On 09/28/2023 at 7:19 AM, Staff W, was again observed wearing an N95 mask with both straps behind the neck. On 09/28/2023 at 9:54 AM, Staff BB, was observed wearing an N95 with the mask straps in the proper position, but placed over their head covering. On 10/02/2023 at 4:40 AM, Staff CC, Nursing Assistant, was observed wearing an N95 with both straps behind the neck. At 4:46 AM, when asked about the position of the mask straps, Staff CC stated the straps sometimes slid down. Staff CC then repositioned the straps to the correct placement. On 10/02/2023 at 4:53 AM, Staff DD, Licensed Practical Nurse, was observed wearing an N95 mask with both straps placed behind the neck. When asked how the straps should be placed, Staff DD check the placement of the straps and repositioned the top strap to the correct placement above the head. On 10/02/2023 at 5:55 AM and 6:55 AM, while working in the kitchen, Staff I, Dietary Aide, was observed to have a full beard that was covered with a beard cover and an N95 mask was worn on top of the beard cover. On 10/02/2023 at 10:42 AM, Staff P, Licensed Practical Nurse, was observed wearing a head covering and an N95 mask. The mask straps were correct position, but the top strap was placed on top of the head covering. In an interview on 10/02/2023 at 12:48 PM, Staff A, Administrator, stated follow up COVID-19 the facility had gone 12 days now with no new positive COVID-19 test results. On 10/03/2023 at 9:41 AM, Staff G, was observed with long facial hair wearing an N95 mask with both straps behind the neck and a surgical mask placed over the N95. (Similar to the observation on 09/25/2023 at 11:57 AM) When asked, Staff G stated they had long facial stubble and the N95 was sliding so they added the surgical mask to hold it in place. During an interview on 10/03/2023 at 1:30 PM, Staff J, Kitchen Manager, stated staff should be clean shaven to wear an N95 mask. In an interview on 10/04/2023 05:00 PM, when informed of the observations of improper mask strap placements, not changing of N95 masks after leaving a room of a resident who had COVID, and wearing an N95 mask with the presence of facial hair, Staff JJ, Infection Control Nurse, stated ongoing education about how to wear PPE had been provided to the staff, and the expectation was staff would don appropriate PPE prior to entering the room and change PPE after providing care to resident who had COVID-19. Staff C stated they were unsure if specific education had been provided regarding wearing an N95 with the presence of facial hair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan to address hearing and hearing assistive devices for one of 29 sample residents (26), reviewed for hearing loss. This failure placed the resident at risk for a decreased quality of life, related to having a diminished ability to hear and understand others. Findings included: Review of the quarterly Minimum Data Set (MDS) dated 02/23/2022 - a document used by the facility to develop a resident-centered care plan - showed Resident 26 had hearing aids and minimal difficulty hearing. Continued review of the quarterly MDS revealed a Brief Interview for Mental Status (BIMS) score of 11, which showed the resident had moderately impaired cognition. The admission MDS of 05/11/2021 showed the same information, related to the resident's hearing ability. Review of the electronic care plan (initiated upon admission on [DATE]), showed no information about Resident 26 having/needing hearing aids or other devices for their hearing deficit. Review of the electronic diagnosis list located on the Medical Diagnosis tab revealed diagnoses including unspecified hearing loss, and the electronic physician orders also showed the resident had the capacity to understand choices and make healthcare decisions, and to have medical consults and treatments for services including hearing. During an observation on 05/04/2022 at 1:36 PM, the resident was in bed with headphones on, watching television. Observation on 05/04/2022 at 3:33 PM revealed Resident 26 was in bed with headphones on watching TV. During an interview on 05/03/2022 at 10:12 AM, Resident 26 stated they were hard of hearing, and asked the surveyor to pull their mask down so that they could hear the surveyor better. No hearing aids were observed, and no other devices which could assist staff to communicate better with a resident with decreased hearing were observed. Per interview on 05/04/2022 at 1:42 PM with Staff R, Certified Medication Assistant (CMA), they stated having to raise their voice a little in order for the resident to hear them. An interview on 05/04/2022 at 3:25 PM with Staff D, Assistant Director of Nursing (ADON), confirmed Resident 26 did have difficulty hearing, and confirmned there was no care plan for accomodating the hearing deficit, to include placement of the hearing aids or other interventions. During an interview on 05/05/2022 at 10:55 AM, Staff G, Activities Director, stated Resident 26 had just been moved to the unit, but verified having to speak up louder to communicate with the resident. Staff G confirmed the resident did not have a communication board or anything else to assist, related to their hearing deficit. Staff G stated the resident's family had provided them with headphones to watch television while in bed. During an interview on 05/05/2022 at 4:12 PM, Staff C, Director of Nursing (DON), stated they had to elevate their voice to communicate with the resident, but had been able to communicate with them. When the surveyor asked if there could be a better way to communicate other than elevating the voice to communicate with the resident, the DON stated yes. On 05/05/2022 at 5:02 PM, a continued interview with Staff C confirmed having an interview with Resident 26, in which they indicated a preference to to have a white board for communication (a board for the resident and staff to write on). Staff C stated the resident's hearing aid for the right ear was in the nurse's cart, and stated the resident would like to wear the hearing aid for communication with people when they did not have headphones on, due to the amplification. Staff C confirmed none of that information was included in the resident's initial or current care plan. During an interview on 05/06/2022 at 10:21 AM, Staff N, Resident Care Manager (RCM), stated they assisted with areas on the care plan such as bladder and bowel, and they did not know about the hearing portion for Resident 26. Staff N stated the care plan was reviewed based on what was brought over by the MDS. Staff N stated they did not review the MDS for changes. Staff N stated they were unaware of the resident having hearing aids or hearing issues, and confirmed there was a breakdown in communication between the MDS and care plan team. Reference (WAC): 388-97-1020(1), (2)(a)(b)

Based on observation, interview, record review, the facility failed to follow an individualized activity program for one of 29 sample residents (15), reviewed for activities. This failure placed the resident at risk for boredom and a diminished quality of life. Findings included Review of the facility's Activity Program policy, updated 07/2015 showed, The Center provides an ongoing program of activities designed to meet the interests as well as physical, mental, and psychosocial well-being of each resident. 1. g. Reflects individual resident evaluations as well as MDS assessments . For residents confined to, or who choose to, remain in their room, the Activity Department provides and assists with in-room activities/projects/leisure pursuits in keeping with needs, abilities, and interests. The 01/27/2022 quarterly assessment showed Resident 15 was moderately cognitively impaired, and needed extensive assistance from staff to move about the facility. In addition, the assessment showed the resident enjoyed doing things with groups of people, going outside, listening to music, and having books, newspapers and magazines to read. Per the record, the resident was admitted in December of 2021 with diagnoses which included muscle weakness, lack of coordination, and multiple sclerosis (a disease that affects the brain, spinal cord and optic nerves). The 01/11/2022 activity care plan showed Resident 15 had a diversional activity deficit, related to physical limitations. Interventions included: a companionship program three times a week, staff were to invite and/or assist the resident with listening to worship music, reading, television, and visiting with family and friends. A revision on 12/30/2021 further showed the resident had limited physical mobility related to generalized weakness, and instructed staff to invite the resident to activity programs that encouraged physical activity, such as exercise groups. On 05/03/2022 at 9:24 AM, Resident 15 was observed sitting up in bed watching their roommate's television. Resident 15 stated there was not much to do, and that they did not go to any group activities. The resident stated that someone from the activities department came to visit and brought reading materials, but it was difficult to hold books and papers with their right hand, and stated the left side of their body was pretty much paralyzed, so they were unable to hold anything with their left hand. No staff were observed offering to provide worship music for the resident, which was an identified activity preference. On 05/03/2022 at 9:37 AM, Staff V, Activity Assistant, was observed on the 100 hallway, passing out reading materials to residents. During an observation on 05/04/2022 at 2:43 PM, Resident 15 was in bed awake, and speaking with someone on their personal cell phone. A quarterly review progress note dated 05/04/2022 showed Resident 15 participated in activities of their choice daily, spent time in their room watching television and reading, and would sometimes read the daily chronicle from the activity cart. The note further showed the resident received cards/letters in the mail, talked on the phone with family, and their daughter visited. In an interview on 05/04/2022 at 2:45 PM, Resident 15 stated they continued to have difficulty using their right upper and lower extremities, and were unable to use the left side of their body. Staff were reported to frequently provide reading materials, but it was difficult to hold the books/magazines with the right hand. The resident further stated they enjoyed listening to music, specifically worship music, but the staff had not offered any music. Resident 15 stated they had a personal cell phone, but didn't know if it could be accessed to listen to music. During an observation on 05/05/2022 at 9:35 AM, the resident was sitting up in bed watching their roommate's TV. No staff were seen during that time offering to turn on worship music, as this was one of the resident's stated activity preferences. During an interview on 05/05/2022 at 10:44 AM Staff O, Registered Nurse, stated Resident 15 had limited use of their hands, and the ability to use the right hand fluctuated due to multiple sclerosis. Staff O stated the resident was dependent on staff for all activities of daily living except for eating. Staff O stated Resident 15 enjoyed music and had limited participation in activities. During an interview on 05/05/2022 at 12:47 PM with Staff G, Activities Director, they stated Resident 15 had their own music and enjoyed reading. When Staff G was told Resident 15 reported they did not have music and had difficulty holding books and paper, Staff G stated they were not aware of that, and would follow up with the resident. During an interview on 05/06/2022 at 11:11 AM, Staff N, Resident Care Manager, stated Resident 15 liked to lay in bed, enjoyed frequent visits from their daughter, and liked to listen to worship/church music. Staff N stated the resident's hands were shaky at times due to multiple sclerosis. Staff N stated they had not seen the resident with reading materials recently, and was not sure if the resident would be able to hold a book independently. Reference (WAC): 388-97-0940(1)

Based on observation, interview, and record review, the facility failed to ensure that assistive devices, including a communication board, related to hearing loss, were obtained for one of one sample residents (26), reviewed for hearing deficits. This failure placed the resident at risk to be affected emotionally and mentally, due to not being able to communicate effectively with facility staff and visitors/family. Findings included . Review of the 02/23/2022 quarterly assessment showed Resident 26 was moderately cognitively impaired, had minimal difficulty hearing, and utilized hearing aids. Physician orders dated 05/04/2021 showed Resident 26 had the capacity to understand choices and make healthcare decisions, and may have medical consultations and treatment for services, including hearing. Review of the electronic admission - readmission Nursing Evaluation, dated 05/04/2021, showed Resident 26 was hard of hearing and had hearing aids. Upon further record review, no documentation was found that showed if the resident had received any services for hearing. During an interview on 05/03/2022 at 10:12 AM, Resident 26 stated they were hard of hearing, and asked the surveyor to pull their mask down so they could hear them better. On 05/04/2022 at 1:36 PM and 3:33 PM, Resident 26 was observed laying in bed with headphones on watching television. No communication board, hearing aids or pictures, were available. During an interview on 05/04/2022 at 1:42 PM, Staff R, Certified Medication Assistant (CMA), stated they had to raise their voice a little when speaking with the resident so they could hear them. At 3:25 PM on 05/04/2022, Staff D, Assistant Director of Nursing, confirmed Resident 26 did not have a communication board. On 05/05/2022 at 10:55 AM, Staff G, Activities Director, stated they had to speak up louder to communicate with Resident 26, and confirmed the resident did not have a white board or any form of communication board. During an interview on 05/05/2022 at 5:02 PM, Staff C, Director of Nursing (DON), stated that during an interview with Resident 26, they stated they would like to have a white board for communication. Staff C further stated the resident's right hearing aid was in the medication cart, and further stated the resident liked to wear the hearing aid for communication with people, when they were not using their headphones. The facility staff were aware of the resident's hearing deficits, but did not consistently provide assistive devices to assist with improved communication. Reference (WAC): 388-97-1060(3)(a)

Based on observation, interview, and record review, the facility failed to ensure expired medications, treatments, and testing kits were disposed of timely, in accordance with currently accepted professional standards, in one of two medication storage rooms. This failure placed residents at risk for receiving compromised or ineffective medication, dressings, and possible inaccurate test results. Findings included: Per observation of the medication storage room located at the end of 300 hallway on 05/26/2022 at 1:44 PM, with Staff Y, Licensed Practical Nurse, showed universal transport medium (used for collecting viral specimens) expired on 08/26/2021, an arterial blood sampling kit expired on 10/31/2019, dressing change trays expired on 02/21/2020, and Influenza vaccines expired on 04/04/2022. During an interview with Staff Y on 05/26/2022 at 1:50 PM, they verified that the above medications, dressings, transport medium, and arterial sampling kit were all expired and should have been disposed of. Review of Policy and Procedure labeled Medication Storage in The Facility (undated), showed outdated, contaminated, or deteriorated medications, and those in containers that were cracked, soiled, or without secure closures should immediately be removed from stock, and disposed of. Reference: (WAC) 483.45(g)(h)(1)(2)

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for one of four sample residents (52), reviewed for food safety. Failure to remove expired food from the resident's personal refrigerator, placed them at risk for food-borne illnesses. Findings included . Review of the facility's policy titled, Resident Personal Refrigerators and Foods Brought into Center by Family/Visitors, updated August 2020, revealed .6. Residents or responsible party may provide their own UL approved personal refrigerator for use in their room,. 8. Perishable foods are covered, labeled, dated, and discarded following use by date guidelines on the food labeling reference guide. Center staff is responsible for providing education to resident and family on food/fluid labeling and dating. 9. Center may at their discretion discard food items that are not safe to eat nor labeled after verbally notifying the resident or responsible party. Review the 03/26/2022 annual assessment showed Resident 52 admitted to the facility in January 2014, and had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated they were cognitively intact. Review of the 03/09/2022 physician orders instructed the licensed nurse to check and log the resident's personal refrigerator temperature. During an interview on 05/03/2022 at 9:15 AM, Resident 52 stated they were responsible to remove food items out of the refrigerator in their room, but staff cleaned it out and checked the temperature. Observation on 05/04/2022 at 9:40 AM showed Resident 52's room refrigerator contained the following: one opened 16 ounce (oz.) container of sour cream, with a use by date of 12/31/2021; one opened 8 oz. container of butter with an expiration of 12/29/2019; one opened 8 oz. tub of cream cheese with an expiration date of 03/25/2022; one opened 7.5 oz. tub of vegetable cream cheese spread; one unopened 4 oz. cup of yogurt vanilla cream with an expiration date of 05/01/2022; and one unopened 16 oz. package of swiss cheese with a use by date of 02/22/2022. During an interview on 05/04/2022 at 10:00 AM, Staff P, Licensed Practical Nurse, stated it was not the resident's responsibility to discard expired food items, but it was the responsibility of the housekeepers to clean and discard them. Staff P further stated a couple of weeks ago, they were instructed by their supervisor to check and record the resident's refrigerator temperatures. During an interview on 05/04/2022 at 1:43 PM, Staff P stated the expired food items had been removed from Resident 52's refrigerator and discarded. Observation on 05/04/2022 at 1:47 PM in Residents 52's room refrigerator with Staff P confirmed the following food items were discarded in the trash can under the bathroom sink: cream cheese, yogurt vanilla cream, sour cream, swiss cheese, and butter. During an interview on 05/05/2022 at 10:52 AM, Staff M, Resident Care Manager, stated some of the housekeeping staff left the facility at the beginning of March 2022, and they had been cleaning, discarding food items, and checking the temperatures in the resident's refrigerators. Continued interview revealed the Regional [NAME] President, Staff B, had directed an order be added for the nurses to check and log the refrigerator tempteratures daily, but it did not include removing expired food items. During an interview on 05/05/22 at 11:03 AM, Staff L, Housekeeping Supervisor, stated they had worked at the facility a month, and stated the housekeepers were cleaning the resident's rooms, but not discarding food items out of the resident personal refrigerators yet. On 05/05/22 at 12:15 PM, Staff B, Regional [NAME] President, stated some housekeepers resigned in February 2022, so the Resident Care Managers (RCM) were instructed to write orders for the nurses to check and record the temperatures and discard expired food items in the resident refrigerators. Staff B stated the RCMs misunderstood the request and had not written the order correctly, so the expired food items were not removed from Resident 52's refrigerator until 05/04/2022. Continued interview with Staff B revealed housekeeping staff would resume taking the temperatures, cleaning, and removing expired food items after the housekeeping supervisor could take on more responsibilities. During an interview on 05/06/2022 at 9:50 AM, Staff A, Administrator, stated they had worked at the facility one month, and expected housekeeping to monitor the resident personal refrigerators daily, which included removing expired food items from the refrigerator. Staff A further stated it was important to remove these items because it was an infection control issue, and could cause food-borne illness. During an interview on 05/06/2022 at 3:19 PM, Staff E, Registered Dietician, verified staff were expected to discard food items in the residents' refrigerators based on the expiration date and use by date per the facility policy, to prevent food-borne illness. Reference (WAC): 388-97-1100(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely care plan conferences and care plan revisions for four of 29 sample residents (2, 15, 62, 68), reviewed for care conferences and care plan revisions. This failure placed the residents at risk for not having the opportunity to participate in care decisions, or to have revisions made to improve their quality of life. Findings included: Review of the facility document titled Care Conference, updated 08/2019, showed care conferences were to be held upon admission/within 72 hours, quarterly, with significant changes in condition, annually, and with discharge planning. Review of Resident 2's electronic medical record showed the resident was admitted on [DATE] with diagnoses including diabetes with hyperglycemia (high blood sugars), and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS) - a required document completed in order to develop a resident-centered care plan - dated 02/03/2022, showed Resident 2 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Per review of the resident's care plans showed there were updates made to it on 10/11/2021, 12/20/2021, and 04/22/2022. The record also showed care conferences were held 05/17/2021, 12/09/2021, and 03/10/2022. During an interview on 05/03/22 at 11:00 AM, Resident 2 stated they did not recall being invited to any care conferences or any meetings regarding their care, but they would like to be. Per interview on 05/06/2022 at 10:52 AM with Staff N, Resident Care Manager (RCM), confirmed Resident 2 had an annual MDS assessment on 10/02/2021 with care plan updated on 10/11/2021, and a quarterly MDS on 02/03/2022, but the care plan was not updated until 04/22/22. Staff N confirmed that a care conference in August 2021 was not held, but should have been. An interview on 05/06/2022 at 2:23 PM with the Staff F, Social Services Director, and Staff W, Social Services Assistant, confirmed Resident 2 did not have a care conference in August 2021, but should have. Review of Resident 15's admission record showed the resident was admitted on [DATE], with diagnoses including multiple sclerosis (a chronic disease affecting the central nervous system), metabolic encephalopathy (damage or loss of brain function caused by an illness or condition unrelated to the brain), muscle weakness, and lack of coordination. Review of the resident's quarterly MDS, dated [DATE], showed they had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. Review of the resident's care plan showed a baseline care plan was initiated on 12/29/2021, with no additional updates or modifications. Review of the resident's record showed they were re-admitted on [DATE], after a hospitalization. In addition, MDS assessments were completed after that time, including a 02/16/2022 significant change in condition assessment, and a 05/05/2022 quarterly assessment which was in progress. The baseline care plan remained unchanged. The record showed an admission care conference was held on 01/04/2022. Per interview on 05/03/2022 at 9:24 AM, Resident 15 stated they were not aware of being invited to any care conferences or any meetings regarding their care, but would like to be. In an interview on 05/06/2022 at 10:52 AM with Staff N, RCM, confirmed a baseline care plan was completed on 12/29/2021, and stated the resident should have had an updated care plan in February 2022, due to being hospitalized for more than three days. An interview on 05/06/2022 at 2:23 PM with Staff F and Staff W confirmed Resident 15 did not have a care conference held upon readmission [DATE]) following hospitalization (from 02/03/2022 through 02/10/2022). When interviewed on 05/06/2022 at 3:29 PM Staff H, MDS Coordinator, confirmed the significant change MDS assessment triggered additional care areas, and that the care plan should have been updated at that time. Per interview on 05/06/2022 at 4:45 PM with Staff C, Director of Nursing, they confirmed Resident 15 was hospitalized from [DATE] through 02/10/2022, which required a readmission care conference, MDS updates, and care plan updates. Review of Resident 62's electronic admission record showed an admission date of 12/02/2011 with diagnoses including lumbar spina bifida (a defect that occurs at birth which affects the spine). Review of the resident's MDS dated [DATE] showed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the record showed the resident had an emergency room visit on 10/17/2019, at which time they were out of the facility for less than 24 hours. The progress notes showed Resident 62's most recent care conference was held on 07/13/2020. Per interview on 05/03/2022 at 10:15 AM, the resident stated they were not aware of being invited to any care conferences or any meetings regarding their care, but would like to be. An interview on 05/06/2022 at 10:17 AM with Staff N confirmed Resident 62's care plan started on 03/09/2021 and was late, due to not being completed until 05/26/2021. Per Staff N, there was no annual comprehensive care plan review in August 2021, but should have been. When interviewed on 05/06/2022 at 11:10 AM, Staff N confirmed the resident's most recent care conference was held on 07/13/2020, and that the resident should have had multiple quarterly meetings, as well as another annual care conference in July of 2021. In an interview on 05/06/22 at 2:58 PM Staff F, Social Services Director, confirmed Resident 62's most recent care conference was held on 07/13/2020, and stated there should have been multiple quarterly meetings, as well as an annual care conference in July of 2021. Per review of Resident 68's admission record showed they were admitted on [DATE], with diagnoses including chronic respiratory failure. Review of Resident 68's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, which showed the resident was cognitively intact. Review of progress notes showed care conferences were held on 02/04/2020, 05/04/2020, 08/13/2021, and 02/14/2022. Record review of MDS updates included a significant change in condition on 05/03/2021, quarterly assessment on 07/20/2021, 10/06/2021, annual assessments on 12/23/2021 and 03/11/2022, and an additional quarterly assessment on 04/07/2022. Record review showed care plan updates were made on 02/17/2021, 06/23/2021, 10/06/2021, 12/28/2021, and 03/10/2022. Upon interview on 05/03/2022 at 10:21 AM, Resident 68 stated that they were not aware of being invited to any care conferences or any meetings regarding their care, but would like to be. In an interview on 05/06/2022 at 11:00 AM Staff N, RCM, confirmed Resident 68 had no care conferences for approximately 15 months (from May 2020 until August 2021), and a November 2021 care conference also was not held. On 05/04/2022 at 9:00 AM, Staff F stated the facility expected for care conferences to be held at least 72 hours after admission, quarterly, when there was a significant change in status, and annually. In addition, when interviewed on 05/06/2022 at 2:44 PM, Staff F also confirmed no care conferences had been held for the resident for approximately 15 months, that the next care conference was held on 08/13/2021, and then not again until 02/14/2022. Staff F confirmed care conferences should have been held quarterly but were not. Per interview on 05/06/2022 at 10:52 AM, Staff N confirmed care plans should be created upon admission, then updated quarterly and annually. Staff N stated that RCMs do not update care plans with a significant change in condition. Per Staff N, currently, the social worker provided a calendar of care conferences to the RCMs, and the MDS nurses updated the care plans with quarterly MDS updates. Staff N staff that ideally, the RCMs were to be involved in the care conferences that should be held quarterly, annually, and with any significant changes in condition, and further clarified that each department updated their own section of the care plan (example: dietary, activities, therapy). During an interview on 05/06/2022 at 10:17 AM, Staff M and Staff N, two Resident Care Managers, stated the RCMs performed basic assessments on the residents, and that care plan reviews were done within the MDS department. Staff M further stated care conference should be held upon admission, quarterly, annually, and with any significant changes in condition. Staff N stated not being aware of care conferences being held after hospitalization, unless there was a new medical condition for the resident. During an interview on 05/06/2022 at 2:23 PM, Staff F and Staff W stated ideally, the MDS assessment should be performed, then the care conference held, and lastly the care plan would be updated by each department. The facility expectation was for this process to be completed quarterly. Staff F stated there had not been post-hospitalization care conferences because there was no change in condition. Staff F stated Resident 15 was hospitalized due to low blood pressure, and stated that was in fact a change in condition with a new diagnosis. In an interview on 05/06/2022 at 4:45 PM, Staff C, Director of Nursing, confirmed no readmission care conference was held but should have been, and that no care plan updates were made due to significant changes, but should have been for Resident 15. Reference (WAC): 388-97-1020(2)(c)(d)