Every finding on record at Bainbridge Island Health & Rehab Center

Based on interviews and record review, the facility failed to follow professional nursing standards for wound care and documentation for 2 of 3 residents (Resident 3 and 4) reviewed for wound care. This failure placed residents at risk of clinical complications, infection and inaccurate medical records.Findings included.RESIDENT 3Resident 3 was admitted on [DATE] after hospitalization for hip surgery.Review of Resident 3's physician orders, dated 08/05/2026, showed a wound care order to the left hip surgical incision every day.Review of Resident 3's Treatment Administration Record (TAR), dated 08/01/2026 through 08/31/2026, showed documentation the wound care was completed daily from 08/06/2026 through 08/11/2026.Review of the facility's investigation report, dated 08/11/2026 at 1700 (5:00 PM), showed Resident 3 had alerted facility staff that the dressing on their hip incision had not been changed for a few days. The investigation showed the surgical site was assessed and the RCM [Resident Care Manager] removed a dressing that was dated 08/06/2026. The investigation showed the TAR was reviewed and they identified two licensed nurses had signed that the dressing had been changed daily on 08/07/2026, 08/08/2026, 08/09/2026, and 08/10/2026.On 08/20/2026 at 1:17 PM, Staff C, Director of Nursing, said the licensed nurses had not completed the daily wound care on Resident 3 and had falsely documented in the electronic medical record they had completed it.RESIDENT 4Resident 4 was admitted on [DATE] after hospitalization for hip surgery.Review of Resident 4's physician orders, dated 08/04/2026, showed a wound care order to the left hip surgical incision every day.Review of Resident 4's Treatment Administration Record (TAR), dated 08/01/2026 through 08/31/2026, showed documentation the wound care was completed daily from 08/04/2026 through 08/11/2026.Review of the facility's investigation report, dated 08/11/2026 at 1805 (6:05 PM), showed Resident 4's surgical site dressing was checked following a report finding from Resident 3's investigation. The investigation showed the surgical site was assessed and the RCM removed a dressing that was dated 08/08/2026. The investigation showed the TAR was reviewed and they identified a licensed nurse had signed the dressing had been changed daily on 08/09/2026 and 08/10/2026.On 08/20/2026 at 1:17 PM, Staff C, Director of Nursing, said the licensed nurse had not completed the daily wound care on Resident 4 and had falsely documented in the electronic medical record they had completed it.Reference WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)

Based on observations, interviews and record review, facility staff failed to perform hand hygiene and maintain separation between clean and dirty tasks during wound care for 2 of 3 staff (Staff A and B) observed. This failure placed residents at risk of contagious disease, infection and clinical complications.Findings included.Review of the Center of Disease Control's webpage titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, showed healthcare personnel should perform hand hygiene and change gloves when moving from work on a soiled body site to a clean body site on the same patient.STAFF AOn 08/20/2026 at 10:33 AM, Staff A, Licensed Practical Nurse (LPN), was observed providing wound care on Resident 1's heel. Staff A was observed to perform hand hygiene and put on a gown and gloves. Staff A removed Resident 1's shoe from their right foot, the foot was bare and there was no dressing observed on the heel. Staff A cleansed the right heel wound with normal saline, patted the area dry, and without changing gloves and/or performing hand hygiene applied a clean dressing.On 08/20/2026 at 10:46 AM, Staff A, LPN, was observed providing wound care to Resident 2's wound on their back. Staff A was observed to perform hand hygiene and put on a gown and gloves. Staff A assisted Resident 2 to turn onto their side. Staff A was observed to remove the soiled dressing from Resident 2's back, cleansed the wound and without changing gloves and/or performing hand hygiene, applied clean wound dressing.On 08/20/2026 at 10:55 AM, Staff A, LPN, said they should have changed their gloves and performed hand hygiene after removing soiled dressings, and applying clean wound dressing.STAFF BOn 08/20/2026 at 12:14 PM, Staff B, Registered Nurse (RN), was observed providing wound care to Resident 4's hip incision. Staff B was observed to perform hand hygiene and put on a gown and gloves. Staff B was observed with their gloved hands, opening the blinds, operating the bed controls, turning on the overhead light and adjusting Resident 4's bed sheets and clothing. Staff B removed the soiled dressing from Resident 4's hip incision, and without changing their gloves and/or performing hand hygiene, cleansed the incision, and applied a clean wound dressing. Staff B then proceeded to reach into their shirt pocket, took out a pen, documented on the dressing and placed the pen back into their shirt pocket without changing their gloves and/or performing hand hygiene.On 08/20/2026 at 12:24 PM, Staff B, RN, said they should have changed their gloves and performed hand hygiene after they removed the soiled dressing from Resident 4's incision and prior to applying clean wound dressing.On 08/20/2026 at 1:17 PM, Staff C, Director of Nursing, said the nursing staff should have performed hand hygiene and changed gloves after removing a soiled wound dressing and applying clean dressing.WAC Reference 388-97-1320

Based on interview and record review, the facility failed to assess, implement interventions and notify the medical provider of inadequate fluid intake for 1 of 3 residents (Resident 1) reviewed for dehydration. This failure placed residents at risk for dehydration, thirst and decreased quality of life.Findings included.Review of the National Library of Medicine article, Hydration Status in Older Adults, dated 06/2023, showed that older adult men would require 2.0 L/d [liter per day and/or 1000 milliliters].Resident 1 was admitted on [DATE] with diagnoses including dementia and multiple sclerosis (a chronic disorder affecting your nervous system) and discharged on 06/15/2026. The discharge Minimum Data Set Assessment, an assessment tool, dated 06/15/2026, showed Resident 1 had severe cognitive impairment and was dependent on staff for eating and drinking.On 06/18/2026 at 4:17 PM, Collateral Contact 1 (CC1), hospital staff member, said that Resident 1 had been at the facility for two weeks for respite and when Resident 1 left the facility they were dehydrated and had to be hospitalized . Resident 1's care plan, dated 06/01/2026, showed Resident 1 was a total assist with eating and staff were to encourage fluid intake and assist to keep skin hydrated.Resident 1's fluid intake document, dated 06/02/2026 through 06/15/2026, showed Resident 1's daily intake as follows: 06/09/2026 240 cc [Cubic Centimeter, a unit of volume equivalent to one milliliter], 06/10/2026 600 cc, 06/11/2026 170cc, 06/12/2026 402 cc, 06/13/2026 111 cc, and 06/14/2026 60 cc.Review of Resident 1's electronic medical record on 07/01/2026, showed no documentation of notification to the medical provider and/or resident representative regarding Resident 1's low fluid intake.On 07/01/2026 at 2:15 PM, Staff A, Director of Nursing, said Resident 1 had been admitted to the facility for respite while their family member was away. Staff A said Resident 1 was very debilitated and was dependent on staff for all care. Staff A reviewed Resident 1's medical record and acknowledged Resident 1 had poor fluid intake. Staff A said Resident 1's medical record showed progressive decline during their stay, and no change of condition was sent to the medical provider per their usual procedure. Staff A said the nursing staff should have notified the resident's representative and the medical provider of Resident 1's failure to consume adequate fluids. Reference WAC 388-97-1060(1)-(3)

Based on interview and record review the facility failed to ensure residents were free of physical abuse from other residents for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of physical injury, fear and a decreased quality of life. Findings included.Review of the facility's policy titled, Abuse: Prevention of and Prohibition Against, revised 12/2023, showed that each resident had the right to be free from abuse, the definition of abuse was willful infliction of injury, intimidation resulting in physical harm, pain or mental anguish and instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Resident 1 was admitted on [DATE] with diagnoses of dementia and depression. The admission Minimum Data Set (MDS), an assessment tool, dated 02/18/2026, showed moderate cognitive impairment and verbal behavioral symptoms directed toward others.Resident 1's care plan, initiated 02/25/2026, showed Resident 1 had the potential to demonstrate verbally abusive behaviors r/t [related to] hx [history] of being verbally abusive, yelling and at risk for harm d/t [due to] hx of aggressive behavior. The care plan showed Resident 1 had verbal altercations with other residents on 03/05/2026, 04/10/2026 and 04/12/2026.Resident 2 was admitted on [DATE] with diagnoses of traumatic brain injury, dementia and mental health disorder. Resident 2's annual MDS, dated [DATE], showed Resident 2 had moderate cognitive impairment.Resident 2's care plan dated 03/20/2018, showed Resident 2 had the potential to demonstrate behaviors toward staff and other residents r/t poor impulse control, psychosis (mental health condition characterized by a disconnection from reality) and may strike out at male residents when agitated and use foul language and verbally lash out when angry at others.Review of a facility incident report dated 04/25/2026, showed Resident 1 was self-propelling in the hallway when Resident 2 was wheeling in the opposite direction. The report showed Resident 1 yelled, what? as Resident 2 was wheeling by Resident 1 and Resident 2 reached out with their left hand and backhanded Resident 1 knocking off Resident 1's hat and glasses and said, don't f ***ing yell at me.On 05/06/2026 at 10:04 AM, Staff A, Certified Nursing Assistant (CNA), said they were in the facility hallway on 04/25/2026 and witnessed Resident 2 wheeling down the hallway towards the entrance and heard Resident 2 say I'm getting out of here. Staff A said Resident 1 was passing Resident 2 in the hallway and said what? Staff A said Resident 2 said don't you f***ing yell at me and with a closed fist whacked Resident 1 on the side of their head. Staff A said Resident 1's glasses and hat went flying.On 05/06/2026 at 10:18 AM, Resident 2 said Resident 1 was always yelling and threatening them. Resident 2 said they were sick of it and tapped Resident 1 up alongside the head. Resident 2 said they wanted Resident 1 to know to stop threatening them. Resident 2 said they didn't do it hard enough to leave a mark because they knew how to hit someone without leaving an injury, but they wanted Resident 1 to know they weren't going to take it anymore.On 05/06/2026 at 12:34 PM, Staff B, CNA, said they had cared for Resident 1 and Resident 2. Staff B said if Resident 1 was in a mood and another resident got in their way Resident 1 sometimes yelled. Staff B said Resident 2 was easily annoyed with little tolerance for loud noise and was very defensive. Staff B said they did not witness the altercation between Resident 1 and Resident 2 but were not surprised that it had happened.On 05/06/2026 at 1:38 PM, Staff C, Director of Nursing, said Resident 1 had been verbally explosive and volatile and even when Resident 1 was not yelling their tone was at times abrasive. Staff C said Resident 1 had been setting other residents off, so they had been attempting to redirect Resident 1. Staff C said Resident 2 had a short attention span and memory issues. Staff C said Resident 2 had a poor tolerance for certain people and they tended to exaggerate their response when they were touched. Staff C said they had not expected Resident 2 to react physically to another resident. Staff C said hitting was physical abuse.Reference WAC 388-97-0640(1)(3)(c)

.Based on observation, interview and record review, the facility failed to accurately identify and/or monitor target behaviors that psychotropic medications (medications that alter mood and behavior used to treat mental health conditions) were initiated to treat, and to evaluate and individualize behavior interventions for 2 of 5 residents (Residents 32 & 7) reviewed for unnecessary medications. These failures detracted from staff's ability to assess the effectiveness and need for ongoing use of psychotropic medications, and placed residents at risk of receiving unnecessary medication, experiencing associated adverse side effects, unwanted effects on mood and behavior and a diminished quality of life Findings included. 1) Resident 32 was admitted on [DATE] with diagnoses of anxiety disorder and dementia. Resident 32's Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 32 had moderate cognitive impairment. On 09/23/2025 at 11:01 AM, Resident 32 was observed to have difficulty answering a question, their face appeared worried, and they muttered I don't know what to do multiple times. On 09/25/2025 at 10:08 AM, Resident 32 was observed sitting up in bed, with breakfast tray on table. Resident 32 continually asked what activity was scheduled and was unable to participate in conversation due to perseveration on the activity schedule even after the schedule was verbalized. Resident 32's anti-anxiety medication care plan, initiated 04/08/2025 and updated 09/15/2025, showed Resident 32 received Buspirone (medication to treat anxiety) and had a goal of decreased episodes of s/sx [signs and symptoms] of anxiety. The care plan showed non-pharmacological (non-medicine) interventions: back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, and provide reassurance. Resident 32's antidepressant medication care plan r/t [related to] GAD [generalized anxiety disorder], dated 04/08/2025, showed Resident 32 received escitalopram (medication to treat depression and anxiety) and had non-pharmacological interventions: one on one, activity, adjust room temperature, back rub, change position, give fluids, give food, re-direct, remove resident from environment, return to room and toilet. Resident 32's Behavior/Psychoactive Medication IDT [intradisciplinary team) Review, dated 04/16/2025, showed Resident 32 had a history of generalized anxiety disorder, frequently became fixated on ideas, had a difficult time altering their thoughts, perseverated on their previous provider and health concerns. The IDT Review showed Resident 32 was receiving an antidepressant medication for anxiety and an anti-anxiety medication for anxiety. The review showed the target behavior of restlessness with interventions; one on one, activity, adjust room temperature, back rub, change position, give fluids, give food, re-direct, remove resident from environment, return to room and toilet. The review showed the target behavior of tearfulness with interventions; back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, and provide reassurance. The review showed that IDT conclusion was the target behavior for both medications was perseverating on medical conditions. The IDT recommended continuing the current medications as ordered and update the target behaviors and interventions to be specific for the resident. Resident 32's Medication Administration (MAR), dated 08/01/2025 through 08/30/2025), showed staff were to document non-pharmacological interventions done: back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, and provide reassurance and one on one, activity, adjust room temperature, back rub, change position, give fluids, give food, re-direct, remove resident from environment, return to room and toilet as needed. The MAR had no documentation of interventions done. Resident 32's progress note dated 09/08/2025, showed Resident 32 was seen by the medical provider with ongoing issues with severe anxiety at times, perseveration on various tasks or worries about their health status to the point of becoming red in the face and having difficulty speaking. The note showed the medications were reviewed and orders received to increase the Buspar (medication for anxiety). Resident 32's Behavior/Psychoactive Medication IDT Review, dated 09/10/2025, showed Resident 32 received an antidepressant for anxiety and an anxiolytic (medication used to treat anxiety disorders) for anxiety. The Review showed Resident 32 continued to perseverate on health concerns, was difficult to redirect or distract from constant worry over what they should be doing and had 35+ episodes on the day shift in August. The Review showed the target behavior was perseverating on medical conditions. The Review showed the current interventions: one on one, activity, adjust room temperature, back rub, change position, give fluids, give food, re-direct, remove resident from environment, return to room and toilet and the interventions were effective at times. The Review showed the IDT recommended continuing current medications as ordered and psych [psychological] referral. Resident 32's Psych follow up provider note, dated 09/11/2025, showed Resident 32 was seen for a routine psychiatric follow up. The note showed that Resident 32's medication for anxiety had been increased due to anxiety symptoms. The note showed a heading of behavioral interventions with no documentation. Resident 32's Medication Administration (MAR), dated 09/01/2025 through 09/27/2025), showed Resident 32 had 275+ episodes on day shift of the target behavior, perseverating on medical conditions. The MAR showed staff were to document non-pharmacological interventions done: back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, and provide reassurance and one on one, activity, adjust room temperature, back rub, change position, give fluids, give food, re-direct, remove resident from environment, return to room and toilet as needed. The MAR had no documentation of interventions done. On 09/29/2025 at 10:08 AM, Staff B, Director of Nursing, said the IDT Behavior review was for reviewing medications and analyzing the target behaviors and interventions. Staff B said Resident 32's anxiety medication was increased on 09/08/2025 due to an increase in anxiety. When asked if the staff had changed the care planned behavioral interventions and/or individualized them to Resident 32's specific needs since admission, Staff B said it did not appear they did but would review the medical record. On 09/29/2025 at 2:02 PM, Staff B said they reviewed Resident 32's medical record and confirmed there had been no changes in the behavioral interventions, they are pretty standard. 2) Resident 7 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, had diagnoses of anxiety disorder and bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs, also known as mania, and lows, also known as depression), had a PHQ-9 score of four (0-4=None to minimal depression), demonstrated no behaviors, and received antidepressant medication during the assessment period. Review of the electronic medical record showed Resident 7 had a 08/30/2025 order for escitalopram (an antidepressant medication) daily for depression. A Behavior/Psychoactive Medication IDT Review, dated 08/20/2025, documented Resident 7 had shown signs of being easily agitated, had diagnoses of bipolar disorder and anxiety disorder, and received escitalopram with the target behavior identified as social isolation. The review showed Resident 7's son spoke with IDT member(s) and reported the best indicator that Resident 7 was experiencing anxiety was the resident's verbalization of it. The IDT documented Resident 7's target behavior for the use of escitalopram would be changed from social isolation to verbalization of anxiety. An antidepressant medication use related to bipolar and anxiety disorders care plan, initiated 08/06/2025, directed staff to monitor for episodes of depression as evidenced by verbalizing anxiety, to attempt non-pharmacological interventions to include conversing with children, reminiscing with others, offering snacks, and to offer to take to the Elder Grow Garden. Review of the September 2025 MAR showed the behavior monitor for the use of escitalopram directed staff to monitor for the target behavior Tearfulness. This was inconsistent with the identified target behavior of verbalization of anxiety as identified on Resident 7's care plan, as documented by the Behavior/Psychoactive Medication IDT review, and as reported by Resident 7's son. The nonpharmacological interventions/behavioral interventions identified on the MAR were one on one, activity, adjust room temperature, back rub, change position, give fluids, give food, redirect, refer to nurses' notes, remove environment, return to room, toilet, and other as needed. These behavioral interventions were not consistent with those identified on Resident 7's care plan. On 09/29/2025 at 9:37 AM, Staff B, DNS, confirmed staff were monitoring for the target behavior Tearfulness for the use of escitalopram. When asked if tearfulness was the target behavior identified for the use of escitalopram by the psychotropic IDT review , identified on the resident's care plan or identified by the resident's son Staff B said no. Staff B also acknowledged the nonpharmacological/behavioral interventions as identified on the residents care plan were inconsistent with the interventions staff were directed to [NAME] on the MAR. Staff B said the interventions should match. Reference WAC 388-97-0620 (1)(a).

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 14 sample residents (Residents 3 & 26) reviewed. Facility nurses' failure to follow and clarify Physician's orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication errors, skin breakdown and unmet care needs. Findings included . 1) Resident 3 readmitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/26/2025, showed the resident was cognitively intact, at risk of developing pressure injuries and required pressure redistribution devices for their bed and wheelchair. Review of the electronic health record (EHR) showed a 06/21/2025 order for a low air loss mattress with bolster cover and direction to facility nurses to check the mattress every shift for placement and function. An at risk for pressure ulcers care plan, with a target date of 12/31/2025, also documented Resident 3 utilized a low air loss mattress with a bolster cover and directed licensed nurses to ensure proper functioning every shift. Observations on 09/23/2025 at 11:16 AM, 09/26/2025 at 10:16 AM and 09/29/2025 at 06:39 AM, showed Resident 3 did not have a low air loss mattress in place. Review of the September 2025 Treatment Administration Record (TAR) showed from 09/23/2025 - 09/29/2025 facility nurses signed that they validated the placement and function of Resident 3's low air loss mattress on 12 of 13 shifts (one shift was left blank). On 09/29/2025 at 9:33 AM, Staff B, Director of Nursing Services (DNS), confirmed Resident 3t had a foam mattress with bolsters not a low air loss mattress as ordered. When asked why facility nurses signed on 12 of 13 shifts (during the survey) they validated the placement and function of a low air loss mattress that was not there Staff B, DNS, indicated the nurses had erroneously signed for a task they had not completed. 2) Resident 26 was admitted on [DATE] with a diagnosis of heart disease. Resident 26's physician orders, dated 06/26/2025, showed staff were to administer Midodrine (medication to treat low blood pressure) every 12 hours as needed for hypotension (low blood pressure) if SB [systolic blood pressure] is less than 100. Resident 26's Medication Administration Record (MAR), dated 09-01-2025 through 09-30-2025, showed blood pressure readings of 86/57 on 09/18/2025 and 89/60 on 09/20/2025. The MAR showed no documentation Midodrine was administered. On 09/29/2025 at 9:30 AM, Staff B, Director of Nursing, confirmed after a review of Resident 26's electronic medical record, the staff did not administer the Midodrine on 09/18/2025 and 09/20/2025 per the physician orders. Reference WAC 388-97--1620(2)(b)(i)(ii),(6)(b)(i) .

Based on observation, interview and record review, the facility failed to provide activity programming designed for and to support cognitively impaired residents in their preferred activities for 2 of 5 residents (Residents 26 & 53) reviewed for activities. This failure placed residents at risk of boredom, restlessness, and a decreased quality of life.Findings included. Review of the facility's Activities policy, revised May 2016, showed the facility would provide for an ongoing program of activities designed to meet, in accordance with their comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Activities meaningful to the resident would be provided at various times throughout every day and evening based on the needs and preferences of each resident. 1) Resident 26 was admitted on [DATE] with diagnosis of severe dementia. The Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 26 had severe cognitive impairment and required staff assistance with activities of daily living. Resident 26's activity care plan, dated 02/11/2025, showed Resident 26 had a potential alteration in diversional activities and benefits from 1:1 activity visit, sensory stimulation programming and small group settings. The care plan showed the goal: use Resident 26's activity interests and strengths to enhance their sense of well – being and/or improve quality of life daily over the next 90 days as evidence by activity logs/progress notes/assessments. Care plan interventions showed: Resident 26 would benefit from all activities and encourage participation in all activities, especially small group activities, invite to and encourage activities with a low stimulation environment when available, assist outside for fresh air and provide 1:1 program to support in-room activities with supplies, conversation and comfort. Resident 26's psychiatric follow up provider notes, dated 08/25/2025, showed Resident 26 had ongoing dementia with cognitive impairment and staff were to encourage structured activities to support orientation and reduce agitation. On 09/22/2025 at 11:36 AM, Resident 26 was observed sitting in the hallway in front of the nursing station. Resident 26 was staring down the hallway. Resident 26 had no food/fluids and/or activity materials available to them. On 09/22/2025 at 12:05 PM, Resident 26 was observed attempting to stand when Staff G, Housekeeper, came over and asked Resident 26 to have a seat. Resident 26 had no food/fluids and/or activity materials available to them. On 09/22/2025 at 12:08 PM, Resident 26 was observed attempting to stand at the nursing station counter and Staff G pushed Resident 26 in their wheelchair over against the wall. Resident 26 was observed with no food/fluid and/or activity materials available to them. On 09/22/2025 at 12:41 PM, Resident 26 was observed attempting to stand. Staff D, Activity Director, was observed to ask Resident 26 to sit down and offered the resident something to drink. Resident 26 had no food and/or activity materials available to them. On 09/22/25 at 12:53 PM, Resident 26 was observed attempting to stand, a staff member was observed asking Resident 26 to sit down. Resident 26 had no food/fluids and/or activity materials available to them. On 09/24/2025 at 9:00 AM, Resident 26 was observed in the hallway in front of the nursing station in their wheelchair with a magazine. On 09/24/2025 at 9:21 AM, Resident 26 was observed in the hallway in front of the nursing station in their wheelchair pushing the tray table away from them and attempting to stand. A staff member was observed asking Resident 26 to sit down. On 09/24/2025 at 9:26 AM, Resident 26 was observed in the hallway in front of the nursing station in their wheelchair attempting to stand, a staff member came over and told Resident 26 to sit back and tilted the wheelchair back and asked them to write in their notebook. On 09/25/2025 at 12:29 PM, Staff D, Activity Director, said they were responsible for the activity programming, and they provided programming that included physical, social, emotional, interactive and spiritual activities. Staff D said they provided activities based on the residents' assessment and care plans. Staff D said they communicated daily activities in the activity calendar and the daily chronicle, but they changed daily. When asked about what activities on the calendar were small groups with low stimulation, Staff D said those activities are not listed on the calendar. Staff D said they do 1:1 activity with residents that need that type of activity and/or when they see a small group of residents that are bored, they put together an activity, for example balloon toss and/or darts. Staff D said they had a great program for residents with cognitive impairment, they do 1:1 activities and occasional activities when they see the residents are bored and the evening activity assistant did the same. When asked what activities they planned and/or provided for Resident 26 for 09/22/2025 through 09/25/2025 during the hours of 8:00 AM to 4:00 PM, staff D said they talked to the resident and had offered them darts that morning. Resident 26's Activity Task documentation, dated 09/01/2025 through 09/22/2025, showed documentation of two creative activities, three mental activities, two social activities, one religious activity and no entertainment and/or 1:1 activity. The Task documentation showed an average of four times per week of independent activity of walking/wheeling and one episode of reading and one episode of TV. The documentation showed no resident refusals. On 09/25/2025 at 2:37 PM, Staff D, Activity Director, was observed passing out papers to residents sitting in the hallway in front of the nursing station. The noise in the area was loud and there were multiple staff members congregating around the area and in the nursing station. Visitors were observed walking through the residents to access the staff at the nursing station to ask questions. Staff D was observed handing Resident 26 a piece of paper and asked Resident 26 if they could find an apple on the paper and then proceeded down the hallway to deliver papers to the residents. Resident 26 was attempting to stand and self-propelling their wheelchair forward with the paper in their hand. Staff D returned at 2:49 PM and asked Resident 26 if they found the apples, the area continued to have multiple staff members in the vicinity, talking to each other and residents creating a noisy atmosphere. On 09/29/2025 at 9:15 AM, Staff D, Activity Director, said they knew as a facility they could improve their programming for cognitively impaired residents, and they had added an evening assistant and reached out to a consultant to assist them in improving their program. 2) Resident 53 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively impaired, dependent on staff for most activities of daily living, and had the following activity preferences: listening to music, having access to newspapers, books and magazine, and going outside for fresh air when the weather was nice were identified as Somewhat important, and being around pets/animals was Very important.Review of the Activity care area assessment (CAA) showed the resident was at risk for reduced activity participation due to cognition, depression and anxiety, and staff would proceed to care plan. Review of the comprehensive care plan showed the Activity care plan had not been developed (note: the comprehensive care plan was not required to be completed yet.) Resident 53's Initial Care Plan, dated 09/18/2025, showed direction to staff to Engage in simple, structured activities that avoid overly demanding tasks. Prefers: (SPECIFY ACTIVITY). Resident 53's preferred activities were not identified. Review of Resident 53's Activity - admission Evaluation, showed it was opened on 09/24/2025, six days after admission but was not performed. On 09/25/2025 at 2:37 PM, Resident 53 was sitting in their wheelchair, which was positioned in the hallway in front of the nurse's station with several other residents. The environment was noisy, with multiple staff congregating at and around the nurses' station and visitors attempting to navigate through the residents/staff. Staff D, Activity Director, was observed passing out papers to the residents in the area including Resident 53 and then proceeded down the hallway. Resident 53 did not appear to understand what the piece of paper was or why it was provided, so they sat there holding in their hand. At 2:42 PM Resident 53 was still grasping the piece of paper. No further interaction with facility staff had occurred. At 2:44 PM Resident 53 asked a nearby staff member why they were there. The staff member responded for rehabilitation. At 2:49 PM Staff D returned and asked some residents positioned close to Resident 53 if they could find the apples on the paper but did not directly interact with Resident 53. Visitors, staff and other residents continued to navigate through/around the residents positioned in front of the nurse's station. At 2:51 PM Resident 53 was asked if they wanted to lie down. Review of Activity documentation showed staff documented Resident 53 actively participated in a word/card game on 09/25/2025. Further review showed from 09/18/2025 -/09/25/2025 no social, religious, trips, or one on one activities were provided. The only other activity documentation present was for a reading activity on 09/22/2025 and for participation in the independent activity of passively watching television on 09/21/2025, 09/22/2025, 09/23/2025 and 09/25/2025. On 09/29/2025 at 10:47 AM, Staff D, Activity Director, said when a new resident admitted they would perform an activity evaluation to identify their preferred activities, cognition etc. When asked what was done with the information Staff D stated an activity program was set up as soon as possible and would be further personalized with completion of their MDS. Review of Resident 53's Activities admission evaluation on 09/29/2025 at 10:52 AM, showed it remained incomplete, 11 days after the resident admission, as did then resident's preferred activities on the initial care plan. Reference WAC 388-97-0940 (1)

.Based on observation, interview and record review, the facility failed to ensure food was prepared in a manner that conserved nutritive value and palatability for 3 of 3 residents (Residents 53, 6, & 19) who required pureed meals. The failure to follow written recipes in th preparation of pureed food placed residents at risk of receiving food with decreased nutritive value and decreased satisfaction with meals. Findings included .On 09/25/2025 at 6:44 AM, Staff E, Cook, was observed preparing pureed sausage links. Staff E used a utensil to push approximately 16 link sausages off a pan into a metal tin. The metal tin was thin dumped into a food processor and pulsed x 3. The contents were then dumped into a pitcher. Staff E took the pitcher over to the beverage machine and added an unmeasured amount of hot water. Staff E then returned to the food processor and emptied the contents of the pitcher into it and blended the mixture for 1 minute. Once stopped the mixture was observed to be thin and soupy. Staff E removed the lid from a container of thickener and tapped it on the edge of food processor dumping an unmeasured amount of thickener with each tap. The mixture was then blended for 30 seconds but still appeared thin and soupy. Staff E poured the mixture into a new container and began mixing it by hand. Staff E again grabbed the thickener and tapped it three times on the edge of the container again delivering an unmeasured amount of thickener with each tap. After mixing it by hand Staff E indicated it was still a little too thin and added more thickener by tapping against the edge of the container twice delivering an unmeasured amount of thickener with each tap. Staff E proceeded to mix it by hand then stated, It is good, you want to see and presented the mixture. On 09/25/2025 at 6:58 AM, when asked if there was a recipe for the pureed sausage Staff E said there was but indicated they had been a cook for so long that they were able to prepare the correct texture by looking at it. Review of the pureed sausage recipe showed to make 25 servings/portions, 25 sausage links would be mixed with three and one quarter cups of water or broth and two tablespoons of thickener. The recipe showed that if there were varying sizes of single portion food items dietary staff were to adjust the recipe accordingly to ensure recipe integrity and serving amount.On 09/25/2025 at 11:17 AM, when asked if the cook should follow the pureed recipes when preparing pureed food to ensure nutritive value, palatability and appropriate texture was maintained Staff F stated, Yes, they should.Reference WAC 388-97-1100(1),(2).

Based on interview and record review, the facility failed to ensure residents were administered their prescribed medications for 1 of 3 (Resident 1) residents reviewed for medication administration. This failure placed residents at risk of clinical complications, experiencing side effects from unnecessary medications and delayed treatment for their disease.Findings included.Resident 1 was admitted to the facility on [DATE] with a diagnosis of pulmonary hypertension (a type of high blood pressure that affects the lungs causing respiratory and heart complications).Resident 1's physician's orders, dated 06/20/2025, showed an order for Letairis (a medication used to treat pulmonary hypertension) 5 MG (milligrams) one time a day.Record Review of Resident 1's Medication Administration Record (MAR), dated 06/01/2025 through 06/30/2025, showed Letairis was administered daily from 06/22/2025 through 06/29/2025, for a total of eight doses.In an interview on 07/15/2025 at 12:15 PM, Staff A, Licensed Practical Nurse and Resident Care Manager, said prior to administering medications they ensured the medication label matched the physician's order in the MAR. Staff A said they were administering medications to Resident 1 on 06/30/2025. Staff A said Resident 1's MAR showed the resident was to receive Letairis 5 MG. Staff A said they could not locate the medication Letairis but found Letrozole (a medication to treat breast cancer). Staff A said the label on the Letrozole showed it was to treat pulmonary hypertension. Staff A said they knew this was incorrect and the resident had received the wrong medication. Staff A said they contacted the pharmacy, the medical provider, and completed an incident report.Review of the facility's incident report, dated 06/30/2025, showed Resident 1 was prescribed Letairis 5MG but the pharmacy had erroneously dispensed Letrozole. The report showed the licensed nurses had administered eight doses of the Letrozole to Resident 1. The incident report showed Resident 1 was not prescribed Letrozole.In an interview on 07/15/2025 at 1:55 PM, Staff B, Director of Nursing, said the best practice when administering medications was to ensure the physician's order in the MAR matched the label of the medication. Staff B said if they did not match, the nurse should investigate the discrepancy. Staff B said the licensed nurses that administered the incorrect medication to Resident 1 did not follow this practice.Reference WAC 388-97-1060 (3)(k)(iii).

Based on observation and interview, the facility failed to maintain a kitchen environment which allowed each resident to have nourishing, palatable and well-balanced meals without cross contamination for 1 of 1 kitchen reviewed for food safety. This failure put residents at risk for food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . <Food preparation observations> On 09/11/2024 at 11:53 AM, Staff H, Cook, dropped his writing pen on the floor, he picked it up with bare hands and did not clean the pen. Staff H then wrote on a clip board and put the pen back onto his shirt by clipping the pen onto his shirt collar. Staff H did not wash hands after using the pen. At 1:09 PM, during tray line observation, Staff H, with gloved hands took the pen from out of his shirt and wrote on a piece of paper that was on the food tray, then with the same gloves picked up a hamburger bun and put it on a plate and continued to build burgers. <Tray line observations> Tray line assembly started on 09/11/2024 at 11:58 AM. At 11:58 AM, Staff H, went to the steam table and began taking temperatures of food without cleaning the thermometer in between items temped on steam table. At 12:08 PM, Staff H, adjusted their glasses with bare hands, did not wash hands, grabbed gloves and put them on. At 12:24 PM, Staff H, touched their glasses and then touched their mask with gloves on, did not change gloves and picked up plates and placed them on the steam table. Staff H picked up hamburger buns and placed them on plates. Staff H then used a spatula to transfer hamburger patties onto hamburger buns, touching the top of the hamburger patty with the other hand. Staff H did not wash hands or change gloves. At 12:27 PM, Staff H, pushed their reading glasses up with gloved hands and adjusted hat, then went to plate warmer lifted the lid and took plates out, and continued to plate food. No glove change was observed. At 12:31 PM, Staff H, used gloves to flip hanging name tag to back of his shirt, did not change gloves and got plate from plate warmer, then picked up hamburger buns and placed them on the plate. At 12:35 PM, Staff H, pushed up reading glasses on his face with gloves, then grabbed condiment packets from container and placed them on the food tray. Staff H put hamburger buns on a plate along with lettuce and tomato. Staff H then used spatula to transfer hamburger patties onto hamburger buns, touching the top of the hamburger patty with the other hand. Staff H did not wash hands or change gloves. At 12:41 PM, Staff H, adjusted dials on the steamer table and resumed plating food without a glove change. At 12:44 PM, Staff H, wiped thermometer with dish towel that had been used to wipe steam table counter, then began temping food on steam table. At 12:49 PM, Staff H, adjusted the temperature with the dial on the steam table with gloved hands, then got plates out of the warmer, he then picked up hamburger buns and put them on the plate. Staff H then used spatula to transfer hamburger patties onto hamburger buns, touching the top of the hamburger patty with the other hand. Staff H did not wash hands or change gloves. At 12:56 PM, Staff H, took several plates out of the plate warmer and held the stack of plates' edges against his shirt, he then placed the plates on the steam table. Staff H picked up two condiment packets and placed them on a tray and then picked up hamburger buns and placed them on a plate. Staff H then used spatula to transfer hamburger patties onto hamburger buns, touching the top of the hamburger patty with the other hand. Staff H moved a nearby cart by its handles, then continued to plate food, grabbing lettuce. Staff H then wiped gloves on a dishtowel that was observed to have been used to wipe down steamer table, and then picked up tomatos and placed them on hamburger patty. Staff H did not wash hands or change gloves. On 09/11/2024 at 2:45 PM, Staff I, Dietary Supervisor, said that usually during food service ladles and tongs wereused. Staff I said after adjusting glasses, touching a name tag or touching mask, that those actions would be an interruption to touching food, and he would expect them to use clean gloves when going back to handling food. When asked about touching food condiment packages and then touching food, Staff I said it would have been better to have the dietary aid put the condiments on the tray. When asked what the process would be for cleaning the thermometer between each food temping, Staff I said staff should be using sanitizer bucket and towel to wipe down between each poke. On 09/13/2024 at 10:21 AM, Staff A, Administrator and Staff C, Interim Administrator, said their expectation was to prevent cross contamination of food borne illness in the kitchen by following guidelines such as hand washing, hair nets, temperatures of foods and use by dates. When asked if it would it be acceptable for staff to touch glasses, hair/hat, badge or mask then touch food, Staff C said it was not acceptable without staff changing their gloves. When asked if it was acceptable to use a pen that had been dropped on the floor then touch food with the same gloved hands, Staff C said that was not acceptable. When asked if they would expect staff to use gloved hands to build a burger and with gloves touch buns, patties, lettuce, and tomatos, Staff C said they should be using utensils. Reference WAC 388-97-1100

Based on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 1 of 5 sampled residents (Resident 27) reviewed for bowel management. The failure to initiate bowel care in accordance with physicians' orders placed residents at risk for pain/discomfort, nausea, decreased appetite and a diminished quality of life. Findings included . Resident 27 was admitted to the facility on [DATE]. The Significant Change Minimal Data Set, (MDS, an assessment tool), dated 07/30/2024 documented Resident 27 was severely cognitively impaired. A physician's order, dated 01/24/2024, documented Miralax (a laxative) 17 grams was to be mixed with eight ounces of fluids and given to resident, if no bowel movement (BM)after three days or if resident complained of constipation with abdominal discomfort. A physician's order, dated 09/05/2023, documented bisacodyl (a laxative) 5 milligrams (mg) was to be given 12 hours after no results with Miralax. A physician's order, dated 01/24/2024, documented bisacodyl suppository 10 mg was to be given 12 hours after no results with bisacodyl 5 mg. A physician's order, dated 01/24/2024, documented Fleet enema 7-19 grams was to be given 12 hours after no results with bisacodyl 10 mg. A physician's order, dated 07/27/2024, documented Senna (laxative) 10 milliliters (ml) was to be given two times daily, and increase to 17.6 mg after two days with no BM. Resident 27's bowel record documented no BMs on 06/27/2024-07/01/2024 (5 days), 07/10/204-07/18/2024 (9 days), 08/13/2024-08/26/2024 (13 days) and 09/05/2024-09/10/2024 (6 days). Resident 27's 06/27/2024-07/01/2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented no administration of the bowel protocol medications. A progress note, dated 07/01/2024, documented Resident 27 was toileted but it was not documented on the bowel record. Resident 27's 07/10/2024-07/18/2024 MAR/TAR documented the bisacodyl 5 mg was administered on 07/16/2024 (after seven days with no BM). A progress noted dated 07/17/2024 documented a fleet enema was given to Resident 27. The fleet enema was documented as effective. Resident 27's July 2024 bowel record documented no BM until 07/19/2024. Resident 27's 08/13/2024-08/26/2024 MAR/TAR showed no documentation on 06/16/2024 (four days without a BM). Miralax 17 grams was given on 08/17/2024 and 08/18/2024, but no further bowel protocol was followed. A progress note, dated 08/19/2024, documented Resident 27 had gone three or more days without a BM. No further intervention was given until 08/20/2024, when a bisacodyl 10 gm was given (eight days with no BM). A progress note dated 08/21/2024, documented Miralax 17 gm was given. There was no documentation on 08/22/2024-08/23/2024, regarding any bowel protocol/management. On 08/24/2024 Miralax 17 gm was given (12 days without a BM). Resident 27's 09/05/2024-09/10/2024 MAR/TAR showed no documentation regarding any bowel protocol/management. A hospice note, dated 09/09/2024, documented Resident 27 had gone four days without a BM and an enema had not been completed. No documentation provided for bowel protocol/management on 09/10/2024. On 09/12/2024 at 9:29 AM, Staff D, Licensed Practical Nurse/Resident Care Manager, said the bowel protocol was initiated after a resident has no BM for three days. If there was still no BM, then on the next shift, staff would offer a suppository. If there was still no BM on the next shift, then staff would offer an enema. Staff D said all refusals need to be reported to the provider. At 2:46 PM, Staff B, Director of Nursing Services, with Staff C, Interim Administrator present for interview, said the general bowel protocol was after three days with no BM, Miralax was to be given. If still no BM, then on the next shift a bisacodyl suppository was offered. If there were still no results the next shift would offer a fleet enema. Staff B said some residents had different bowel management protocols specific to that resident. When asked about Resident 27's bowel protocol, Staff B said Resident 27 had standing (routine/daily) orders for Miralax and Senna. However, if Resident 27 had gone three days without a BM, then they would have started with giving Resident 27 an extra dose of Miralax (17 grams). If no results, then they give bisacodyl 5 mg. If there was still no results, then a second bisacodyl 10 mg suppository would be offered. If there was still no result, then staff would offer a fleet enema. When shown the 06/27/2024-07/01/2024 dates with no BM, Staff B said the bowel protocol should have been started. When shown the 07/10/2024-07/18/2024 dates with no BM, Staff B said the bowel protocol should have been started. When shown the 08/13/2024-08/26/2024 dates with no BM, Staff B said the bowel protocol should have been started. When shown the 09/05/2024-09/10/2024 dates with no BM, Staff B said the bowel protocol should have been started. Reference WAC 388-97 -1060 (1)

Based on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (NC, flexible tubing that sits inside the nose and delivers oxygen) for 1 of 1 sampled resident (Resident 9) reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and a diminished quality of life. Findings included . The facility Oxygen Administration policy, revised 04/2024, documented oxygen tubing is to be replaced every seven (7) days or when visible soiled. Resident 9 was admitted to the facility on [DATE]. The Annual Minimal Data Set, (MDS, an assessment tool), dated 06/25/2024, documented Resident 9 was moderately cognitively impaired. A physician's order, dated 04/23/2024, documented oxygen tubing was to be changed every Sunday or as needed. On 09/09/2024 at 12:29 PM, Resident 9 was wearing the NC. The oxygen machine was running at 3 liters per minute. Oxygen tubing was dated 09/01/2024. On 09/11/2024 at 9:54 AM, Resident 9 was wearing the NC. The oxygen machine was running at 3 liters per minute. Oxygen tubing was dated 09/11/2024. The September 2024 oxygen Treatment Administration Record (TAR) documented the oxygen tubing was changed on 09/01/2024 (Sunday) and 09/08/2024 (Sunday). On 09/11/2024 at 9:56 AM, Staff B, Director of Nursing Services, was asked to observe the oxygen tubing on Resident 9's oxygen machine. Staff B said the date on the tubing was marked 09/11/2024. After showing Staff B the September 2024 TAR, Staff B said her expectation was the oxygen tubing was to be changed every Sunday, as ordered. When asked if the oxygen tubing should have been changed on 09/08/2024, Staff B said yes. When asked if staff should be signing for things that have not completed, Staff B said no. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview and record review the facility failed to follow transmission-based precautions (TBP) when donning (taking on)/doffing (taking off) Personal Protective Equipment (PPE) for 1 of 2 sampled rooms (room [ROOM NUMBER]) reviewed for TBP. This failure placed the residents at an increased risk for infections and a decreased quality of life. Findings included . On 09/09/2024 at 1:36 PM, during lunch meal services, Staff J, Registered Nurse, donned gown, gloves, a N95 mask (fitted mask to protect against COVID and other droplet transmitted illnesses)over the top of an already worn surgical mask and gloves. Staff J entered room [ROOM NUMBER] and was handed a lunch meal tray. At 1:46 PM, Staff J existed room [ROOM NUMBER] wearing only a surgical mask (had doffed in room [ROOM NUMBER]), and then went into to room [ROOM NUMBER] wearing the same surgical mask. On 09/12/2024 at 9:29 AM, Staff D, Licensed Practical Nurse/Resident Care Manager, said the proper PPE donning procedure for a COVID positive room was putting on a gown, an N95, goggles and gloves. When asked if double masking was acceptable, Staff D stated, No, you want a tight seal. At 10:22 AM, Staff B, Director of Nursing Services, said the proper donning procedures was to put on the gown, gloves, switch from a surgical mask to N95 mask and then goggles before entering the room. When asked if double masking was acceptable, Staff B said no. When the observation was reported, Staff B said that was not acceptable. Reference WAC 388-97-1320 (2)(b)

Based on observation, interview and record review, the facility failed to ensure food products were dated when opened, discarded when beyond the use by date, kitchen equipment was clean and sanitary, food holding temperatures were accurately obtained and recorded, and that the low temperature dishwasher washer met the minimum wash and rinse cycle temperatures and the required minimum chemical concentration of sanitizer for proper cleaning and sanitization of resident dishes and utensils. Failure to ensure food was held at appropriate temperatures prior to serving, that meals were served on clean and sanitized disheware, and that outdated food products were not served to residents placed residents at risk for unpalatable food and foodborne illness. Findings included . Initial observations of the facility's dietary department on 09/25/2023 from 10:07 AM until 10:53 AM revealed the following: Dry Storage Observation on 09/25/2023 showed a package of Spanish rice and a cream of wheat were opened but undated. During an interview on 09/25/2023 at 10:07 AM, Staff G, Nutrition Services Manager, stated that food packages should be dated when opened and acknowledged the above referenced were not. Refrigerator One Observation of refrigerator one showed a eight pound carton of macaroni salad, opened 09/21/2023, with instructions on the side of the container that read Keep refrigerated at 33-40 degrees Fahrenheit (df). Review of the refrigerator one temperature log showed eight of the nine recorded refrigerator temperatures since 09/21/2023 (date the macaroni salad was opened) were greater than 40 df. During an interview on 09/25/2023 at 10:53 AM Staff G, Nutrition Service Manager, stated that the macaroni should have been stored from 33-40 df as recommended by the manufacturer. Refrigerator Two Observation of refrigerator two showed half a pepperoni pizza for Resident 12 and half a pepperoni pizza for an unidentified resident, both dated 09/20/2023 were stored in the dietary refrigerator. During an interview on 09/25/2023 at 10:53 AM Staff G, stated that leftovers should be tossed out after three days and acknowledged the resident pizzas should have been discarded on 09/23/2023. Additionally, Staff G stated that residents' personal food was not usually stored in the dietary refrigerator, but indicated the residents' refrigerator was broke and needed to be replaced. Kitchen Equipment On 09/29/2023 at 6:51 AM the facility's Nescafe coffee and hot water machine was observed with copious amounts of dark brown debris on the metal vented platform. Under the platform was standing brown liquid. During an interview on 09/29/2023 at 6:51 AM, Staff J, Dietary Aide, confirmed the facility's Nescafe machine was soiled and had not been cleaned. Low Temperature Dishwasher During observation of meal preparation on 09/29/2023 at 6:58 AM, Staff J was observed putting dishes through the low temperature dishwasher. According to the Dishwasher Temperature/ Sanitizer Solution Log the dishwasher needed to reach a minimum water temperature of 120 df during the wash cycle, 130 df during the rinse cycle and the sanitizer solution needed to be 50-100 parts per million (ppm) for effective cleaning and sanitization of dishware and utensils. Review of the September 2023 dishwasher log showed on the following dates, for the following meals the minimum wash/ rinse temperatures were not reached and /or the sanitizer solution did not meet the minimum concentration of 50 PPM as required. 1) 09/04/2023 breakfast- sanitizer concentration was 48 ppm, and lunch and dinner concentrations were 49 ppm. 2) 09/06/2023 breakfast- rinse cycle temperature was 122 df. 3) 09/07/2023 breakfast- rinse cycle temperature was 125 df and the sanitizer concentration was 49 ppm. 4) 09/08/2023 breakfast- rinse cycle temperature was 126 df. 5) 09/09/2023 breakfast- rinse cycle temperature was 127 df. 6) 09/11/2023 breakfast- rinse cycle temperature was 127 df and the sanitizer concentration was 48 ppm. 7) 09/12/2023 breakfast- rinse cycle temperature was 126 df and the sanitizer concentration was 49 ppm; lunch- rinse temperature was 128 df. 8) 09/13/2023 breakfast- rinse cycle temperature was 127 df and the lunch rinse cycle temperature was 120 df. 9) 09/18/2023 breakfast- the sanitizer concentration was 45 ppm. 10) 09/19/2023 breakfast- the sanitizer concentration was 49 ppm. 11) 09/22/2023 breakfast- the sanitizer concentration was 49 ppm. 12) 09/23/2023 breakfast- the sanitizer concentration was 49 ppm. 13) 09/26/2023 breakfast- the sanitizer concentration was 49 ppm. During an interview on 09/29/2023 at 9:10 AM, Staff G, Nutritional Service Manager, indicated when dietary staff test the low temperature dishwasher, if the minimum wash/rinse water temperatures or the sanitizer minimum concentration was not met, staff should re-check the dishwasher. Staff G acknowledged there was no record of this being done on the above refenced dates. When asked if dietary staff took appropriate action when the dishwasher's water temperature and/or sanitizer concentration tested below the minimum required ranges Staff G stated, No. Meal Service Observation of tray line on 09/29/2023 at 7:54 AM showed Staff H, Dietary Cook, checking the holding temperature of all items on the steam table. No temperature of cold beverages was observed to be taken. When a temperature of cold beverages was requested Staff H, Dietary Cook, provided the thermometer utilized to temp the food on the tray line to Staff G, Nutrition Service Manager, to test a cup of milk. Staff G placed the thermometer into a cup of milk, which was cool to touch, and the thermometer read 77.5 df. Staff G retested the milk with the same thermometer and again it read that the milk was 77.5 df. Staff G was observed to go and retrieve a different thermometer, which showed the milk temperature to be 45.5 df. The dietary staff then proceeded to serve resident meals, despite the thermometer used to test the holding temperatures being identified as inaccurate. During an interview on 09/29/2023 at 9:10 AM, when asked if there was any way he could confirm the holding temperatures recorded for the breakfast meal were accurate, given the thermometer used was determined to be inaccurate Staff G stated, No, I cannot. Reference WAC 388-97-1100(3)

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), were completed within 14 days for 1of 1 resident (Resident 17) reviewed for a decline in activities of daily living (ADLs). Failure to identify Resident 17's decline ADL function and to complete a SCSA placed the resident at risk for unidentified and/or unmet care needs. Findings included . According to the Resident Assessment Instrument Manual (RAI, a manual that directs staff on how to accurately assess the status of residents) a SCSA must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A SCSA is a comprehensive assessment that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. Review of the guidelines showed, a SCSA is appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). Resident 17 Resident 17 admitted to the facility on [DATE]. Review of the 10/26/2022 annual Minimum Data Set (MDS, an assessment tool), and the 01/24/2023 quarterly MDS, showed the resident required supervision for eating and locomotion on and off the unit, limited assistance (staff provided guided maneuvering but no weight bearing support) from one staff member for transfers, and extensive assistance (weight bearing support required from staff) from one staff member for bed mobility, toileting, dressing and hygiene. Additionally, review of the 01/24/2023 quarterly MDS showed Resident 17 had no falls since the prior assessment. Review of Resident 17's 01/26/2023 Functional Performance Evaluation showed the resident was assessed to require setup or clean-up assistance with eating; supervision with oral hygiene; supervision with moving from a laying to sitting position; supervision with moving from a sitting to a standing position; and supervision with transferring from bed to chair or wheelchair to bed. According to the 02/24/2023 11:21 AM interdisciplinary team (IDT) fall committee note, Resident 17 had shown progressive decline in their cognitive and physical abilities. Review of Resident 17's 04/24/2023 quarterly MDS, showed the resident required two-person extensive assistance with transfers, bed mobility and dressing, one-person extensive assistance with eating and hygiene, was dependent (full staff performance every time during the entire 7-day assessment period) on staff for toileting, and had two or more falls since the prior assessment. This showed a decline in ADL performance from: supervision to extensive assistance with eating; limited assistance of one with transfers, to extensive assistance of two; extensive assistance of one with toileting to total dependence on staff; from extensive assistance of one with dressing to extensive assistance of two; and an increase in frequency of falls. Review of Resident 17's 04/24/2023 Functional Performance Evaluation showed the resident was assessed to require substantial/ maximal assistance with eating; was dependent on staff for oral care; required assistance with moving from a laying to sitting position; substantial/ maximal assistance when moving from a sitting to a standing position; and substantial/ maximal assistance with transferring from bed to chair or chair to bed. Review of Resident 17's electronic health record (EHR) showed no documentation that the facility IDT identified the resident's decline in multiple aspects of ADL performance, determined if the declines were self-limiting and/or whether they anticipated Resident 17 to return to baseline within 14 days. Review of Resident 17's EHR showed the following progress notes: 05/03/2023weight committee note which recommended adding supplements to address the resident's weight loss and cognitive decline; a 05/29/2023 fall committee note which identified the resident had shown progressive decline in their cognition and physical abilities; and a 07/24/2023 provider note stated that the provider knew the Resident 17 well, and the resident had recently declined significantly. The note indicated Resident 17 no longer responded to direct questions and was essentially non-verbal. Review of Resident 17's 07/25/2023 quarterly MDS showed the resident continued to require two-person extensive assistance with transfers, bed mobility and dressing, one-person extensive assistance with eating and hygiene, total dependence on staff for toileting. The assessment also showed Resident 17 fell two or more times since the prior assessment. The assessment showed that Resident 17 did not return to their prior level of function within 14 days. Review of Resident 17'sEHR showed no documentation that the facility IDT identified the resident's decline in multiple aspects of ADL performance from the previous comprehensive assessment, determined if the declines in function were self-limiting and/or considered the need for a SCSA. During an interview on 09/28/2023 at 12:08 PM, Staff F, MDS Coordinator, stated that they were taught a SCSA was not indicated unless a resident's self-performance declined by two levels, in two or more ADLs areas (e.g., a decline in transfer status from supervision to extensive would be a decline of two levels, from supervision to limited, and from limited to extensive) or decline of two levels in one ADL combined with a decline in another area of the MDS. When asked if a SCSA should have been performed for Resident 17 Staff F stated, No. Reference WAC 388-97-1000(3)(b)

Based on interview and record review, the facility failed to ensure assessments accurately reflected residents' health status and/or care needs for 3 of 13 sample residents (Residents 27, 36, and 10) reviewed. The failure to assess resident cognitive patterns and to perform pain interviews as required, and to ensure assessments accurately reflected resident behaviors related to rejection of care, placed residents at risk for unidentified and unmet pain, cognitive and behavioral care needs. Findings included . According to the Resident Assessment Instrument Manual (RAI, a manual that directs staff on how to accurately assess the status of residents), staff should attempt to conduct a Brief Interview for Mental Status (BIMS, used to assess cognitive status in elderly patients) and pain assessment interview on all residents. The manual directed staff not to conduct a staff assessment of cognitive status or a staff assessment for pain if a BIMS and pain assessment interview should have been done. Resident 27 According to Resident 27's 05/02/2023 significant change Minimum Data Set (MDS, an assessment tool), staff assessed that a BIMS and a pain assessment interview should be conducted. Review of the BIMS assessment and pain assessment interview showed staff documented not assessed. Additionally, a staff assessment of cognitive status was completed for Resident 27. Review of Resident 27's electronic health record (EHR) showed the resident was in the facility during the assessment period and revealed no documentation or indication why facility staff failed to assess the resident's cognitive patterns or pain as directed in the RAI manual. During an interview on 09/29/2023 at 11:08 AM, Staff B, Director of Nursing (DNS), stated that Resident 27's BIMS and pain assessment interview were not conducted as required, due to the facility's MDS person working offsite. Review of Resident 27's 07/31/2023 quarterly MDS showed the resident rejected care on one to three days during the assessment period. Review of Resident 27's's July 2023 Medication Administration Record (MAR) showed the resident refused their peridex (antimicrobial) mouth wash on 07/25/2023, 07/26/2023, 07/28/2023, 07/29/2023, 07/30/2023 and 07/31/2023, six of seven days during the assessment period. During an interview on 09/29/2023 at 11:08 AM, Staff B, DNS, acknowledged Resident 27 refused their peridex mouthwash on six of seven days during the assessment period and it was not reflected on the resident's MDS. Resident 36 Resident 36 admitted to the facility on [DATE].According to the 09/08/2023 admission MDS, the resident demonstrated no rejection of care. Review of Resident 36's EHR showed three 09/07/2023 nurses' notes which indicated Resident 36 refused removal of their urinary catheter (a tube inserted into the bladder to drain urine.) Review of Resident 36's September 2023 MAR showed the resident refused an ordered lidocaine patch on 09/05/2023, 09/06/2023, 09/07/2023 and 09/08/2023, four of four days of the assessment period. During an interview on 09/29/2023 at 11:00 AM, Staff B, DNS, stated that the refusals were missed. Resident 10 According to Resident 10's the 06/25/2023 significant change MDS, the resident demonstrated no rejection of care. Review of Resident 10's's June 2023 MAR showed the resident refused their bedtime dose of carvedilol (blood pressure medication.) During an interview on 09/29/2023 at 11:05 AM, Staff B, DNS, acknowledged the medication refusal occurred during the assessment period and was not reflected on Resident 10's MDS. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 1 of 13 residents (Residents 17) whose care plans were reviewed. These failures placed the resident at risk for unmet care needs and diminished quality of life. Findings included . Resident 17 Review of Resident 17's activities of daily living care plan, with a target date of 11/20/2023, showed the resident was to be bathed two times a week in the AM and that they transferred independently at times and may require one person assistance with transfers at times. Review of Resident 17's 04/24/2023 and 07/25/2023 quarterly Minimum Data Sets (MDS, an assessment tool) showed the resident required two-person extensive assistance with transfers. Review of Resident 17's point of care charting (computer program where nurse aides document the amount of assistance provided) for July, August, and September 2023, showed no documentation that Resident 17 transferred independently. Additionally, review of Resident 17's August 2023 bathing record showed the resident was bathed eight times during the month, with the bathing time ranging from 3:49 PM to 10:29 PM. No AM bathing was provided as care planned. During an interview on 09/29/2023 at 10:29 AM, Staff B, Director of Nursing, stated that Resident 17's care plan needed to be revised. Reference WAC 388-97-1020(2)(c)(d)

Based on observation, interview and record review, the facility failed to provide assistance with nail care for 1 of 13 residents (Resident 28) reviewed for activities of daily living (ADLs.) The failure to provide assistance with nail care placed the resident at risk for unmet care needs, poor hygiene, and diminished quality of life. Findings included . Resident 28 During an observation and interview on 09/25/2023 at 11:15 AM and 09/27/2023 at 08:44 AM, Resident 28 was noted to have long fingernails and toenails with discolored debris under their nail beds. The resident stated that their toenails were too long, and they hurt when they wear socks or shoes. The resident further stated that their fingernails were long and rough around the edges. During an interview on 09/27/2023 at 08:48 AM, Staff C, Certified Nursing Assistant (CNA), stated the License Nurses (LN) usually do nail care for all the residents. During an interview on 09/27/2023 at 09:37 AM Staff D, License Practical Nurse (LPN), stated they usually do nail care for diabetic residents if there was a physician's order in the electronic health record and all other nail care for non-diabetic residents was done by a CNA. During an interview on 09/27/2023 at 1:45 PM Staff E, Assistant Director of Nursing/ Infection control preventionist ADON/IP, stated that nail care was usually done by the LN, or the CNA. LNs usually do nail care for diabetic residents and CNAs do nail care for all non-diabetic residents. Staff E further stated that nail care should have been completed for Resident 28 but was not done. Reference WAC 388-97-1060 (2)(a)(b)

Based on observation, interview and record review, the facility failed to provide assistance with nail care for 1 of 13 residents (Resident 2) reviewed for activities of daily living (ADLs.) The failure to provide assistance with nail care to a resident who was dependent on staff, placed the resident at risk for unmet care needs, poor hygiene, and diminished quality of life. Findings Included . Resident 2 Review of Resident 2's electronic health record (EHR) showed the resident was admitted to the facility on [DATE] with diagnosis of quadriplegia (a form of paralysis that affects all four limbs, plus the torso). During an observation on 09/25/2023 at 11:30 AM and 09/26/2023 at 08:48 AM, Resident 2 was noted to have long fingernails with discolored debris under their nail beds. Review of Resident 2's EHR on 09/26/2023, showed that a physician's order and care plan was in place for License Nurses to complete nail care weekly as needed. The physician order read: keep fingernails short, smooth, file nails after showers, don't clip with clippers. During an interview on 09/27/2023 at 08:48 AM, Staff C, Certified Nursing Assistant (CNA), stated that License Nurses (LN) usually do nail care for all the residents. During an interview on 09/27/2023 at 09:37 AM Staff D, License Practical Nurse (LPN), stated that they usually do nail care for diabetic residents if there was a physician's order in the EHR. During an interview on 09/27/2023 at 1:45 PM Staff E, Assistant Director of Nursing/ Infection control preventionist ADON/IP, stated that nail care was usually done by the LN or the CNA. LNs usually do nail care for diabetic residents and CNAs do the nail care for all non-diabetic residents. Staff E further stated that nail care should have been completed for Resident 2 but was not done. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to ensure monitoring of side effects of blood pressure medications for two of five residents (Resident 10 and 140) reviewed for unnecessary medication usage. The facility failed to follow blood pressure and pulse parameters as ordered by the physician which placed the resident at risk for adverse side effects, medical complications, and the unnecessary use of medication. Findings included . Review of the facility's policy titled, Policy/ Procedure - Medication Administration dated 03/2022, showed medication will be accurately prepared, administered and documented per physician order. Resident 10 Review of Resident 10's electronic health record (EHR) showed the resident had a 07/05/2022 order for carvedilol twice a day, with orders to hold the medication for SBP less than 110 or a pulse (P) less than 60. Review of Resident 10's August and September 2023 MARs showed on the following occasions the resident was administered carvedilol (a medication used to treat high blood pressure and heart rate) when it should have been held for a SBP less than 110 or a P less than 60: August 2023- 8/1/2023 AM dose P-58; 8/5/2023 AM dose P-52; 8/8/2023 AM dose SBP-105 and P-51; 8/24/2023 AM dose P-50 and PM dose P- 50; 8/25/2023 AM dose P-50 and PM dose P- 50; 8/26/2023 AM dose P- 50; 8/29/2023 AM dose SBP-107 and P- 50; September 2023- 09/06/2023 PM d SBP-92 and P-55; 9/13/2023 PM dose P-54; 9/20/2023 PM dose P-51; and 9/27/2023 PM dose SBP-112 and P-58. During an interview on 09/28/2023 at 11:25 AM, Staff B, DNS, stated that facility nurses should have held Resident 10's carvedilol as ordered, but acknowledged they failed to do so. 34567 Resident 140 Review of the entry Minimum Data Set (MDS, a required assessment tool) dated 09/12/2023, showed Resident 140 admitted to the facility on [DATE] with a diagnosis of high blood pressure. Review of Resident 140's Medication Administration Record (MAR) dated September 2023 showed that Resident 140 had been ordered carvedilol along with parameters to hold if the resident blood pressure was less than 120 systolic (the top number refers to the amount of pressure in the arteries during the contraction of the heart muscle) on 09/22/2023. The MAR showed that the resident's systolic blood pressure (SBP) was documented less than 120, twice (once on evening shift 09/23/2023 [102/72] and day shift 09/24/2023 [106/69]. The MAR showed that the medication was not held as ordered during this time frame and the residents progress notes showed that the licensed nurse (LN) did not notify provider. During an interview on 09/27/2023 at 10:22 AM, Staff E, Assistance Director of Nursing/Infection Preventionist (ADON/IP), stated that Resident 140 had the blood pressures parameters put into place for carvedilol and that that LNs were to ensure that the medication was not to be administered if the blood pressure was less than 120 systolic. Furthermore, Staff E, ADON/IP stated that the medication, should not have been administered during that time. During an interview on 09/27/2023 at 10:32 AM, Staff B, Director of Nursing (DNS), stated that it was the expectation of LNs to not administer blood pressure medication if it was outside the parameters. Reference WAC 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to implement care planned interventions to prevent a fall for 1 of 4 residents (Resident 1) reviewed for falls. This failure resulted in harm when Resident 1 rolled out of bed during care and sustained a leg fracture. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include stroke and right sided weakness. Review of the Minimum Data Set assessment, dated 11/30/2022, showed the resident required extensive assistance of two people with bed mobility. Resident 1's Activity of Daily Living care plan, dated 09/12/2021, showed Resident 1 required two staff persons to reposition and turn Resident 1 in bed. Resident 1's progress note, dated 12/03/2022 at 2:30 AM, showed that Resident 1 had a witnessed fall during care, landed on their right side and was in severe pain. The progress note further showed that the physician ordered x-rays of the right upper and lower body to rule out a fracture post fall. Resident 1's x-ray report, dated 12/03/2022 at 2:41 PM, showed a fracture to the right femur (leg bone). Resident 1's progress note, dated 12/03/2022 at 8:19 PM, showed Resident 1 was transported to the emergency room for treatment of the femur fracture. The facility investigation, dated 12/06/2022, showed that Staff B, Certified Nursing Assistant (CNA), had assisted Resident 1 in bed with incontinent care. The investigation further showed that when Resident 1 turned over in the bed during care, they rolled out of the bed and landed on the floor. The investigation showed the care planned second staff member was not in attendance. On 01/03/2023 at 2:46 PM, Staff B, CNA, stated that on 12/03/2022 she was assisting Resident 1 with incontinent care prior to the resident's fall. Staff B stated that when the Resident 1 rolled to the side away from her, the resident continued to roll off the bed. Staff B stated they had provided care to Resident 1 in bed without a second staff member present many times prior to the fall and thought Resident 1 could be cared for with one staff member. Staff B stated that Resident 1's care plan was not reviewed prior to the fall and was unaware Resident 1's care plan directed two staff to assist with Resident 1's bed mobility. On 01/03/2023 at 4:12 PM, Staff A, Director of Nursing, stated that staff were expected to provide care based on a resident's care plan. Staff A stated that Resident 1's care plan showed the resident required two staff persons to assist with bed mobility prior to the fall on 12/03/2022. Staff A stated that the expectation was for Staff B to have followed Resident 1's care plan with a second staff person in attendance during care. Staff A stated that there was a breakdown in the system and Staff B did not follow the care plan when they provided care to Resident 1 prior to the fall. WAC Reference 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to obtain or clarify physician's orders for pain medications or alternate treatment for [REDACTED].#s 13, 14, 44, 45, 46) reviewed for pain. This prevented staff from providing effective pain management and resulted in harm for three residents (Resident #s 14, 45, 46). Findings included . Review of the facility policy titled, Recognition and Management of Pain, dated (MONTH) (YEAR), showed the Policy was to .provide an environment and programs that assist each resident to attain or maintain the resident's highest practical physical, mental and psychosocial well-being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The purpose of the policy was, to assist each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: -Interview or observe the resident to determine if pain is present -Identify if circumstances when pain can be anticipated -Evaluate pain and work with the resident to develop a plan of care that considers their needs, preferences, and goals -Developing and implementing a plan, using non-pharmacologic and/or pharmacologic interventions to manage and/or prevent pain RESIDENT #45 Refer to F553 for additional information and resident history. Refer to F610 for additional information related to investigations. Record review of the significant change Minimum Data Set (MDS, a required assessment tool) dated [DATE], showed Resident #45 was admitted on [DATE] with Hospice services and [DIAGNOSES REDACTED]. The resident required two person assistance for transfers, one person assistance for bed mobility and activities of daily living (ADL's), and independently utilized a wheelchair for mobility. The [DATE] MDS further showed Resident #45 experienced pain almost constantly, was prescribed routine and as needed (PRN) pain medication, that impacted his sleep. Record review of the Care Area Assessment (CAA, areas triggered on the MDS that identified the resident as being at risk) dated [DATE], showed Resident #45 triggered for pain due to frequency, reports of it affecting his sleep, and the severity level of a 7. Resident #45 experienced chronic pain related to [MEDICAL CONDITION] ([MEDICAL CONDITION], a condition of the blood vessels that cause reduced blood flow, cause nerve damage and other tissue damage), venous ulcers and [MEDICAL CONDITION]. The resident described burning pain in his lower extremities at night. Resident #45 was prescribed and taking [MEDICATION NAME] 10mg (pain medication and used to decrease pain medication dependence) twice daily, [MEDICATION NAME] 4mg (moderate to severe pain medication) every eight hours PRN and [MEDICATION NAME] (moderate to severe pain medication) every three hours PRN for pain level between 6 to 10. The resident used each of the PRNs once to twice daily. Pain was rated constantly at a 7. The resident was up in his wheelchair for long periods of time, did not always elevate his legs or wear compression stockings. Will continue to encourage these interventions. No additional interventions were attempted. Review of the care plan dated [DATE], showed Resident #45 experienced pain, ineffective coping skills and alteration in diversional activities to include socializing with others while smoking off grounds, watering the plants in the garden, being outside, listening to music and used to be a mechanic. In an interview and observation on [DATE] at 2:30 PM, Resident #45 stated he was currently on nothing for pain, My doctor took me off everything. The resident stated he experienced pain mostly in his lower extremities. Resident #45 pulled up his pants leg, showed both legs with discoloration, bruising, and abrasions. The resident stated he had blood on his ankle as he pointed on the medial side of his lower right leg at his foot. My legs are sensitive. I don't even like the aides putting lotion on them. (Staff F, Medical Director) won't listen to me, and just tells me that it is what he is doing. I just want [MEDICATION NAME] (nerve pain and [MEDICAL CONDITION] medication)-that is what works for me. My insurance won't pay for it. I am not prescribed anything for pain currently other than Tylenol. Resident #45 said he self-medicated at times because he needed pain relief. Resident #45 reported his current pain level was a seven out of 10. On [DATE] at 2:30 PM, Resident #45 further stated when he was prescribed narcotic medication, the facility ran out at times. He said Staff C, RCM, tried to help and called the pharmacy, but didn't always get a response. I was in pain in the meantime, and Pain makes it hard to want to go on. Review of the document titled, Grievance Resolution Form, dated [DATE], showed Resident #45 reported he was upset it took four to five days to get the [MEDICATION NAME] from the pharmacy. He stated he didn't feel the nurses were doing their job in contacting the MD/pharmacy. The conclusion showed Resident #45 did in fact miss doses of his routine [MEDICATION NAME] on [DATE] and [DATE]. Review of the Social Service assessment dated [DATE], showed Resident exhibited a mood decline since last review due to changes in pain medication. The resident scored a 20 on the PHQ-9, which indicated moderate to severe depression, up from a score of 12 from (MONTH) (YEAR). The assessment also showed that Resident #45 refused his medications except for the [MEDICATION NAME] (antianxiety medication). Staff H, Social Services Supervisor (SS), was to make a referral to hospice and crisis line on [DATE]. Record review of physician progress notes [REDACTED].#45 was seen by the physician related to the pain in the resident's knees, the resident may not be a surgical candidate due to his heart conditions, and had bone on bone pain with arthritic symptoms. The patient was agreeable to the idea of trying a non-opioid to manage pain. He has been on opioids for about seven months. The physician, Staff F, Medical Director, documented the resident recently came off of hospice and did not have terminal diagnosis. Resident #45 had been placed on a number of opioid medications, explained to him the rationale about staying away from opioids as this appeared to be turning into a chronic pain type picture. The assessment determined bone on bone pain, and will continue a gradual opioid taper, and discussed the use of alternate medications like [MEDICATION NAME] to avoid the use of long term use opioids. Record review of physician's orders dated [DATE], showed Staff F, Medical Director, initiated the [MEDICATION NAME] taper on [DATE], and discontinued the order completely on [DATE], leaving Resident #45 on an antidepressant, antianxiety, aspirin and [MEDICATION NAME] medication for pain management. Record review of physician's progress note dated [DATE], showed Resident #45 continued to request pain medication and wanted an increase in benzodiazepines (antianxiety, tranquilizer medication), as they were being tapered and had episodes of panic and anxiety, and the use of oxygen was not always effective. Staff F, Medical Director documented, We have been tapering down meds that can cause sedation and respiratory arrest. I explained to him that there was a reason why you don't give both benzos and opioids together. The taper was to be continued and no other options or recommendations were provided or reviewed with the resident. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The resident experienced a pain level of seven, four times after [DATE]. Afternoon shift recorded a pain level of five or greater 20 out of 31 days. Night shift recorded a pain level for Resident #45 at a five or greater 18 out of 31 days, with a pain level of a nine on [DATE]. Record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Fifteen of the recorded pain levels were a 7 out of 10 or above, an increase from the previous month. Additionally, afternoon shift recorded pain levels for the resident a 5 and above for 21 out of 30 days, with 12 of those shifts at a level of a seven or above, also an increase from the previous month. Review of a nursing progress note dated [DATE] at 2:56 PM, showed Resident #45 refused all his cardiac medications, inhaler and daily weight because, if he can't have his [MEDICATION NAME] then he isn't going to take any of this meds. His plan is to get sick and go back on Hospice so he can get pain medication. MD notified. Review of the document titled, IDT-Care Plan Review, dated [DATE], showed Resident #45 exhibited a mood decline related to changes in his pain medication. A referral to hospice was initiated for intake. Last mental health consult occurred on [DATE]. Mental health recommendations were not included and no further plans were documented. Review of the document titled, Psychiatric Consultation Service, dated [DATE], showed Resident #45 refused medications, as he did not care if he died . The resident had resumed his medications after consulting with his cardiologist. Resident #45 complained of pain. The resident reported the medication [MEDICATION NAME] was helpful, but the insurance refused to pay. The evaluation showed Resident #45 had few inherent coping skills, suspected the resident didn't have much treatment for [REDACTED]. In an interview on [DATE] at 4:30 PM, Resident #45 stated he was experiencing pain at an eight out of 10 level. When asked who he could talk to or problem solve with, the resident said, No one. Everyone is gone or dead. The resident said the mental health nurse practitioner (MH-ARNP) did not help him at all. All recommendations and orders had to go through my physician anyway. Resident #45 stated staff didn't believe him and his pain because he was up in my chair or out in the community. I have to get out. I am in pain. I don't know what to do. When asked if he was aware he had the right to choose his own physician, the resident stated, I didn't know that. In an interview on [DATE] at 12:38 AM, Staff O, Licensed Practical Nurse (LPN), stated Resident #45 used to be on hospice. Since he came off, he was tapered off his [MEDICATION NAME] and has been more active. Tylenol was sometimes effective for his pain, but would take it for a headache. Today, he was upset and angry at the doctor and refused all his medications. Staff O had not yet notified the physician of the refused medications. Staff O, LN stated Resident #45 had pain, but probably hid it well. When asked if the resident self-medicated, she wasn't aware that he did. In interview on [DATE] at 12:53 PM, Staff H, Social Service Supervisor (SS), said she was currently working on discharge planning for Resident #45 to another facility. The resident had a history of [REDACTED]. He wanted to get sick and go back on hospice. He was on hospice when he was first admitted . When asked if he was in pain, Staff H, SS stated he said he was in pain but goes everywhere. Pain was the nursing department's expertise and was not aware if he was referred to a pain clinic. What I have seen with him is more anger since the taper. The support plan for him was to meet with him to talk, and the MH-ARNP available when needed, and a discharge plan so he can be where he wants to be. Staff C believed he was still in contact with his children for support as well as other male residents. Staff H, SS, stated she was not aware that Resident #45 recently refused his medications. If he has refused meds, that is new. In an interview on [DATE] at 12:38 AM, Staff C, Resident Care Manager (RCM), said Resident #45 had chronic pain. The resident was on Hospice on admission, and hospice was managing his pain. He came off of Hospice services recently, and his pain medications were tapered. His underlying health was not good. Resident #45 had moderate to severe [MEDICAL CONDITION]. He was non-compliant with lotion being applied to his legs due to pain. The physician recently started the resident on [MEDICATION NAME] for [MEDICAL CONDITION] ([MEDICAL CONDITION] and nerve pain medication). The insurance will not pay for [MEDICATION NAME], the medication Resident #45 stated that worked for his pain, until a failed trial has been documented. Staff C, RCM stated they haven't done the best job at documenting the [MEDICATION NAME], but continue to work on it. Staff C was aware Resident #45 was refusing medications because he was upset with the doctor and felt he was not addressing his pain. Staff C stated Resident #45 could sustain some adverse consequences for not taking his cardiac medications. When asked if a conversation had been held to communicate and involve the resident in a pain management program, Staff C said, I can try to advocate for him, but the doctor has the final say. In an interview on [DATE] at 11:16 AM, when asked about the fax dated [DATE], that Resident #45 did not receive his [MEDICATION NAME] for two nights, and Staff F, MD signed and returned the fax on [DATE], three days later, Staff B RN/DNS said it was not uncommon to get a response from the physician in that time frame. Resident #45 was supposed to see the Mental Health Nurse Practitioner (MH ARNP) that morning for his refusing of all medications, but the professional called due to a family emergency. The facility recently lost the contract for a mental health provider and was not aware of a backup for the MH ARNP. Staff B, RN/DNS offered to send him to the emergency room (ER), but he didn't want to go. Staff B, RN/DNS was not certain if he had been offered to go to a pain clinic. In further interview on [DATE] at 11:16 AM, when asked about documentation for pharmacy guidelines on refusing to pay for [MEDICATION NAME], documentation of a failed trial of [MEDICATION NAME] in the past, or a conversation with Staff F, MD and the resident to include a pain management plan, Staff B, RN/DNS was unable to provide documentation from the pharmacy, a previous failed trial of [MEDICATION NAME], and stated Staff F, MD, referred to the state regulations and put it on the facility to reduce the use of drugs. In an interview on [DATE] at 3:04 PM, Resident #45 was lying in bed in his room upon arrival. He stated he was fed up with everything. No one is listening and no one cares. I'm fed up with everything and have no faith in the system. I came here to die. The hospital gave me six months. I might as well just do what I came here to do. The resident complained of 8 out of 10 pain, and said staff suggested for him to go to the ER for his pain, but didn't want to go as they would give him 10 pills and send me back. What good would that do? I'm done. When asked why he chose to refuse all his medications, the resident said, That's all I can do, right? The resident continued to make negative comments, I don't care anymore. I'm just done. When asked what he did to get through the day, he did not respond. When asked who he talked to about things, Resident #45 stated everyone he used to talk to was gone or dead. The resident said he believed the facility was not doing anything to help him and his pain. When asked what he wanted to happen, I just want some pain control, and said that the medication [MEDICATION NAME] had helped him in the past and had been on it for two to three years. They said they would only get it for 14 days. That won't help. The resident stated he refused medications because, I need pain management. I don't care if I get sick- I can go back on hospice and get pain management again. The resident also stated the facility had not offered or referred him to a pain clinic. Review of the document titled, Pain Management Review, dated [DATE], showed Resident #45 denied pain at the time he was assessed, and denied pain or hurting in the last five days. The remainder of the assessment was blank, to include when he experienced pain where it was, what it felt like, what time of day it occurred, what made the pain worse, what non-pharmacological approaches made the pain better, what medications relieved the pain in the past, and how well has the pain been managed. In an interview on [DATE] at 8:47 AM, Resident #45 complained of shortness of breath and eight out of 10 pain. He admitted to drinking alcohol recently, I just needed a break from the pain. He stated he used to drink, but stopped over two decades ago. I stopped because I drove and didn't want to kill anyone or be in jail for the rest of my life. I don't want to go back to that- just want pain control. Additionally, Resident #45 said Social Services provided him a list of physicians in the area, but told him to look himself. The resident was aware an in agreement with moving to another facility, and found out he was not accepted to the first referral. The resident stated he accepted [MEDICATION NAME] (antianxiety medication), otherwise he would go crazy. When asked more specific what that looked like, he mentioned being angry, yelling, and denied physical aggression. In continued interview with Resident #45, when asked about a recent pain assessment and that it showed the resident had no pain at that time and to describe what regime he used to achieve it, the resident denied and stated his pain never had been a zero. He recalled someone asking him recently about his pain and stated, What is the point? The doctor doesn't do anything about it anyway. RESIDENT #14 Record review of the annual MDS dated [DATE], showed Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented, good memory recall, and required assistance of two staff for transfers one person assistance for dressing and bathing, and was independent with mobility and the use of a motorized wheelchair. In further review of the [DATE] MDS, showed Resident #14 experienced pain almost constantly, made it hard to sleep at night, and limit day to day activities. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the care plan dated [DATE], showed Resident #14 experienced an alteration in comfort related to chronic pain due to MS, restless leg syndrome, right BKA, constipation, depression, left lower extremity [MEDICAL CONDITIONS], right hand contracture and muscle spasms. During an interview on [DATE] at 9:30 AM, Resident #14 stated that her pain was not managed well before when under Staff F, Medical Director (MD)'s care. The resident said since she changed doctors, her pain has been more manageable. In addition, Resident #14 stated that she was not in agreement with Staff F, MD's continued scheduled [MEDICATION NAME] dose decrease after her surgical procedures last fall, didn't do well and had more pain than I should have, with the surgical procedure. In an observation and interview on [DATE] at 8:39 AM, Resident #14 sat in her wheelchair in her room with her head bent over. When asked how she was, the resident she was upset that she had missed her 12:00 AM and 6:00 AM dose of MS Contin. The resident stated that it happened on more than one occasion. When asked, Resident #14's pain level was eight out of 10. She stated she was angry, started to feel the effects of withdrawal from the [MEDICATION NAME], and increased pain. In an interview on [DATE] at 8:41 AM, Staff E, Registered Nurse (RN), stated she was working on getting Resident #14 her 6:00 AM dose of [MEDICATION NAME] was not aware that the resident missed her midnight dose, as the previous shift did not communicate. Staff E, RN, stated that Staff C, RCM, contacted the doctor of the missed [MEDICATION NAME], per policy, as the medication was late and needed the pharmacy to call the doctor to write a new prescription. In an interview on [DATE] at 8:51 AM, Staff D, Staff Development/Infection Control (SD/IC) stated the process for re-ordering medication was if the medication inventory was identified as getting low, it was the nurses' responsibility to re-order and call the doctor to get a new prescription for the medication. Record review of the pain assessment dated [DATE] at 10:46 AM, Resident #14 was currently on [MEDICATION NAME] 30mg every six hours for pain management related to MS. (The resident) was due to have a 6:00 AM dose but unable to get it from the E-kit due to MD has not signed the narcotic prescription . Offered [MEDICATION NAME] and [MEDICATION NAME] but declined. (Resident #14) received her [MEDICATION NAME] at approximately 9:00 AM. When staff followed up, the resident stated her pain was not new and had it for years. The resident was on the waiting list for the pain clinic. The pain assessment was incomplete, to include current level of pain, pattern of pain in the last five days, where the pain was located, what the pain felt like, and what made the pain worse. Record review of the (MONTH) (YEAR) through (MONTH) (YEAR) Physician's orders showed decreases in Resident #14's [MEDICATION NAME] doses on the following dates: [DATE], [DATE], [DATE], and [DATE]. Review of the nursing progress notes dated [DATE] at 12:50 AM, showed Resident #14 was very upset concerning the decrease in frequency of [MEDICATION NAME]. Resident rates her pain all over as a seven on a ,[DATE] pain scale. Review of the nursing progress notes dated [DATE] at 10:56 PM, showed Resident #14 not happy with decrease of [MEDICATION NAME], complained of increased pain since decrease. Pain mostly in hands, arms, and right lower extremity. Will continue to monitor. Review of nursing progress notes dated [DATE], showed Resident #14 had a suprapubic catheter surgically placed (a tube surgically inserted into the abdomen that drains urine out of your bladder). Review of nursing progress notes dated [DATE] at 12:16 AM, showed Resident #14 complained of increased pain related to the placement of the suprapubic catheter. Review of nursing progress notes dated [DATE] at 3:05 PM, showed Resident #14 rated her pain an eight out of 10, and isn't happy with the continued decrease in [MEDICATION NAME]. Review of nursing progress notes dated [DATE] at 4:18 PM, showed Resident #14 reports that her pain is worse and doesn't understand why the taper. This writer will send a communication with the PCP to notify issues with pain control. In an interview on [DATE] at 11:14 AM, Staff A, Administrator and Staff B, DNS stated Staff E, RN was not informed of the missed [MEDICATION NAME] medication at midnight, she was only aware of the 6:00 AM dose. There was no non-pharmacological interventions documented in the progress notes from night shift. There was an issue getting an authorization code. We have been working with pharmacy services to get a better system. We would offer the resident to go to the hospital if we could not get medication in a timely manner. Don't think this was offered to Resident #14. Staff B, DNS and Staff A, Administrator continued to state that Resident #14 did not like the way Staff F, Medical Director handled her pain management program, so she got a new physician. RESIDENT #13 Refer to F610 for additional information and resident history related to falls/investigation Review of the annual MDS dated [DATE], showed Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had short and long term memory loss, was not oriented to date or time, had difficulty expressing needs and wants and understanding others, vision impairment. The resident required one person assistance from staff for transfers, dressing, bathing, and bed mobility. The [DATE] MDS showed Resident #13 experienced moderate to severe signs and symptoms of depression greater than 10 days in the last 14 days as evidenced by: little interest or pleasure in doing things, feeling down or depressed, feeling tired, having little energy, sleep disturbance, feeling bad about herself, trouble concentrating, moving and speaking slowly more than usual. The resident rejected care one to three days in the assessment period, and a deterioration in behavioral symptoms since last review period. The MDS further showed Resident #13 experienced pain in an unknown frequency, if it made it difficult to sleep at night, and if it limited daily activities as the resident was unable to answer. Staff interviewed stated Resident #13 showed the following indicators two to four days in a five day period during the assessment period: nonverbal sounds (moaning/whining/groaning), complaining of pain, and facial expressions exhibited (furrowed brow/grimacing/clenched jaw). Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The [MEDICATION NAME] was not given in (MONTH) (YEAR) before it was discontinued on [DATE]. Record review of the history and physical dated [DATE] showed Resident #13 had chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] joint disease (DJD), depression and anxiety. She reportedly used marijuana prior to hospitalization , but did not state why. In an observation on [DATE] at 6:17 PM, Resident #13 entered the dining room in a wheelchair propelled by an unidentified male staff member. The resident held a baby doll by the leg as it dangled off her lap, was moaning and saying, Oh, come on . The staff member parked Resident #13 at a table for dinner walked away, telling the resident she was going to be fine. The resident had a worried expression on face and continued to moan. In continued observation on [DATE] at 6:21 PM, Resident #13 repeatedly told staff she wanted to go. An unidentified female staff member sat down at the table next her and provided repeated several cues to keep eating, or take another bite, while the resident continued to say she took the bite, and please lets go, and pushed her wheelchair backwards away from the table. Resident #13 appeared to get increasingly agitated the longer she stayed in the dining room and said, damn it . In several observations throughout the survey period, the resident was closely placed next to staff, holding on to staff, telling staff to not leave, and making moaning noises on the following dates and times: [DATE] at 12:51 PM, [DATE] at 4:30 PM, [DATE] at 8:50 AM, [DATE] at 2:45 PM, [DATE] at 11: 17 AM and 2:54 PM, and [DATE] at 10:33 AM. Review of mental health services evaluation dated [DATE], showed Staff report that (Resident #13) seeks constant attention and reassurance. The mental health provider assessed the resident has having impaired thought process, judgment and anxious mood. Resident #13 complained of mouth pain and fanny pain. It was recommended to increase the [MEDICATION NAME], or if you think she is in pain, consider a switch to duloxetine. In an interview on [DATE] at 3:26 PM, Staff U, NAC, stated the aides would notify the nurses when there was a change in behavior or condition, not necessarily when the resident exhibits a baseline behavior or mood. When asked about Resident #13, Staff U, NAC stated the resident liked to be in bed and never wanted to be alone. She is hard to figure out- sometimes she will go up and down the hall, sometimes wants you to be with her. She always wants to be in bed. In an interview on [DATE] at 2:15 PM, when asked about Resident #13's history, Staff H, SS stated the resident had a long history of being on pain medications. The resident's son was not aware where she had her pain, how severe it was or why. He also thought the resident was addicted to pain medications. Resident #13 had a lot of anxiety, which increase when the [MEDICATION NAME] was discontinued. Several other medication changes had occurred, including [MEDICATION NAME] and reinstating the [MEDICATION NAME]. In further interview, Staff H, SS, stated No additional history was obtained on Resident #13. The resident did enjoy the baby doll that the facility gave to her to carry around. She attended activities, but was unable to stay focused or keep her attention, and left frequently. The resident's son visited, which one would think that would improve her mood, but it did not. When asked about the medication [MEDICATION NAME], Staff H, SS stated she was aware it was also used for pain, but did not consider the resident's change in mood and anxiety when it was discontinued and improved when reinstated. When asked if or how pain was ruled out as a possible contributing factor for mood related symptoms, Staff H stated it was, would look for documentation and referred to Staff C, RCM for further information. In an interview on [DATE] at 4:30 PM, Staff C, RCM stated she believed the facility ruled out pain as a contributing factor with Resident #13. The resident would get a crease in between her eyes when she was in pain. When asked how pain was ruled out if there was documentation to provide evidence, Staff C, RCM presented three pain assessments dated [DATE], [DATE], and [DATE]. Review of pain assessments dated [DATE], [DATE], and [DATE], showed during each assessment, Resident #13 complained of pain at that time and within the last five days, which ranged from daily or several times a day, to less than daily. The [DATE] assessment left the question blank. The pain level in each assessment was not rated, but described the pain as joint pain in the [DATE] assessment; joint, hip and leg pain in the [DATE] and [DATE] assessments; and other pain in the [DATE] assessment, which was not described or clarified. Staff observations of possible indicators of pain the resident exhibited included negative verbalizations (groaning, whimpering, crying), facial expressions (grimacing, frowning), and difficulty eating or loss of appetite. Each assessment was incomplete, to include what the pain felt like, how it affected the resident's daily life, what made the pain better, what made the pain worse, and what medications relieved pain in the past. All three assessments documented that in the last three months, Resident #13's pain has been well managed. In an interview on [DATE] at 4:40 PM, when asked how it was determined Resident #13's pain was well controlled but the resident verbalized pain each time she was asked, Staff C, RCM said she wasn't sure. RESIDENT #46 Review of Resident #46's annual MDS dated [DATE], showed that the resident readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed that the resident was alert and oriented and able to make needs known. The MDS further showed that Resident #46 took routine scheduled pain medication and had a PRN (as needed) pain medication ordered. In addition, the MDS showed that the resident's pain rating at the time of assessment was a 7 out of a ,[DATE] pain rating scale. Observation on [DATE] at 3:10 PM, showed Residen(TRUNCATED)

Based on observation, interview and record review the facility failed to provide correct medication in a timely manner to treat an infection for one of five residents (Resident #44) reviewed for quality of care. This failure caused unnecessary pain, anxiety, and harm, to the resident due to a delay in treatment. Findings included . Review of the Admission Record showed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognitive assessment indicated she was mentally intact. The residents' primary [DIAGNOSES REDACTED]. In Interview with Resident #44 on 04/24/18 at 10:11 AM, she lay in her bed, shaking, teary eyed and stated she was hurting and though she had a urinary tract infection, this was worse. Resident #44 said she needed pain medication. When asked her pain level, she said a 9 (scale of 0-10). When asked if she had put on her call light that was in her hand, she said yes, but when checked, it was not on. She pushed the button again and a staff person came in almost immediately. The resident told the nurse about the pain and the need for pain medication. The nurse told the resident no results had been received on the urinalysis collected the previous evening. Shortly thereafter, an aide entered the room and both attended to the resident. The nurse asked the resident if she wanted to go to the emergency room (ER) to be seen for her pain. The resident stated she was uncertain if that would help. The staff person left the room to talk to the nurse about pain medication for the resident. When entering the hallway at 10:13 AM, the staff person was observed talking with the medication nurse, Staff N, Registered Nurse (RN). At 10:14 AM, Staff N, RN went into the room followed by the other nurse. On 04/24/18 at 10:56 AM, Resident #44 was not in her bed. Staff N, RN, said she gave the resident a [MEDICATION NAME] and she agreed to go to the ER for evaluation. Staff N said the UA done last night had no results yet and should be received by facility. Staff N, said the resident was fearful of going out. BLS (ambulance) to transport. Staff N, RN said [MEDICATION NAME] takes the edge off, it does not take the pain totally away. Review of the emergency department (ED) provider Notes dated 04/24/18 at 1:59 PM, showed Resident #44 was seen for abdominal pain, flank pain. The patient had a history of [REDACTED].). The urinalysis (UA) with culture-abnormal. The antibiotic [MEDICATION NAME] was ordered, Take 1 capsule (500 mg total) by mouth 4 (four) times a day for 10 days. Starting 4/24/2018, until Friday 05/04/18. Review of Residents #44's clinical record on 04/30/18 at 12:30 PM showed the same infection as the previous hospitalization on the culture and sensitivity (C &S) results for the UA drawn on 04/23/18. The results were sent to the facility on [DATE] at 11:15 am. The infection was not sensitive to the [MEDICATION NAME] antibiotic prescribed days earlier in the ED. Review of nursing progress notes dated 04/27/18 at 12:54 PM showed, Microbiology result received reported to Dr. (Staff F), and at 1:10 PM documentation showed, Talked to (Staff F), aware of microbiology results and that patient is on Keflex 500 mg for 10 days. Lab result and ER results/ ER notes to be refaxed to Dr. (Staff F). Review of the fax from Staff F, MD/PCP showed orders for [MEDICATION NAME] was received 04/30/18 with the first dose to be given at 8:00 PM that evening, over three days after the C&S results were received by the facility and the provider notified. On 4/27/18 at 5:13 PM the progress note recorded a Change of Condition for Resident #44. Symptoms or signs noted of condition change: Abdominal pain other change in condition behavioral symptoms (e.g. agitation, [MEDICAL CONDITION]) c/o chronic back pain, 8/10, next pain med due [MEDICAL CONDITION]:00 PM, refused all other interventions. (Staff F) notified at 6:15 PM and family member or resident representative notified at 6:16 PM. was sent to the ER for excruciating pain not relieved by her pain medications. This pain was recorded in the Hospital Summary notes for the previous hospitalization for a UTI. The dose of [MEDICATION NAME]-[MEDICATION NAME] was changed from every eight (8) hours to every four (4) hours as needed. Review of the Microbiology Results for the C&S dated 04/27/18 at 11:15 AM showed the results were faxed to Staff F, MD/PCP on 04/27/18 with a call back at 12:53 PM. A fax of the same Microbiology Results was reviewed with a date and time stamp of 05/01/18 at 5:32 PM. The information handwritten and signed by Staff F said: On Keflex not S (sensitive). Allergic to sulfa + (plus) latex. New order-[MEDICATION NAME] 250 mg TID (three times a day) x (for) 5d (five days). Called to UM 04/30/18. In interview on 05/09/18 at 2:41 PM, Staff F stated he does not work on Saturday and visits the facility twice a week, sometimes three. He said his time was consumed addressing the state opioid requirement. Reference WAC 388-97-1060(1)