Every finding on record at Bethany at Silver Lake

Based on observation, interview and record review, the facility failed to ensure skilled rehab services were delivered in accordance with resident evaluations and treatment plans for 3 of 4 residents (8,91,119) reviewed for rehab and restorative services. This failure placed residents at risk for delay in recovery and/or discharge and decreased quality of life. Findings included .In an interview on 03/19/2026 at 10:52 AM, Staff J, Director of Rehabilitation Services, stated the new therapy company started on 03/01/2026. Staff J stated they were provided transitional evaluations from the outgoing therapy company. Staff J stated the transitional evaluations provided a baseline for them to work from and then updated goals as they began treating residents. Staff J stated residents were all set up to be seen at the maximum frequency and at least 5 times per week. <RESIDENT 119> Resident 119 admitted [DATE] with diagnoses which included gait impairment and a fractured right arm which did not require surgery. The resident was transferred to the facility for skilled therapy to return to their prior level of function. In an interview and observation on 03/16/2026 at 12:19 PM, Resident 119 was in bed with a sling on the right arm. Resident 119 stated they were here because of their arm. Resident 119 stated they did not think they were getting as much therapy as they were supposed to be getting, stating they didn't know exactly, but just felt like they weren't getting very much. Review of Resident 119's transitional therapy evaluation dated 02/26/2026 showed therapy frequency: Physical Therapy (PT) 3-5 times per week. Occupational Therapy (OT) 3-5 times per week. Review of the therapy service logs for the month of March 1-18, 2026 showed:March 1-18, 2026 the resident received skilled PT a total of 5 visits and OT a total of 7 visits. The week of 3/11-3/17, the resident received OT only twice. The week of 3/11-3/17, the resident received PT only twice. <RESIDENT 8> Resident 8 admitted [DATE] with diagnoses which included a left upper leg fracture from a fall. In an interview on 03/16/2026 at 8:24 AM, Resident 8 stated they thought some of the therapists were inexperienced, and stated they saw a lot of the OT people, but not much of the PT and stated they thought they needed to do more strength training. In an observation on 03/18/2026 at 9:06 AM, Resident 8 was observed in the therapy gym with OT staff using a resistance band while seated in the wheelchair. Review of a therapy evaluation dated 02/17/2026 showed recommendations for: Physical Therapy 3-5 times per week. Occupational Therapy 3-5 times per week Review of the therapy service logs for the month of March 1-18,2026 showedNo PT the first 5 days of the month. A total of 4 PT visits. The week of 03/04-03/10, the resident received PT only twice The week of 03/11-03/17, the resident received PT only twice with 03/13/2026 marked as OTH which was listed as a missed therapy code, not further defined. <RESIDENT 91>Resident 91 re-admitted on [DATE] with diagnoses which included toe amputations due to infection. In an interview on 03/16/2026 at 9:32 AM, Resident 91 stated it had been at least 4 days since they had therapy. Resident 91 stated they knew it was a new therapy company, but wanted more therapy and didn't understand why there were big gaps in receiving treatments. Review of a transitional therapy evaluation dated 02/05/2026 showed recommendations for: Physical Therapy 3-5 times per week. Occupational Therapy 3-5 times per week Review of the therapy service logs for the month of March 1-18, 2026 showed:A total of 5 PT visits. No PT visits from 03/11- 03/18/2026 (print date/time of report was 03/18/2026 at 3:12PM.) In a follow-up interview with Staff J on 03/19/2026 2:16 PM, Staff J confirmed the therapy week was defined as Sunday-Saturday and after review of Resident 119, 8 and 91 therapy logs, Staff J stated there had been a physical therapist assistant out and confirmed there had been missed PT visits for residents related to lack of PT staff. Staff J stated they had been utilizing OT to attempt to fill in gaps in the PT staffing. Staff J stated they were attempting to utilize on call or per diem staff. In an interview on 03/20/2026 at 09:20 AM, Staff C, Director of Clinical Operations, and Staff B, Director of Nursing Services, stated the new therapy company had taken over on 03/01/2026 and they had not been aware of any therapy staffing issues or aware that residents had concerns about not receiving their ordered therapy. Refer to WAC 388-97-1280 (1)(a)(b)(4)

Based on interview and record review the facility failed to ensure resident grievances were filed and addressed for 1 of 5 residents (Resident 29) reviewed for grievances. This failure to address and resolve resident grievances placed residents at risk for diminished dignity, unresolved missing property and diminished quality of life.Findings included .Review of the facility's policy titled Grievance Policy and Procedure for Residents, revision date 10/2022, documented any employee that is informed of a grievance by a resident will immediately initiate the procedures for resolution of a grievance. Upon learning of grievance, prompt action will be taken to resolve and provide timely response of concern.Resident 29 was admitted on [DATE]. According to the quarterly Minimum Data Set (an assessment tool) assessment dated [DATE], the resident was cognitively intact.In an interview on 03/16/2026 at 10:02 AM, Resident 29 stated they had a Samsung tablet that's been missing for two to three months. They added that the staff were aware of this but had not heard of any follow-up regarding the missing tablet. In a review of the grievances since April of 2025, Resident 29's missing tablet was not found listed.In an interview on 03/17/2026 at 2:42 PM, Resident 29 stated they reported the missing tablet to Staff K in Social Services. In an interview on 03/17/2026 at 2:57 PM, Staff K, Social Services Assistant, stated they were aware of Resident 29's missing tablet. Staff K was unable to remember when the resident reported the missing tablet. Staff K stated that they had been trying to reach resident's family members to verify if they took the tablet but had not received any call back from relatives at this time. Staff K stated when a resident reports a personal item missing, they fill out a grievance form. Requested a copy of the grievance form and investigation regarding the missing tablet. In an interview on 03/19/2026 at 9:54 AM, Staff K, stated they could not find the grievance form related to the missing tablet. They will fill out a grievance form today and investigate the missing tablet.Refer to WAC 388-97-0460(1)(2).

Based on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set, (MDS, an assessment tool that was used to develop the resident centered care plan) for 1 of 2 residents (Resident 2) reviewed for communication and 2 of 3 residents (Resident 22 and 86) reviewed for insulin (a hormone that body secretes to regulate the amount of sugar in the blood) use. Failure to accurately complete the MDS placed residents at risk for inappropriate medical care and decreased quality of life.Findings included. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE]. According to the 12/26/2025 MDS, the resident's primary language was not English. On 03/16/2025 at 9:53 AM, Staff U, Licensed Practical Nurse (LPN), reported Resident 2 had dementia (disease affecting cognitive function and memory). Staff U reported the staff communicated with Resident 2 by family translating for resident or used staff that spoke the same language. On 03/16/2026 at 12:57 PM, during an interview with Resident 2 and the use of an interpreter, resident was noted to have difficulty communicating. The interpreter stated that Resident 2 was having difficulty understanding the questions even if the interpreter repeated the question. The answers Resident 2 provided were not always related to the question asked. Resident 2 could not elaborate on their concerns regarding food or missing clothing. During an observation and interview on 03/18/2026 at 10:47 AM, Staff V, Nursing Assistant Certified, reported they used gestures and simple English phrases to communicate with Resident 2. During an observation of care, Staff V used gestures to cue Resident 2 to turn in bed and held up choices of clothing for Resident 2 to point at what they wanted to wear. Review of Resident 2's Care plan showed a Focus statement that documented resident had a communication problem related to a language barrier and their primary language was not English, dated 11/07/2024. There was another Focus statement that documented resident had moderately impaired cognition, dated 04/21/2025. Review of the MDS, dated [DATE], showed Resident 2 was understood and understands in Section B and they were rarely or never understood in Section C. On 03/18/2026 at 3:13 PM, Staff D, Social Service Assistant, stated they had coded Rarely Understood under section C as Resident 2's family had reported the resident was not making sense in their language. Staff D reported Resident 2 can understand gestures and can make simple needs known. On 03/19/2026 at 8:30 AM, Staff G, MDS coordinator/LPN, stated Resident 2 can make basic needs known by gestures or using family to translate. Staff G did report Resident 2 had some confusion. Staff G reported that the coding between Section 2 and Section 3 was conflicting. On 03/19/2026 at 8:45 AM, Staff B, Director of Nursing Services (DNS), reported Resident 2's ability to communicate was hit and miss depending on their mood. Staff B reviewed sections B and C of the MDS and reported there appeared to be a discrepancy for Resident 2's communication and cognition. <RESIDENT 22> Review of Resident 22's MDS, dated [DATE], documented the resident had received one insulin injection in the prior seven days. Review of Resident 22's February 2026 Medication Administration Records (MAR) showed no documentation of the resident receiving an insulin injection. <RESIDENT 86> Review of Resident 86's MDS, dated [DATE], documented the resident had received one insulin injection in the prior seven days. Review of Resident 86s February 2026 Medication Administration Records (MAR) showed no documentation of the resident receiving an insulin injection During an interview on 03/19/2026 at 8:37 AM, Staff G reported they had coded the MDS for insulin injections as resident had received an injection of tirzepatide (GLP-1 medication, a medication that enhances the body's ability to secrete insulin). Staff G reported they were aware the medication was used for diabetes (disease where body cannot adequately control the sugar in the blood), but was not aware it was not an insulin product. During an interview on 03/19/2026 at 8:45 AM, Staff B stated they expected the MDS to be coded for insulin if the resident received insulin injections and not for receiving a GLP medication. Refer to WAC 388-97-1000 (1)(d), (4)(a)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 11) reviewed for activities had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the individual resident's physical and mental needs. Based on the reasonable person concept, not having adequate recreation and/or sensory stimulation placed the resident at risk for social isolation, lack of stimulation and diminished quality of life.Findings included .Resident 11 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (an assessment tool) assessment dated [DATE], the resident had severely impaired cognition.In a telephone interview on 03/16/2026 at 1:29 PM, Resident 11's Collateral Contact 1 stated that the resident was being left on their own for many hours without any stimulation or activities.During observations on 03/18/2026 at 8:12 AM, 10:10 AM and 2:00 PM, Resident 11 was in bed with no lights on and TV was off. During observations on 03/19/2026 at 8:21 AM and 9:07 AM, Resident 11 was in bed, TV was off and roommate's light was on.In an interview on 03/19/2026 at 8:32 AM, Staff N, Certified Nursing Assistant (CNA) stated that Resident 11 does not get out of bed. Staff N did not know what activities the resident did or attended but they sometimes turned the TV on for them.In an interview on 03/19/2026 at 9:40 AM, Staff L, Activity Director, stated they review residents' activities quarterly and update their preferences if there were any changes. For residents that don't get out of bed they provide room visits, talk to them, and offer daily reading if they request that. Staff L stated Resident 11 used to attend activities but has not attended any lately and has been in bed most of the time. They visit Resident 11 in their room, but they were asleep most of the time, so they don't provide activities for them. Staff L was made aware of multiple observations of the resident in bed with no lights on, no TV on, and no other stimulation. The resident was able to respond when talking to them. Staff L stated they can go and check on the resident and can play light music for them to listen to.In an interview on 03/20/2026 at 10:15 AM, Staff L, Activity Director stated that they usually spend 15 minutes on average with each resident they visit. Staff L did not think that 15 minutes a day was enough time to provide activity and stimulation for a resident in a 24-hour period. Staff L stated they will work on offering more activities and stimulations for Resident 11.Refer to WAC 388-97-0940(1)(2

Based on observation, interview, and record review, the facility failed to ensure that 1 of 2 residents (Resident 24) reviewed for limited Range of Motion (ROM) received necessary care and services. The facility failed to ensure residents received appropriate services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff). This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life.Findings included. Review of the facility policy titled, Restorative Nursing Documentation, reviewed 01/12/2026 stated the facility maintains documentation of treatments and responses to those treatments.if an unusual event occurs during a treatment (i.e. pain, swelling, skin breakdown) document in the narrative note and report to the charge nurse.evaluation will be documented quarterly and as needed if a change to the program or new service was started. care plan will be updated on routine intervals and as indicated. Resident 24 readmitted to the facility on [DATE] with diagnosis that included history of stroke, generalized osteoarthritis (joint condition, can cause pain, and stiffness) and rheumatoid arthritis (autoimmune disease that affects joints causing pain and swelling). The Annual Minimum Data Set Assessment (MDS - assessment tool) dated 06/09/2025 documented the resident had severe impaired cognition. Review of Resident 24's care plan focus dated 07/22/2023, documented the resident had limited physical mobility related to chronic pain, and advanced dementia with cognitive and physical decline. The goal of care was to tolerate restorative passive exercises without pain or discomfort, maintain current level of function, and remain free of complications such as contractures. Interventions included passive range of motion (PROM) to upper and lower extremities five to six days a week, and therapy referrals as needed. Review of Resident 24's therapy restorative nursing program (RNP) referral form dated 10/04/2023 documented the resident was to receive PROM to upper and lower extremities to maintain range of motion, and strength, six times a week as tolerated. Review of Resident 24's provider notes 03/18/2025 - 03/19/2026, documented on 12/16/2025 and 01/30/2026 the resident had severe extremity contractures. No documentation of contractures was found prior to 12/16/2025. Review of Resident 24's MDS progress notes dated 05/28/2025, 08/26/2025, 11/20/2025, and 02/12/2026 showed no changes to the current RNP were required, as Resident 24 remained a high risk for contractures. In observations on 03/16/2026 at 8:01 AM, 10:25 AM, 1:01 PM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In observations on 03/17/2026 at 9:05 AM, and 11:58 AM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In an observation on 03/18/2026 at 8:20 AM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In a review of Resident 24's care plan and physician orders on 03/18/2026, no documentation was found related to Resident 24's contracted hands, or that they required washcloths to both hands. In an interview on 03/18/2026 at 1:30 PM, Staff N, Nursing Assistant Certified (NAC) stated Resident 24 was dependent on staff for all activities of daily living. Staff N stated they thought the resident had to have washcloths to prevent their nails from digging into the palm of their hands due to their clenched fingers. Staff N stated they thought the restorative aids (RA) were responsible for maintaining the washcloths, but they would assist if needed. In an interview on 03/18/2026 at 3:07 PM, Staff O, NAC/RA stated they perform PROM on Resident 24 to upper and lower extremities. Staff O stated they remembered the washcloths were started awhile ago. Staff O stated the resident was able to partially open their hands and would try to scratch their nose, but we (facility) noticed they were having more swelling and pain to their hands, so the washcloths were started to assist the resident. Staff O was asked who was responsible for implementing the washcloths daily and stated it was mostly the floor staff, but they would assist as needed. In an interview on 03/18/2026 at 3:50 PM, Staff C, Director of Clinical Services (DCS) stated they were unable to locate any occupational therapy evaluations or notes for Resident 24, and the resident had not been seen by skilled therapy services since 2023. In an observation on 03/19/2026 at 8:56 AM and 12:46 PM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In an interview on 03/19/2026 at 9:10 AM, Staff P, NAC/RA stated they could not recall how long they have been placing washcloths to Resident 24's hands, stated sometime in the last year. Staff P stated their hands are tight, and their fingernails will poke into their skin. In an interview on 03/19/2026 at 9:16 AM, Staff T, NAC stated they were the assigned staff for Resident 24 on that day. Staff T stated they were not familiar with Resident 24's routine care and stated they noticed the washcloths on both of their hands but were unaware they needed to do anything with them. In an interview on 03/19/2026 at 11:03 AM, Staff Q, NAC stated they Resident 24 used to be able to open and close their hands, until recently their hands had been tight and their nails were poking into their skin. Staff Q stated that was why they used the washcloths. Staff Q stated within the last year the facility was placing the washcloths in Resident 24's hands. In an interview on 03/19/2026 at 11:30 AM, Staff R, Registered Nurse (RN) stated Resident 24's hands were very contracted, and their fingernails will dig into their skin, so they apply the washcloths for that prevention. Staff R stated the floor staff, and RAs are usually the ones that applied them. Staff R stated they have worked with Resident 24 since they started in September/2025, and their hands had been that way. Staff R was asked what the process was when a resident presented with a decline or had shown signs of a contracture. Staff R stated they would assess them, notify the provider and then go from there. Staff R was asked if the provider or therapy were notified of Resident 24's contractures, and Staff R stated they were not aware. In an interview on 03/19/2026 at 1:14 PM, Staff G, Licensed Practical Nurse (LPN)/MDS stated they were the licensed nurse who was responsible for overseeing the restorative nursing program at the facility. Staff G stated Resident 24 had been on a PROM RA program for some time. Staff G stated the washcloths were implemented by nursing not through the Restorative program. Staff G was asked if there was a referral or conversation about Resident 24's contracted hands, Staff G stated they did not remember or know of any right now. In an interview on 03/19/2026 at 1:30 PM, Staff S, LPN/Resident Care Manager (RCM) stated they recently took over the RCM role about two weeks ago, however, have known Resident 24 for about two years. Staff S stated Resident 24's hands have been contracted for a while, and the use of the washcloths was to prevent more contracture and prevent their nails from poking into their skin. Staff S was not aware of any assessment, referral for occupational therapy related to Resident 24's contracted hands. In a joint interview on 03/19/2026 at 2:48 PM, Staff B, Director of Nursing Services, and Staff C, DCS. Staff B stated they were not aware Resident 24 had washcloths on both hands until this week. Staff B stated they were unclear on the rationale and documentation to support why it was started. Staff C stated they were reviewing the medical record to determine when the decline occurred. Staff C stated again there had been no skilled therapy services provided to Resident 24 since 2023. Staff B and Staff C were unable to provide any further information. Refer to WAC 388-97-1060(3)(d)

Based on interview and record review the facility failed to ensure one of five staff reviewed, (Staff H) received timely annual performance evaluations. Failure to complete timely evaluations of nursing staff performance, conduct education and in-services based on those evaluations had the potential to result in decreased quality of resident care. Findings included .Staff H was hired 02/18/2020 and was a certified nursing assistant. Review of requested employee evaluations on 03/18/2026 showed the most recent employee evaluation provided for Staff H was dated 08/13/2024. In an interview on 03/18/2026 at 3:00 PM, Staff I, Administrative Assistant, stated there were no more recent evaluations found for Staff H. In an interview on 03/20/2026 at 09:20 AM, Staff B, Director of Nursing Services, acknowledged late evaluation for Staff H and stated the expectation was that evaluations were done yearly. Refer to WAC 388-97-1680(1)(2)(a)-(c)

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Two medication errors were identified for 2 of 4 residents (Resident 97 and 39) observed during 25 medication opportunities which resulted in an error rate of 8%. Failure to provide medications on an empty stomach as ordered and failure to prime the needle prior to administration of insulin (synthetic hormone that allows sugar to enter cells and regulates the amount of sugar in the blood) placed residents at risk of decreased medication efficacy.Findings included.Review of a facility policy titled, Medication Administration, dated 06/18/2020, documented medications were to be administered 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. Review of a facility policy titled, Procedure for Insulin Pen Administration, dated 08/2018, documented the insulin flow was to be checked prior to each injection. Dial two to three units and slowly depress the button to check that a drop of insulin appeared at the end of the needle. <RESIDENT 97> Review of Resident 97's Order Summary Report documented a physician order for lispro (fast acting) insulin 5 units three times a day since 01/08/2026. During an observation on 03/17/2026 at 7:45 AM, Staff E, Registered Nurse (RN), attached a disposable needle onto the lispro pen (multidose container of insulin in shape of a pen). Staff E set the dial of the pen to 5 units. Staff E injected the insulin into Resident 97. Staff E did not prime the needle prior to injection. During an interview on 03/17/2026 at 7:46 AM, Staff E stated that they were not aware of how to prime the insulin needle prior to use. During an interview on 03/18/2026 at 12:08 PM, Staff B, Director of Nursing Services (DNS), reported they were aware of Staff E not priming the needle prior to insulin administration and that it was their expectation nurses primed the needle prior to each insulin administration. <RESIDENT 39> Review of Resident 39's Order Summary Report documented a physician order for omeprazole (medication to decrease stomach acid) one time a day before breakfast since 10/29/2024. Review of Resident 39's March 2026 Medication Administration record revealed omeprazole was scheduled to be given at 7:30 AM. During an observation on 03/17/2026 at 8:20 AM, Staff F, RN, provided omeprazole to Resident 39. Resident 39 had already had breakfast. During an interview on 03/17/2026 at 8:35 AM, Staff F stated it was always an issue getting the medications scheduled before breakfast, done before breakfast. During an interview on 03/18/2026 at 12:08 PM, Staff B stated if a medication order documented the medication was to be administered before breakfast, they expected the nurse to provide the medication before breakfast arrived. Refer to WAC 388-97-1060 (3)(k)(ii)

Based on record review and interview, the facility failed to provide 4 of 5 residents (Resident 28, 86, 35, 508) with a summary of their baseline care plan. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services and placed them at risk for unmet needs and possible complications. Findings included . Review of a facility policy, titled, Baseline Care Plan, dated 02/05/2020, showed the base line care plan: - Be developed within 48 hours of a resident's admission, - Admitting nurse shall gather information from hospital information, physician orders and discussion with the resident, - A written summary of the baseline care plan will be provided to the resident, - The written summary will be signed by the resident and included in the medical record. <RESIDENT 28> Resident 28 readmitted to the facility on [DATE]. Review of Resident 28's baseline care plan form showed which staff had completed the base line care plan. There was a signature by Staff N, Social Service Assistant and Staff O, Licensed Practical Nurse, dated 08/30/2024. The section that showed the baseline care plan had been reviewed with the resident and/or representative and the space where a copy had been provided to the resident were both blank. <RESIDENT 86> Resident 86 admitted to the facility on [DATE]. Review of Resident 86's Baseline Care plan form showed which staff had completed the base line care plan. There was a signature by Staff E, Registered Nurse (RN)/nurse manager (NM), on 10/23/2024. There was a signature by Staff N, dated 10/28/2024, five days after admission. The section showed the baseline care plan was reviewed with the resident and/or representative and the space where a copy had been provided to the resident was blank. 51551 <RESIDENT 35> Resident 35 admitted to the facility on [DATE]. Review of the Baseline Care plan form showed a section for staff that had completed the base line care plan. There was a signature by Staff N, dated 10/16/2024, no other disciplines had completed the baseline care plan. The section showed the baseline care plan was reviewed with the resident and/or representative and the space where a copy had been provided to the resident was blank. Review of Resident 35's Electronic Health Record (EHR) showed no documentation that a written summary of the baseline care plan was provided to the resident or their representative. <RESIDENT 508> Resident 508 admitted to the facility on [DATE]. Review of the Baseline Care plan form showed a section for staff that had completed the base line care plan. There was a signature by Staff K, Social Service Director, dated 12/16/2024, no other disciplines had completed the baseline care plan. The section showed the baseline care plan was reviewed with the resident and/or representative and the space where a copy had been provided to the resident was blank. Review of Resident 508's EHR, showed no documentation that a written summary of the baseline care plan was provided to the resident or their representative. In an interview on 12/18/2024 at 1:55 PM, Staff H, RN/NM, stated the admission nurse initiated the baseline care plan and the baseline care plan should be done within 48 hours. Staff H stated it was social service's responsibility to set up a meeting with the family which also included nursing and therapy departments. In an interview on 12/18/2024 at 2:09 PM, Staff B, Interim Director of Nursing, stated whomever the nurse was that completed the admission should be the one to put the baseline care plan information together within 24 hours. The admission nurse should discuss with the resident their basic care, including pain, skin, Activity of daily living (ADL) .as much as possible. Staff B stated the baseline care plan should be printed and provided and have residents or representatives sign. The signed copy of the baseline care plan should be scanned into the EHR. Staff B stated a brief care conference should be held within 24 hours and should include social service, nursing and a therapist. Staff B replied they did not see documentation that Resident 28, 86, 35 or 508 had reviewed their baseline care plan with facility staff. Refer to WAC 388-97-1020(3)(4)(b)

Based on observation, interview, and record review the facility failed to review and revise care plans for 1 of 2 sampled residents (Resident 69) reviewed for activities of daily living (ADLs), 1 of 1 sampled residents (Resident 75) reviewed for discharge planning, 1 of 2 sampled residents (Resident 9) reviewed for communication, 1 of 4 sampled residents (Resident 18) reviewed for dementia care, 1 of 1 sampled residents (Resident 40) reviewed for dental services, and 1 of 1 sampled residents (Resident 83) reviewed for urinary management. These failures placed the residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life. Findings include . Review of the facility policy titled, Comprehensive Care Plans, dated February 2023, showed that the facility will develop and implement a comprehensive person centered care plan for all residents, consistent with resident rights, that include measurable objectives and timeframes to meet the needs, comprehensive care plan will be revised and reviewed by the interdisciplinary team after each comprehensive and quarterly assessment, objectives will be used to monitor the residents progress, and alternate interventions will be documented as needed. <DEMENTIA CARE> Resident 18 admitted to the facility on [DATE] with diagnoses to include Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions). According to the quarterly Minimum Date Set (MDS- an assessment tool) assessment dated [DATE], Resident 18 had severely impaired cognition. In a record review on 12/17/2024, Resident 18's care plan under focus revised 09/09/2022, showed that Resident 18 and Power of Attorney (POA) wished the resident to remain on the memory care unit at the facility and only be asked about returning to the community on comprehensive assessments. The facility no longer has a memory care unit. In a record review on 12/17/2024, Resident 18's care plan under focus stated resident was high risk for falls related to history of recurrent falls and unaware of safety needs, revised on 06/05/2024. Under the intervention it showed Resident 18 required a fall mat to the left side of the bed (door side), this was revised 09/05/2023, a four Wheeled [NAME] (4WW) at bedside and in common areas to remind resident to use it, this was revised on 1/01/2023. In an observation on 12/17/2024 at 1:30 PM, Resident 18 was in bed with eyes closed, no floor mat on the floor and did not see a 4WW in the room. In an interview on 12/18/2024 at 1:58 PM, Staff F, Nursing Assistant Certified (NAC), stated that Resident 18 was total assist with all their care needs. Staff F stated that resident had not walked since they started working at the facility and had not used floor mat on the floor when resident was in bed. In an interview on 12/19/2024 at 9:55 AM with Staff G, NAC, stated that Resident 18 required total assist with their care needs. Staff G stated resident no longer walked and does not use 4WW. They also stated that they don't place the floor mat on the floor when resident was in bed. In an interview on 12/19/2024 at 2:00 PM Staff E, Registered Nurse (RN)/ Nurse Manager (NM) stated that when there were changes or updates on resident's care, they were required to update the care plan as soon as possible. Otherwise, they review care plans quarterly and yearly. They were unsure why Resident 18's care plan was not updated. In an observation on 12/19/2024 at 2:15 PM, Resident 18 was in bed asleep, no floor mat and did not see a 4WW in the room. <ACTIVITIES DAILY LIVING> Resident 69 admitted to the facility on [DATE]. According to the quarterly MDS assessment dated [DATE], resident was cognitively intact. In an interview on 12/16/2024 at 10:12 AM, Resident 69 stated that the staff brings their dinner and place it on their table and leave without waking resident up. In a record review with a print date 12/17/2024, Resident 69's care plan under intervention for Restorative showed, NAC Restorative Aide (RA) Program: Eating/Swallowing Program; set up, assure upright for meals, remains upright 20-30 minutes after meals, cues/assist to eat/drink slowly, to take small bites/sips, to swallow before taking another bite/sip, to alternate liquids, solids, temps, textures, to take on bite/sip at a time. Monitor for food pocketing and safe swallow. Notify LN if frequently coughs, monitor intake, provide meal replace for poor intake per protocol. Document total # minutes with eating program throughout shift. Date initiated was 08/18/2023. In an observation on 12/17/2024 at 12:42 PM, Resident 69 was observed lying on their bed with their lunch tray on their table with half drank milk and an empty bowl. In interview on 12/18/2024 at 10:45 AM, Staff I, Restorative Assistant (RA) stated that they had not assisted Resident 69 with meals and resident was not on Eating/Swallowing Program. In an interview on 12/18/2024 at 1:30 PM, Staff E stated that Resident 69 was no longer on Restorative Feeding Program and that they would update the care plan. 51312 <DISCHARGE PLANNING> Resident 75 admitted to the facility on [DATE] with diagnoses to include bilateral (both) below the knee amputation. According to the quarterly MDS assessment dated [DATE], resident was cognitively intact. In an interview on 12/16/2024 at 2:12 PM, Resident 75 stated their goal was to return to the community. They stated no one at the facility had discussed their discharge plan with them. In a review of Resident 75's care plan on 12/19/2024 showed no focus area for discharge planning. In a joint interview on 12/19/2024 at 1:49 PM, Staff N, Social Services Assistant and Staff S, Social Services, Staff S reported they had not discussed discharge planning with Resident 75. Staff N reported they spoke with DSHS (Department of Social and Human Services) case manager in April 2024 when they admitted to the facility and had not followed-up on a plan since then. During an interview on 12/19/2024 at 2:45 PM, Staff B, Interim Director of Nursing Services (DNS), stated social services were responsible for resident discharge planning. 47047 <DENTAL> Resident 40 admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease (COPD-progressive lung disease that limits airflow and makes it difficult to breath). In an observation and interview on 12/16/2024 at 1:32 PM Resident 40 stated they needed to get their teeth pulled so they could get dentures. Resident 40 was observed to have several missing teeth, two lower teeth and no upper teeth. In a review of Resident 40's care plan dated 11/28/2022 showed resident did not want to have dentures and did not want their diet changed. In a review of Resident 40's Admission Minimum Data Set, dated dated dated [DATE] showed the resident had mouth or facial pain, discomfort or difficulty with chewing. In a review of Resident 40's Annual MDS dated [DATE] showed resident had no mouth or facial pain, discomfort or difficulty with chewing. In an interview on 12/19/2024 at 1:19 PM Staff C, RN/NM stated residents are offered dental services at admission and as needed. Staff C stated residents are re-offered services when it was determined they had any dental problems or pain. Staff C stated they did not know the last time dental services were discussed with Resident 40. <COMMUNICATION> Resident 9 admitted to the facility on [DATE] with diagnoses that included stoke, hearing loss, and diabetes mellitus 2 (disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves). In an interview and observation on 12/16/2024 at 2:37 PM, Resident 9 was in their room laying in their bed. When attempted to speak with Resident 9, they pointed to a white board/dry erase board, sitting on their bed side table and stated the pen did not work. A new dry erase pen was provided from Staff C, RN/Nurse Manager. Review of Resident 9's progress notes from 12/01/2024 through 12/18/2024 showed they frequently refused use of their hearing aids. No other information was provided about the reason for the refusals. Review of Resident 9's care plan dated 07/29/2024 showed they had a communication problem related to a hearing deficit and just obtained hearing aids. The goals for Resident 9 included they would be able to make their needs and wants known by verbal communication and tolerate wearing their hearing aids throughout the day. Resident 9 would be assisted daily with placement of their hearing aids in the morning and removal at the night. There was no intervention in Resident 9's care plan regarding the use of a dry erase board for communication. In an interview on 12/19/2024 at 9:27 AM, Staff P NAC stated they know how to care for a resident by reviewing the care plan, information provided to them from the nurse or other aides. In an interview on 12/19/24 01:23 PM, Staff C stated Resident 9 was able to communicate if speaking directly in front of them. Staff C stated the resident used the dry erase board infrequently, did not know how the dry erase board was implemented. Staff C stated the resident had hearing aids and heard just fine with them, but often declined to wear them because they heard more than what they wanted. <URINARY> Resident 83 admitted to the facility on [DATE] with diagnoses that included stroke and heart failure. Review of Resident 83's care plan dated 12/05/2024 showed the resident had bladder incontinence related to their disease process and was at risk for infections, skin breakdown and was being treated for a urinary tract infection. The goals on Resident 83's care plan included no skin breakdown and resolution of a urinary tract infection. Interventions included changing the resident every two hours and as needed in addition to establishing a voiding pattern. Review of Resident 83's electronic medical record showed no information about establishing a voiding pattern. In an interview on 12/19/2024 at 1:25 PM Staff C stated updating care plans was a process that includes the interdisciplinary team. Staff C stated the care plan for Resident 83 needed to be updated as they were beyond finding a pattern to voiding given Resident 83 was incontinent of urine. In a joint interview on 12/20/2024 at 10:48 AM, Staff A, Administrator and Staff B, Interim DNS both stated they were unaware of the concerns with implementation and revision of resident's comprehensive care plans. Refer to WAC 388-97-1020(5)(b)

Based on observation, interview and record review the facility failed to accommodate resident preferences for 3 of 5 sampled residents (Resident 508, 35, and 92) regarding important daily routines and health care. The failure of the facility to honor resident choice placed residents at risk for a diminished quality of life. Findings included . <RESIDENT 508> Resident 508 admitted to the facility on [DATE]. In an interview on 12/16/2024 at 10:26 AM, Resident 508 stated they preferred not to be awakened at 6:00 AM. Resident 508 stated they had told the nurses not to come in and they did not want breakfast, but the staff kept coming in and waking them up. Review of Resident 508's choice assessment, dated 12/14/2024, showed Resident 508 preferred to get up at 8:00 AM. Review a progress note dated 12/16/2024 at 1:45 PM, showed Resident 508 was angry for being woken up in the morning, and they refused vitals (blood pressure and heart rate) checked, breakfast, blood sugar check (checks sugar level in blood) and weight. Review of a progress note dated 12/17/2024 at 12:06 PM showed Resident 508 refused blood sugar check at 7:00 AM and refused their breakfast. Review of a progress note dated 12/18/2024 at 7:22 AM, showed Resident 508 refused having their blood sugar checked. In an interview on 12/18/2024 at 10:56 AM, Staff J, Licensed Practical Nurse (LPN), stated Resident 508 had refused their blood sugar check and insulin at 7:00 AM on 12/16/2024-12/18/2024 because they did not want to be woke up before 8:00 AM. Staff J stated they reported this to the nurse practitioner on 12/17/2024. Review of a facility form, titled, Nurse Practitioner non urgent communication log, showed the provider had been notified of Resident 508's preference to not be woke up before 8:00 AM and had morning medications scheduled at 7:00 AM. The form showed the provider had responded on 12/16/2024 to change AM (morning) medications to be administered after 8 AM. Review of Resident 508's Medication Administration Record (MAR), dated December 2024, showed the morning medications were still ordered to be administered at 7:00 AM. In an interview on 12/18/2024 at 1:55 PM, Staff H, Registered Nurse (RN)/Nurse Manger, stated that they were not aware of Resident 508's preference because they had not done a care conference yet. Staff H stated the responses on the nurse practitioner non urgent communication log were supposed to be implemented within 24 hours. Staff H stated Resident 508's orders had not yet changed since the provider's 12/16/2024 response. <RESIDENT 35> Resident 35 admitted to the facility on [DATE]. According to the Minimum Data Set (MDS-assessment tool) assessment, dated 12/06/2024, the resident was cognitively intact. In an interview on 12/16/2024 at 2:32PM, Resident 35 stated they preferred more frequent showers or bed baths. Resident 35 stated they did not have a shower last week because they preferred female aides. There were only two young male aides working on their scheduled shower day. Review of Resident 35's shower task record, print date 12/17/2024, showed during the last 30 days the resident had received one shower on 12/14/2024. Staff documented not applicable for shower tasks on 11/19/2024, 12/05/2024 and 12/12/2024. Review of a facility form titled, Central Shower Schedule, copied on 12/18/2024, showed Resident 35 was scheduled for showers once a week on Thursday evenings. Review of a progress note dated 12/12/2024 at 03:44 PM, showed Resident 35 refused to take a shower with a male caregiver they preferred to shower with a female aide and the resident was scheduled to have a shower the next day. There was no documentation that Resident 35 was offered a shower with female caregivers on the following day. Reviewed of Resident 35's care plan, dated 12/16/2024, showed no documentation of Resident 35's preference for female caregiver with showers. In an interview on 12/18/2024 at 11:23 AM, Staff J, stated residents were assigned for showers once a week based on what room the resident was in, and staff do not ask residents about their shower preferences. In an interview on 12/18/2024 at 1:11 PM, Staff K, Social Service Director, stated nursing staff oversaw obtaining shower preferences. Social services would not ask for preferences unless the resident brought them up themselves during the care conferences. In an interview on 12/18/2024 at 1:45 PM, Staff H, stated nurses should chart resident refused instead of not applicable on the documentation of shower task records. Staff H stated nurses should offer the shower the next day if resident refused due to no female caregiver. Staff H stated they were not aware of Resident 35's preference to have more frequent showers. Staff H reviewed the shower documentation for the last 30 days for Resident 35 and agreed it showed Resident 35 had received one shower on 12/14/2024 and did not receive showers as scheduled. In an interview on 12/18/2024 at 2:09 PM, Staff B, Interim Director of Nursing (DNS), stated staff were to determine the reason why Resident 35 refused their shower and should offer a shower the following day to accommodate the residents shower needs. 51312 <RESIDENT 92> Resident 92 was admitted to the facility on [DATE]. In an interview on 12/16/2024 at 10:33 AM, Resident 92 stated scheduled showers are once a week. Resident 92 stated when they refuse to shower, they are not given a choice to have a shower at another time or with assistance from a female aide during the week. During an interview on 12/19/2024 at 2:15 PM, Staff H, RN/Nurse Manager, stated when residents are admitted , they are given a sheet of paper about their choices, and are able to document their preferences. If a resident refused to shower, the shower aid should ask why and tell the nurse manager and social worker. Record review of documentation on the 'Documented Survey Report V2 (documentation of care provided by staff), dated November 2024, showed that Resident 92 received one shower in November. Refer to WAC 388-97-0900(1)

Based on interview and record review, the facility failed to promptly report and document resident grievances for 1 of 3 sampled residents (Resident 35) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing property and placed residents at risk for frustration and diminished quality of life. Findings included . Review of the facility policy, titled, Grievance Policy and Procedure for Residents, revised date of June 2022, showed any employee that is informed of a grievance by a resident will immediately initiate the procedures for resolution of a grievance. Resident 35 admitted to the facility on [DATE]. According to the Admission Minimum Data Set (MDS-an assessment tool) assessment, dated 12/06/2024, the resident was cognitively intact. In an interview on 12/16/2024 at 2:34 PM, Resident 35 stated they were missing a left-hand arthritis glove, and it had been missing for one week, and they had told everyone about it. Resident 35 stated the gloves provided comfort for their hands. Review of the facility grievance logs for 07/16/2024 through 12/16/2024 showed no grievances were logged for Resident 35. In an interview on 12/17/2024 at 2:00 PM, Staff L, Occupational Therapist, stated Resident 35 had arthritis gloves but one was missing since about one week ago. In an interview on 12/18/2024 at 1:11 PM, Staff K, Social Service Director, stated they had received the grievance form for Resident 35 on 12/17/2024 and they were not aware the arthritis glove had been missing for one week. Staff K stated everyone in the facility could complete the grievance form when the resident reported their missing items. In a follow up interview on 12/18/2024 at 2:24 PM, Staff L stated they had not completed a grievance form when Resident 35 reported missing the arthritis glove. Staff L stated Resident 35 had told a lot of people, including aides, they had lost their glove one week ago. In an interview on 12/18/2024 at 1:45 PM, Staff H, Registered Nurse/Nurse Manager, stated Resident 35 lost their arthritis glove one week ago. Staff H stated the person with knowledge of the missing glove should have completed the grievance form immediately. Refer to WAC 388-97-0460(2)

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 82) reviewed for blood sugar (BS) monitoring received BS checks per standards of practice/care. This failure exposed residents to an increased risk of inaccurate insulin administration and the potential for decreased blood sugar. Finding Included . A review of the facility policy, titled Timely Administration of Insulin, dated June 2020, stated that insulin administration will be coordinated with mealtimes and snacks. Resident 82 admitted to the facility on [DATE] with diagnoses to include diabetes type 2 (a chronic disease that occurs when the sugar level in the blood stream was too high.) In an observation and interview on 12/19/2024 at 12:56 PM, Staff Q, Licensed Practical Nurse (LPN) assessed Resident 82's BS after they had eaten their lunch. Staff Q then administered sliding-scale (an insulin prescription that adjusts the amount of insulin a person receives based on their blood sugar level) insulin (medication injected into the skin to help regulate blood sugar levels) to the resident. Staff Q stated they needed to administer Resident 82's insulin and nothing more. Record review of Resident 82's Medication Administration Record (MAR) for December 2024 showed six units (measurement for insulin) of insulin was administered on 12/19/2024, based on their sliding scale BS level of 292. In an interview on 12/19/2024 at 2:10 PM Staff R, LPN, stated Resident 82's sliding scale insulin needed to be administered even after they had eaten, and the provider would not need to be notified. In an interview on 12/19/2024 at 2:20 PM, Staff E, Registered Nurse (RN)/Nurse Manager, stated when a resident had their BS taken after they had eaten, the nurse was to notify and obtain guidance from the provider. In an Interview on 12/19/2024 at 2:45 PM, Staff B, Director of Nursing Services (DNS), stated the provider should be notified and asked for guidance if a BS was checked after a meal. In an interview on 12/19/2024 at 3:00 PM, Staff C, RN/Nurse Manager, stated when a BS was taken after a resident had eaten, then the sliding scale insulin would be administered, and a note placed in the resident record to show the BS was taken after the meal. Refer to WAC 388-97-1620(2)(b)(ii)

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 40) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, undated, showed oxygen would be administered to resident's who needed it, consistent with professional standards of practice, the comprehensive care plan and the resident's goals and preferences. The explanation and guidelines outlined in the policy showed oxygen was administered under orders of a physician. Resident 40 admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease (COPD-progressive lung disease that limits airflow and makes it difficult to breath). On 12/16/2024 at 1:51 PM, Resident 40 was observed lying in their bed. Resident 40 was wearing a nasal cannula (a thin flexible tube that goes around the head and into the nose that administers oxygen) which was attached to the oxygen concentrator. The concentrator was set to administer 4 liters per minute of oxygen (lpm). On 12/17/2024 at 2:38 PM, Resident 40 was observed lying in their bed on their back, the head of the bed slightly elevated. Observed the oxygen concentrator setting at 4 lpm. Review of Resident 40's Medication Administration Record (MAR) for December 2024, showed they had a physician order to apply oxygen, per nasal cannula, at 2 lpm to keep oxygen saturations (a measurement of the amount of oxygen in the blood) greater than or equal to 88-92 percent as needed. Review of Resident 40's care plan revised on 08/11/2023, showed oxygen settings included O2 by use of nasal prongs at 2 lpm as needed to keep O2 saturations above 88-92 percent. In an interview on 12/17/ 2024 at 3:15 PM, Staff D, Licensed Practical Nurse (LPN) stated the process for residents on O2 included checking their O2 saturations and changing the tubing every Monday. When asked how the settings on the concentrator are determined, Staff D stated they follow the physician orders. Staff D stated the concentrator settings are checked every time they go into the room. Staff D stated Resident 40 had a physician order for O2 as needed at 2 lpm. Staff D stated Resident 40 always wore their oxygen, they always wanted to use it and it was usuaslly set at 2 lpm. Staff D stated they could not find an order for Resident 40's oxygen use. On 12/17/2024 at 3:20 PM, Staff D entered Resident 40's room and checked the setting on the concentrato, stated the concentrator was set at 4 lpm. Staff D adjusted the concentrator settings from 4 lpm to 2 lpm . In an interview on 12/17/2024 at 3:24 PM Staff C, Registered Nurse/Nurse Manager, stated O2 settings should be checked each time a nurse enters a resident's room, but at minimum each shift. Staff C stated Resident 40 has a physician order for O2 use at 2 lpm as needed, but the resident wanted to use it all the time. Refer to WAC 388-97-1060(3)(j)(vi)

Based on interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Residents 1 and 2), who resided on a secured Special Care Unit (SCU), were free from sexual abuse. Resident 2 experienced pyshcosocial harm in the form of emotional distress, applying the reasonable person approach, when the facility failed to prevent sexual activity between two residents with cognitive deficits who were unable to consent to sexual relations. This failure placed all residents on the unit at risk of unwanted sexual contact, injury and psychological harm. Findings included . Review of an undated facility policy, titled, Special Care Unit, showed the unit provided a safe environment for independent ambulation or wheelchair mobility for residents with poor safety judgement such as a resident who wandered into other resident's rooms. Review of a facility policy, titled, SCU Admission, Transfer, Discharge, revised date 10/11/2021, showed the unit was intended to provide a structured and secure environment for residents with dementia (a condition with impairment of memory and decision-making ability). Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 02/03/2023, showed sexual abuse, is defined as non-consensual sexual contact of any type with a resident. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnosis of dementia. Review of the census tab in the electronic record showed Resident 1 resided in the South unit (SCU) from 04/03/2024-04/17/2024. The resident was moved to the SCU due to wandering/elopement behaviors. Review of the Admission Minimum Data Set, (MDS, assessment of resident's abilities and medical conditions), dated 03/19/2024, showed Resident 1 had a BIMS (cognitive function test) score of four which meant they had severe cognitive impairment and required supervision to propel their wheelchair and walk 10 feet. Review of Resident 1's current care plan, showed a focus area for altered thought processes initiated on 03/23/2024 with an intervention of cue, reorient and supervise as needed. There was a focus area for Behavior problem of hypersexuality-asking others to have sex with them initiated on 04/29/2024 with an intervention for 1:1 monitoring that was initiated on 04/29/2024. Review of a progress note, dated 04/17/2024 at 11:20 PM, showed Resident 1 was moved to the North Unit (a non-secure unit) from the South unit (SCU) at 3:00 PM. The nurse documented the resident was forgetful and confused. During an interview on, 04/22/2024 at 3:57 PM, Resident 1 was observed sitting in their wheelchair in the hallway outside of their room and an interview was attempted. Resident 1 was not able to give any details about an incident with Resident 2 and stated they did not know why they had been moved from the previous unit (SCU). Review of a progress note, dated 04/22/2024 at 10:30 AM, showed Resident 1 was in another resident's room and told staff that the other resident was their sister. Review of a progress note, dated 04/25/2024 at 10:30 AM, showed Resident 1 came to the activity office several times, raised their eyebrows, and told the staff member hello gorgeous. When the staff member told Resident 1 that was not appropriate communication, Resident 1 swore at the staff member and left the office. Review of a progress note, dated 04/29/2024 at 2:39 PM, showed Resident 1 asked staff if they had sex with someone would that get them kicked out of here (facility). This was reported to the administrator and the resident was then placed on 1:1 monitoring. Review of a behavioral health services note, dated 04/29/2024, showed that Resident 1's immediate recall was impaired (remembered zero of three items,) and that their judgement and insight were limited. The note showed they recommended close monitoring of behaviors. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] and resided on the SCU. Resident 2 had a diagnosis of dementia. Review of the Quarterly MDS assessment, dated 03/22/2204, showed Resident 2 had severe cognitive impairment and was rarely understood. Review of Resident 2's current care plan showed a focus area of wandering, initiated on 10/11/2023, and impaired cognitive function with impaired decision making, initiated on 09/30/2023. The care plan was updated on 04/17/2024 with the addition of disrobing to the focus area and interventions of redirect, assist with clothing, and provide privacy when behavior occurs was added to the care plan on 04/18/2024. During an interview on 04/22/2024 at 4:10 PM, Staff F, Licensed Practical Nurse (LPN)/Nurse manager, stated Resident 2 liked to hold hands with others. During an interview on 04/22/2024 at 4:16 PM, Staff G, LPN, stated that Resident 2 sometimes would hold other peoples' hands. During an interview on, 04/22/2024 at 4:34 PM, Resident2 was observed lying in bed with no clothes covering their legs and pants were noted on the floor at the bedside. An interview was attempted but Resident 2 was not able to give any details about an incident with Resident 1. Resident 2 shrugged their shoulders to one question and stated I don't know to another. <SEXUAL ABUSE> Review of a facility risk management system document, labeled other, dated 04/16/2024, showed Resident 1 was found in Resident 2's bed and both residents were naked. Review of a witness statement included with the risk management system document showed Staff C, hospitality aide, found both residents in bed together. Staff C had documented that Resident 1 had reported they had the hots for (Resident 2) earlier. The statement showed Staff C observed Resident 1 providing oral sex to Resident 2. Review of Resident 2's progress note, dated 04/16/2024 at 8:20 PM, showed Resident 2 was in their bed with another resident and they were both naked. The note showed Resident 2 was tearful for a short while after the incident. During an interview on 4/22/2024 at 4:16 PM, Staff D, Registered Nurse (RN), stated they entered Resident 2's room after Staff C reported the two residents were naked in bed together. Staff D stated Resident 1 was putting on their clothes and reported it was all their (Resident 1's) fault. Staff D stated Resident 2 was capable of disrobing and getting into bed without assistance. Staff D stated they were in the hallway near Resident 2's room when the incident occurred but had their back to that room, so they did not see Resident 1 enter the room. During an interview on 04/29/2024 at 3:47 PM, Staff C stated they had gone to check on Resident 1 and they were not in their room. Staff C stated they looked for the resident and found them in Resident 2's room. Staff C stated they observed both residents were naked. Resident 2 was lying in bed and Resident 1 was hunched over Resident 2, providing oral sex. During an interview on 04/29/2024 at 4:22 PM, Staff E, Assistant Director of Nursing Services/ RN, stated both Resident 1 and Resident 2 were cognitively impaired and not able to consent to sexual activity. Staff E stated that Resident 1 had been seen by a behavioral health professional and they reported Resident 1 did not have the cognitive ability to not attempt sexual behavior with other residents, so Resident 1 was placed on 1:1 monitoring. Refer to WAC 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the occurrence of avoidable Pressure Ulcer/Pressure Injury (PU/PI) for 1 of 4 sampled residents (Resident 32) who was admitted without a PU/PI and had multiple co-morbidities with an increased risk for PU/PI development. Resident 32 experienced harm when they developed a Stage 3 (defined as full thickness loss of tissue) PU/PI to the resident's coccyx (tailbone region). The facility did not document refusals to reposition, or recognize the need to evaluate/modify the interventions to prevent a PU/PI when Resident 32 was non-compliant with repositioning. Thes failures placed other residents at risk for developing PU/PI's, medical complications, and unmet care needs. Findings include . Review of the Minimum Data Set (MDS), an assessment tool, 3.0 Resident Assessment Instrument manual, dated 2019, shows a PU defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. A stage 3 PU is defined as full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (non-viable [dead] tissue) may be present but does not obscure the depth of tissue loss. Review of the facility policy titled, Skin Integrity - Skin Tears and Pressure Injury, undated states that the facility will manage in accordance with professional standards of practice to prevent PU/PI. The attending physician will assume responsibility for the overall care and treatment of the residents wound, with referral to wound care specialist. The facility will notify the attending physician of the progression of the wound or lack of healing. The interventions will be modified in the resident's plan of care if the resident is non-compliant. Resident 32 admitted to the facility on [DATE] with diagnoses including depression, heart failure, and low nutritional levels (had low potassium and magnesium levels in their blood). Review of the Admission MDS Assessment, dated 09/23/2023 showed Resident 32 had a moderate cognition impairment, had no refusal of care, required extensive assist from one person for bed mobility, transfers, ambulation, toilet use and personal hygiene. The resident was always incontinent (no voluntary control) of bowel and bladder. The resident admitted without a PU/PI and was deemed at risk to develop a PU/PI, interventions were to be a reduction mattress (a mattress to evenly disperse body weight) and topical ointment (prescribed ointment applied directly to the skin). Review of the Braden Assessments (pressure ulcer assessment tool) for Resident 32, dated 09/15/2023, 09/18/2023, 09/26/2023, and 10/4/2023 placed the resident at risk for development of a PU/PI. Review of the nutritional assessment for Resident 32, dated 09/15/2023 showed the resident was deemed malnourished. Review of Resident 32's care plan with a focus, dated 09/28/2023 showed the resident had potential for development of a PU/PI related to dehydration, decreased mobility, incontinence, malnutrition, and depression. Interventions included administer treatment and monitor effectiveness, educate on repositioning, follow facility policy and procedures for prevention/treatment of skin breakdown, if the resident refused care the Interdisciplinary Team (IDT) was to determine alternative methods to gain compliance, and document the alternatives. Review of Resident 32's skin evaluation, dated 09/26/2023 showed the residents coccyx area was red in color. Review of Resident 32's skin evaluation, dated 10/04/2023 showed the resident's coccyx area had an open area that measured 1.6 centimeters (cm) in length by 0.8 cm wide. The evaluation stated the resident laid supine (on their back) only. Review of Resident 32's progress note, dated 10/04/2023 at 9:38 PM, showed the resident's had developed an open area to their coccyx. Review of Resident 32's care plan with a focus, dated 10/05/2023 showed the resident had an actual PU/PI with interventions for a pressure reduction mattress for the bed. Review of Resident 32's progress note, dated 10/20/2023 at 7:27 PM, showed the open area to the coccyx measured 1.7cm in length by 0.5cm wide by 0.1cm in depth. Review of the Resident 32's medical records dated 10/04/2023 - 10/20/2023, showed no documentation that the open area to the coccyx had been monitored, or whether the interventions put in place were effective. Review of Resident 32's physician orders, showed on order, dated 10/05/2023, instructed the nurse to clean the coccyx wound, apply a prescription wound treatment and cover with a secured dressing as needed. Review of Resident 32's nursing notes or Treatment Administration Record (TAR) or electronic medical record (EMR), showed no documentation the as needed dressing had been implemented. Review of Resident 32's physician orders, showed on order, dated 10/07/2023, instructed nursing to cleanse the coccyx wound, apply prescription wound treatment and cover with a secure dressing every Wednesday and Saturday. Review of Resident 32's EMR, from 10/04/2023 through 10/26/2023, showed no assessment of the effectiveness of the wound treatment. Review of Resident 32's physician orders, showed an order, dated 10/20/2023, showed a referral to the wound care specialist. In an observation on 10/25/2023 at 9:23 AM, and 3:28 PM, Resident 32 was observed lying on an air mattress on their backside in bed where their wound was located. Resident 32 was not interviewable. In an observation and interview on 10/25/2023 at 1:22 PM, Collateral Contact (CC) 4, Physician Assistant for the wound care specialist, was at Resident 32's bedside to assess the coccyx area wound. CC4 stated they were going to surgically debride (remove dead tissue) from the wound. CC4 stated the wound was a Stage 3, and it appeared the resident had not been repositioning from lying on their back. Review of Resident 32's wound care specialist note, dated 10/25/2023, showed that the nursing had reported the resident had a PU/PI to the coccyx. The note stated wound has had delayed wound closure likely secondary to poor repositioning from lying on their back. The resident was encouraged to rotate sides every two hours. In an observation on 10/26/2023 at 8:40 AM, and 9:32 AM, Resident 32 was observed lying on their back in bed. In an observation on 10/27/2023 at 8:05 AM, 10:32 AM, and 1:07 PM, Resident 32 was observed lying on their back in bed. In an interview on 10/27/2023 at 10:37 AM, Staff J, Nursing Assistant Certified (NAC), stated Resident 32 would refuse to reposition off their back. Staff J was unaware that the resident had a PU/PI to their coccyx area. In an observation on 10/30/2023 at 8:58 AM, 10:22 AM, 12:14 PM, and 2:51 PM, and 10/31/2023 at 9:08 AM, Resident 32 was observed lying on their backside in bed where their wound was located. In an interview on 10/31/2023 at 9:20 AM, Staff M, NAC, stated they had tried to place pillows under Resident 32 to reposition them, but they will refuse and throw the pillows on the ground. Staff M stated they did not document refusals of care, only verbalized to the nurse. In an interview on 10/31/2023 at 9:27 AM, Staff N, NAC/Restorative Aide (RA) stated they tried to place pillows on Resident 32's side to reposition them, but they refuse all the time. Staff N stated when a resident refused care, they were instructed to inform the nurse, they can also chart in the electronic record as well. In an interview on 10/31/2023 at 9:31 AM, Staff O, Licensed Practice Nurse (LPN) stated Resident 32 required encouragement to reposition. Staff O stated they were not consistent about documentation of resident refusal of care/treatment. In an interview on 10/31/2023 at 9:36 AM, Staff L, Registered Nurse (RN)/Nurse Manager stated they notified the provider on 10/04/2023 when they first discovered the open area to the coccyx. Staff L was unaware if the provider had assessed the open area. Staff L stated they had tried to encourage the resident to reposition on of their back. Staff L was asked what was done when the resident continued to refuse the interventions in place, Staff L did not provide an answer. In an interview on 10/31/2023 at 10:00 AM, CC2, Nurse Practitioner (NP), stated they were aware the resident had an open area to the coccyx. CC2 stated they had not discussed the status of the wound, or the ineffectiveness of the interventions that had been in place with the facility. CC2 stated they were aware that the wound care specialist had been in to assess and that the wound was a Stage 3 PU/PI. In an interview on 10/31/2023 at 12:56 PM, Staff B, Director of Nursing Services (DNS) stated that all residents are assessed for potential skin breakdown when they are admitted to the facility. A Braden Assessment was completed, and based on the results of that interventions were put into place. Staff B stated they discussed all skin issues on a weekly basis, that was documented in the resident's medical record. Staff B stated the expectation was that if the wound had worsened the provider would be notified and modifications to the plan of care should occur. Staff B was asked if Resident 32's interventions were discussed and if there was any collaboration with the provider on the plan of care for the wound, Staff B did not offer any information. Refer to WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD's) for 5 of 12 sampled residents (Residents 160, 32, 75, 6 and 100) reviewed for AD's. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . <RESIDENT 160> Resident 160 was admitted to the facility on [DATE] with diagnosis including aftercare following left leg amputation. Resident 160's profile information records showed the resident was self- responsible in making their own decisions. Review of Resident 160's records on 10/25/23 and 10/31/2023, showed no documentation of AD's. Review of email received on 10/31/2023 at 12:02 PM, Staff A, Administrator, indicated Resident 160's admission paperwork had not yet been completed that included information regarding AD's. 44110 <RESIDENT 32> Resident 32 admitted to the facility on [DATE] with diagnoses including depression and heart failure. Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/23/2023, showed Resident 32 had moderate cognitive impairment. Review of Resident 32's admission paperwork, dated 10/10/2023, stated the resident's family member was their durable power of attorney (DPOA). Review of Resident 32's medical record on 10/27/2023, showed no record of a DPOA that was on file. Review of Resident 32's progress note, dated 09/24/2023, showed Staff F, Social Service Assistant (SSA), documented they had no DPOA on file and would follow up. In an interview on 10/27/2023 at 10:30 AM, Staff F stated they had not followed up with the family member regarding the DPOA paperwork. Staff F stated they possibly had discussed that in the care conference but was unsure as there was no documentation of the conversation. In an interview on 10/31/2023 at 12:56 PM, Staff A stated they were unaware that the AD's had not been obtained for Resident 32. 47047 <RESIDENT 75> Resident 75 admitted to the facility on [DATE], most recently readmitted on [DATE], diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), and weakness. In a review of Resident 75's Electronic Medical Record (EMR) on 10/24/2023, showed the resident had a Power of Attorney (POA) for finances on file. In an interview on 10/26/2023 at 2:32 PM, Staff U, SSA, stated Resident 75 had an advanced directive on file and stated it was a POLST (Physician Orders for Life Sustaining Treatment). Staff U stated Resident 75 had a POA, was able to locate the financial POA, but not the healthcare POA. In an interview on 10/26/2023 at 3:29 PM, Staff U provided a copy of Resident 75's POLST and an admission document describing AD's. Staff U stated they were unable to locate the POA document for healthcare and they would follow up with Resident 75's family to obtain the document. <RESIDENT 6> Resident 6 admitted to the facility on [DATE], most recently admitted on [DATE] diagnoses include paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own), encephalopathy (damage or disease that affects the brain), and unspecified dementia (mild memory disturbance due to known physiological condition). In an interview on 10/26/2023 at 2:32 PM, Staff U stated Resident 6 had an advanced directive on file and that was a POLST. Staff U stated Resident 6 had a POA but was unable to locate the document. In an interview at 10/26/2023 at 3:56 PM, Staff U provided the POA document for Resident 6. In an interview on 10/27/2023 at 12:46 PM, Staff U stated they received the POA document the day prior (10/26/2023) after requesting it from Resident 6's family member. 47104 <RESIDENT 100> Resident 100 admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis (damaged muscles that release protein into the blood) and falls at home. Review of the resident's admission MDS assessment, dated 08/25/2023, showed the resident had moderate cognitive impairment. Review of Resident 100's medical record on 10/24/2023, showed no documentation of AD's. Review of Resident 100's progress notes, showed no documentation of staff discussing AD's with the resident. In an interview on 10/30/2023 at 9:20 AM, Staff T, Medical Records, stated there was no advanced directive in Resident 100's medical record. In an interview on 10/30/2023 at 9:56 PM, Staff U stated Resident 100 does not have an AD. Staff U stated resident 100 had declined an AD and stated there was no documentation in the resident's record. Refer to WAC 388-97-0280(3)(a)(c)(i)

Based on observation, interview, and record review, the facility failed to provide a dignified and homelike dining experience in 2 of 3 (Southeast and South) dining rooms during 3 of 3 dining observations for dignity. These failures placed residents at risk for feelings of frustration, diminished self-worth, embarrassment, and a potential decline in nutritional status. Findings included . <SOUTHEAST DINING ROOM> Observation on 10/24/2023 at 11:37 AM, Resident 101's meal tray was served. The resident's tablemates, Resident 76, and Resident 33, were observed to watch Resident 101 eat until their lunch arrived at 11:43 PM, six minutes later. The resident's food and drinks were not removed from the serving tray for the dining experience. Observation on 10/27/2023 at 11:28 AM, trays were delivered to the unit. Resident 33's meal was served at 11:30 AM, followed by their tablemates Resident 76's at 11:34 AM and Resident 1's meal at 11:35 AM. At the same table Resident 101 was staring at their tablemates eating and inquiring as to where their food was. Collateral Contact 1 (CC1), Resident 101's, significant other, commented that maybe the facility had put them (Resident 101) on a diet. Resident 101's lunch was delivered at 11:37 AM. Resident 101's food and drinks were not removed from their serving tray for the dining experience. Observation on 10/30/2023 at 11:37 AM, Resident 117's lunch was served. Resident 101 was seated at the table and watching Resident 117 eat until their tray was delivered at 11:41 AM. Resident 101's food and drinks were not removed from the serving tray for the dining experience. In an interview on 10/30/2023 at 12:30 PM, Staff G, Nurse's Aide Registered (NAR), said they leave the plates and cups on the tray during meals unless the resident requested otherwise. Staff G said they served the meals in the order of the meal cart arrangement. In an interview on 10/30/2023 at 2:45 PM, Staff E, Registered Nurse (RN), said they always served the meals on the tray and kept them on the tray so that resident's would know whose food was who's. Staff E said they tried to serve meals to the table at the same time, so others were not waiting and watching others eat. 44110 <SOUTH DINING ROOM> Observation on 10/24/2023 at 12:01 PM, the staff were observed to serve Resident 52, and Resident 105 their lunch. The residents food and drinks were not removed from the serving tray for the dining experience. Observation on 10/24/2023 at 12:02 PM, the staff were observed to serve Resident 65, Resident 28 and Resident 16 their lunch. The residents food and drinks were not removed from the serving tray for the dining experience. Observation on 10/24/2023 at 12:03 PM, the staff were observed to serve Resident 80 their lunch without removing their food and drinks from the serving tray. Resident 77 lunch arrived at 12:07, four minutes later. The resident's food and drinks were not removed from the serving tray for the dining experience. In a continuous observation on 10/24/2023 at 12:05 PM, the staff were observed to serve Resident 26, Resident 33, Resident 17, and Resident 38 their lunch. The resident's food and drinks were not removed from the serving tray for the dining experience. Resident 26 was observed to have their head tucked into their shirt, their food was sitting placed in front of them, uncovered and untouched. At 12:16 PM, staff was observed to verbally tell Resident 26 to eat their lunch, Resident 26 did not respond. At 12:21 PM, 16 minutes after their food had been delivered, staff were observed to stand over Resident 26 and provide physical assistance to the resident to eat one bite of food then the staff walked away. At 12:27 PM, a staff member sat down next to Resident 26 and provided physical assistant to the resident to eat their lunch, 22 minutes after their food was placed in front of them. Observation on 10/26/2023 at 11:51 AM, the staff were observed to serve Resident 38 and Resident 17 their lunch. There were two other residents (Resident 33 and Resident 26) that sat at the same table, they were not served their lunch till 11:57, six minutes after the first tray was delivered. In a continuous observation on 10/26/2023 at 11:51 AM, the staff were observed to serve Resident 65 their lunch to their table. Resident 73 was sitting at the table with Resident 65. Resident 73 then moved in their wheelchair over to the food cart full of trays and stated to staff where is mine? Resident 73 then moved in their wheelchair back to the table and leaned over at Resident 65, pointed at the food, and stated, I want some of that, it looks good. At 11:55 AM, Resident 73 lunch was placed in front of them, four minutes later. In an interview on 10/26/2023 at 1:28 PM, Staff P, Activity Assistant, stated they assist with meal delivery at times. Staff P stated they try to pass to one table at a time, but they were not always able to. In an interview on 10/30/2023 at 9:58 AM, Staff K, RN, stated they pass the trays to the residents as they were stacked in the meal cart when it was delivered. In an interview on 10/30/2023 at 12:50 PM, Staff L, RN/Nurse Manager, stated the expectation in the dining room was all residents at the same table were served their meal at the same time. All items on the meal tray should be removed and placed on the table. In an interview on 10/31/2023 at 12:56 PM, Staff A, Administrator, stated the management team was unaware the staff had been not removing the food items off the tray during meal service. Staff A stated they were also unaware residents were not served one table at a time. Staff A stated the expectation was, staff were to serve one table at a time, with food and drinks removed from the serving tray. Refer to WAC 388-97-0860 (1)(a)

Based on interview and record review, the facility failed to ensure 4 of 5 residents (Resident 86, 14, 83, and 73) were free of unnecessary drugs due to: 1) lack of specific target behavior monitoring, 2) not obtaining the monthly orthostatic vital signs, 3) not developing and implementing non-medical behavioral interventions, and 4) not having appropriate indication, documentation, and goals for use of psychotropic medications. These failures placed residents at risk for receiving unnecessary medications and for experiencing medication-related adverse side effects. Findings included . Review of the Food and Drugs/Drug (FDA) Safety Information reference, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA Boxed Warning, which accompanied, second-generation anti-psychotics stated, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. Review of the facility policy titled, Use of Psychotropic Medication, revised 2023, showed the residents were not to be given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Review of Center for Medicare and Medicaid Services (CMS) document titled, Atypical Antipsychotic Medications: Use in Adults, dated 2015, showed vascular dementia was not a qualified diagnosis for use of mood stabilizers and anti-psychotic medications. <RESIDENT 86> Resident 86 admitted to the facility on [DATE] with diagnoses to include stroke with dysphagia (difficulty swallowing). Review of the Admission PHQ-9 (an assessment for depression) assessment, dated 10/02/2023, showed the resident had a severity score of 12 indicative of moderate depression. The resident had no diagnosis of depression. Review of Resident 86's 09/25/2023 through 10/31/2023 Medication Administration Records (MARs), revealed the resident received the citalopram hydrobromide daily for a mood disorder. Review of Resident 86's Order Summary Report, for active orders as of 10/30/2023, revealed there was an order for citalopram hydrobromide to be administered daily for a mood disorder. There was an order beginning 09/25/2023 to check the resident's Orthostatic Blood Pressures (b/p's), lying, sitting, and standing, once monthly on the 25th of the month, and to document the b/p's under the vital signs tab in Point Click Care (electronic health record). On 10/30/2023, a review of blood pressure documentation in Point Click Care, revealed no orthostatic b/p's were done in September or October 2023. There was no documentation Resident 86 refused to do orthostatic b/p's on or around September or October 25th. In an interview on 10/30/2023 at 11:16 AM, Staff F, Social Services Assistant, stated Resident 86 was on Celexa (citalopram) for maybe pain. Staff F said they completed the PHQ-9 assessment on the resident that indicated a 12 which was moderate depression. Staff F said the process was to inform the nurse manager of the results, but they were unsure if they had done that. In an interview on 10/30/2023 at 12:17 PM, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner (ARNP), stated they were not informed of Resident 86's PHQ-9 assessment results. When asked what the diagnosis was for the use of citalopram, CC2 said they would have to go through the resident's records to see why they prescribed the medication. In an interview on 10/30/2023 at 12:43 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager (NM), said they thought Resident 86 was on Cymbalta (a different anti-depressant). Staff D said the pharmacist had questioned the lack of a depression diagnosis. Staff D commented the resident did cry at times. Staff D said the facility had psychotropic medication meetings, but they did not always attend them. In an interview on 10/30/2023 at 2:11 PM, Resident 86 stated they were sleepy and didn't want to live any longer and had elected hospice services. The resident stated they had been on Celexa (citalopram) long before hospitalization for depression. They stated their provider had put them on the medication to make them feel better, but it didn't work. In an interview on 10/30/2023 at 2:45 PM, Staff E, Registered Nurse (RN), stated Resident 86 could be tearful and they were on citalopram imagined to be for depression. 43954 <RESIDENT 14> Resident 14 was admitted to the facility on [DATE] with diagnoses to include respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood), heart failure, and dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 14's provider orders showed that they were prescribed risperidone (antipsychotic medication) 0.25 milligrams (mg) every night at bedtime, initiated 09/30/2023. Review of Resident 14's October 2023 MAR, showed there was a medication side effects (s/e) monitor for the antipsychotic medication, initiated 10/02/2023, and nurses were to document every shift a 'y' for yes if any s/e's were observed and to chart using the 'other, see nurses notes' and provide documentation. Nurses were to document 'n' for no if no s/e's were observed. Resident 14's antipsychotic medication s/e monitor had no place to document 'y' or 'n' and there was a checkmark for all documentation. There were no instructions documented related to a checkmark. <RESIDENT 83> Resident 83 was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, and an infection after surgery to remove their gallbladder (organ beneath the liver in which bile is stored). Review of Resident 83's provider orders showed they were prescribed quetiapine (antipsychotic medication) 25 mg every night for psychosis, initiated 08/24/2023, and mirtazapine (antidepressant medication) 7.5 mg every night at bedtime. Review of Resident 83's 08/01/2023 through 10/31/2023 MAR's, showed there was a medication s/e's monitor for the use antipsychotic medication, initiated 08/27/2023, and a monitor for s/e's for the use of the antidepressant medication, initiated on 09/09/2023. Side effect monitor orders showed nurses were to document every shift a 'y' for yes if any s/e's were observed and to chart using the 'other, see nurses notes' and provide documentation. Nurses were to document 'n' for no if no s/e's were observed. Resident 14's MAR had no place to document 'y' or 'n' and there was a checkmark for all documentation. There were no instructions indicating what a checkmark meant. In an interview on 10/31/2023 at 2:42 PM, Staff B, Director of Nursing Services (DNS), stated their expectations were that all psychotropic medications required monitors would have all components, including the supplementary documentation. Staff B stated the admission nurse and NM's should be a safety net to catch all components of the orders were implemented and documented correctly. Staff B stated the directions to document 'y' or 'n' were in the order, so there should be corresponding documentationto catch all components of the orders were implemented and documented correctly. 44110 <RESIDENT 73> Resident 73 was admitted to the facility on [DATE] with diagnoses to include psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality), vascular dementia, and depression. Review of the Quarterly MDS Assessment, dated 08/15/2023, showed Resident 73 had severe cognitive impairment. Review of Resident 73's electronic medical record and electronic treatment record (EMAR/ETAR) showed the resident had the following physician orders: - Risperdal twice a day for psychosis, start date 02/14/2022. - Depakote Extended Release (mood stabilizer medication that treats a mood disorder with episodes of mania-depression) twice a day for vascular dementia with agitation (inappropriate diagnoses), start date 12/15/2021. Review of Resident 73's care plan on 10/30/2023, showed the resident was taking psychotropic medications, did not reflect the actual prescribed anti-psychotic and mood stabilizer with specific signs and symptoms, and interventions to prevent specific disorders. Review of Resident 73's medical record showed the resident had not been offered a gradual dose reduction (GDR is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for their Depakote since 12/15/2021. The resident had received the Depakote for vascular dementia with behavioral disturbance. In an interview on 10/30/2023 at 12:50 PM, Staff L, RN/MN, stated they were unaware vascular dementia was an inappropriate diagnosis for use of Depakote. In an interview on 10/31/2023 at 9:36 AM, Staff L stated there was never a GDR completed for Resident 73's Depakote. In a joint interview on 10/31/2023 at 12:56 PM, Staff C, Assistant Director of Nursing Services (ADNS), stated they meet monthly to review psychotropic medications. The residents were reviewed on the quarterly MDS schedule, as well as any new admits, and any residents with recent behavioral changes. Staff A, Administrator, and Staff B stated they were unaware Resident 73 had an invalid diagnosis for use with Depakote, and there had been no GDR offered. Refer to WAC 388-97-1060(3)(k)(i)(4)

Based on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 3 (Central/South and Southeast) medication refrigerator observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Findings included . In an observation on 10/26/2023 at 1:31 PM, the thermometer in the shared Central/South medication room's refrigerator temperature was 48 degrees Fahrenheit (F). The refrigerator contained vaccines, resident medications, and over the counter medications. The refrigerator temperature form showed temperatures should range from 36 degrees F to 46 degrees F with instructions to notify maintenance if recorded temperatures are above or below range on 2 sequential readings 30 minutes apart. Review of the shared Central/South Unit medication room refrigerator temperature log, dated 10/01/2023 through 10/26/2023, showed 20 missing readings with 10 out of range temperatures for the night shift and 7 missing readings with three out of range for the evening shift. Staff EE, Licensed Practical Nurse/Admission Nurse, confirmed vaccinations were stored in the refrigerator. Staff EE stated the refrigerator required documentation of refrigerator temperatures two times daily and the missing documentation on the temperature log. In an observation and interview on 10/26/23 at 2:18 PM, the medication refrigerator on the Southeast Unit was observed to contain vaccines and resident medications. Review of the Southeast Unit medication refrigerator temperature log dated 10/01/2023 through 10/26/2023, showed seven missing readings for the evening shift. Staff E, Registered Nurse, stated the nurse on shift was responsible for documenting refrigerator temperatures and stated there were instructions on the temperature log for temperatures that were out of range. In an interview 10/26/2023 at 1:51 PM, Staff B, Director of Nursing Services, stated all medication refrigerator temperature logs should be completed. Staff B stated the nurse on shift was responsible for documenting refrigerator temperatures and the nurse managers should be reviewing documentation for completion. Staff B stated the vaccinations and medications may be compromised. Refer to WAC 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 2 of 3 sample residents (Resident 75 and 94), reviewed for quality of life. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included . <RESIDENT 75> Resident 75 admitted to the facility on [DATE], most recently readmitted on [DATE], diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), and weakness. Review of Resident 75's care plan, dated 04/18/2022, showed the resident had a deficit in their ability to care for themselves related to weakness and was at risk for falls. Interventions included to encourage Resident 75 to use their call light for assistance and to have their call light within reach. In an observation and interview on 10/25/2023 at 11:21 AM, Resident 75's call light was observed on the floor. Resident 75 stated they would like a glass of cold ice water. There was no pitcher or water observed in Resident 75's room. In a continuous observation on 10/27/2023 beginning at 9:04 AM until 9:58 AM, Resident 75's call light was observed on the ground next to their bed, out of their reach. In an interview on 10/27/2023 at 9:58 AM Staff Y, Registered Nurse (RN)/Nurse Manager, stated staff should be checking on residents all the time. Staff Y stated they did not know how long Resident 75 had been without their call light, noticed the call light on the floor right away, and placed it within Resident 75's reach. <RESIDENT 94> Resident 94 admitted to the facility on [DATE] with diagnoses included congestive heart failure (condition in which the heart doesn't pump blood as efficiently as it should), weakness, and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) of the right knee. Review of Resident 94's care plan, dated 04/18/2023, showed Resident 94 had a history of not remembering to use their call light and was at risk for falls. The intervention noted was to ensure the call light was within reach, encourage the resident to use their call light, and to place frequently used items within the resident's reach to include the call light. In a continuous observation on 10/27/2023 starting at 9:08 AM Resident 94's call light was on the ground next to their bed on the right side. At 9:45 AM observed Staff AA, Licensed Practical Nurse (LPN), enter Resident 94's room and then exited. Resident 94's call light remained on the floor. At 10:07 AM Staff Z, Certified Nursing Assistant, entered Resident 94's room and upon exiting stated that the resident's call light was on the floor and placed it within their reach. Refer to WAC 387-97-0860 (2)

Based on observation, interview, and record review, the facility failed to prevent a substantial injury when a resident fell from a mechanical lift device for 1 of 4 residents (Resident1) reviewed for dependent transfers. Failure to assure staff had completed competencies and return demonstration on hire, and annually, placed residents at risk of incorrect use of a mechanical lift (a transfer device machine that fully lifted and transferred the resident from surface to surface). Resident 1 experienced harm when a fall occurred while being transferred using a mechanical lift that caused a head injury that required hospital intervention and placed other residents at risk of injury. Findings included . Review of a facility policy titled, Safe Resident Handling/transfers, dated 04/2023, showed that staff must demonstrate competency in the use of mechanical lifts prior to use and annually. Review of Resident 1's Minimum Data Set assessment, dated 03/15/2023, showed the resident had unclear speech, sometimes understood, and had severely impaired decision-making ability. Review of Resident 1's Activity of Daily Living care plan, dated 02/09/2022, showed the resident required the use of a mechanical lift for transfer. Review of a nursing progress note, dated 04/10/2023, showed Resident 1 had fallen during a transfer with a mechanical lift, landing in on the floor with their head against the bed frame. Resident 1 was noted to have a laceration (cut) to the back of their head when they landed on the floor. The laceration required emergency services and the resident was transferred to the hospital for treatment. Review of the hospital admission history and physical, dated 04/10/2023, showed Resident 1 sustained a subdural hematoma (bleeding in the brain) from the fall. Review of the facility investigation report regarding Resident 1's fall on 04/10/2023, showed the likely cause of the fall was related to the sling (part of lift that supports resident during the transfer) had shifted when Resident 1 was being transferred with the mechanical lift. The investigation showed that Resident 1 was being transferred with the mechanical lift by Staff B, Nursing Assistant Certified (NAC), and Staff C, agency NAC. In an interview on 04/14/2023 at 3:01 PM, Staff B stated that they were using the mechanical lift to transfer Resident 1 from their wheelchair to their bed. Staff B stated that they had raised the resident in the lift and were moving the lift over the bed, when the resident fell through the sling, landing on the floor in a sitting position. Staff B stated the resident was waist high when they fell through the sling, causing an injury to their head. In an interview on 04/14/2023 at 2:41 PM, Staff A, Director of Nursing Services, stated the facility provided a booklet of written information about the facility to agency staff for orientation, but that the facility did not conduct any competencies with agency staff before they worked with residents. In an observation on 4/17/2023 at 11:20 AM, Resident 1 was observed sitting up in a w/c. Resident 1 was not interviewable. Review of Staff B's employee education records, showed that they had written and verbal education on mechanical lifts on 07/13/2023, 02/16/2023, 09/23/2019 and 08/06/2019, but there were no competency/return demonstration was noted. In an interview on 04/17/2023 at 3:57 PM, Staff A reported that they were not able to locate any documentation of competency/return demonstration for Staff B on mechanical lift transfers. Reference: WAC 388-97-1060 (1)(3)(g)

Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for four of six Units. The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program during a Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak. The facility failed to ensure the staff appropriately used personal protective equipment (PPE), failed to ensure the staff cleaned and disinfected reusable medical equipment, failed to ensure appropriate hand hygiene practices were followed, failed to ensure Transmission Based Precautions (TBP) were implemented with Coronavirus Disease 2019 (COVID-19) positive residents, and failed to ensure appropriate handling of a urinary catheter bag in accordance with infection control standards of practice. The COVID-19 outbreak at the facility, had a result of 35 residents test positive, 35 staff members test positives, and the death of three residents (110, 113, 114). These failures placed all residents, visitors, and staff at risk for potential exposure to COVID-19, other infections and increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ). On [DATE] at 3:01 PM, the facility was notified of an IJ at CFR 483.80 (a)(2)(iii) F880 related to the facility's failure to implement proper use of PPE for COVID-19 positive residents, and incomplete education to facility staff on PPE use during a COVID-19 facility outbreak. The facility removed the immediacy and was validated on [DATE] at 11:30 AM by implementing a removal plan with staff education on proper use of PPE, disinfection protocol for face shields, proper use of N95 (form of breathing respirator), appropriate hand hygiene protocol, and appropriate TBP procedures for COVID-19 positive residents. Written education and return demonstration training was provided to all staff. Findings include . RESIDENT 110 Resident 110 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had not received Hospice Services, did not require supplemental oxygen, and had received physical and occupational therapy. Review of the Documentation Survey Report v2 (Report of the residents' functional abilities) for [DATE] showed the resident was consuming 51% - 75% of their meals independently, participated in activities daily, had a stable blood pressure, body temperature, and oxygen saturation level and did not require supplemental oxygen. Review of the facility progress note dated [DATE] at 9:14 AM, showed the resident had tested positive for the COVID-19 virus. Review of the facility progress note dated [DATE] at 3:23 PM, showed the resident was in respiratory distress with oxygen saturation (level of oxygen in the blood) levels below baseline, and required supplemental oxygen via nasal tubing (tubing delivering oxygen into the nose). Review of the facility progress note dated [DATE] at 3:39 PM, showed the resident was unresponsive, with labored breathing, the resident's oxygen saturation levels were below baseline, and they required supplemental oxygen via a facial mask (breathing mask that delivers oxygen to the nose and mouth at the same time). The resident had a heart rate that was elevated above baseline and provider (doctor) was notified. Review of the facility progress note dated [DATE] at 5:25 PM, showed the residents wife wanted the resident to be sent to the hospital, the Emergency Medical Technicians (EMT) were contacted via 911 and the resident was sent to the hospital. Review of an email communication dated [DATE] at 12:03 PM, from the Director of Nursing Services (DNS) stated Resident 110 passed away on [DATE] at the hospital. RESIDENT 113 Resident 113 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility Quarterly MDS assessment dated [DATE], showed the resident had intact cognition, had not received supplemental oxygen, and did not require hospice services. The resident was able to transfer with the supervision of one person, ambulated (walked) with no assisted device, and needed supervision for eating and toilet use. Review of the facility progress note dated [DATE] at 9:16 AM, showed the resident had tested positive for the COVID-19 virus. Review of the facility progress note dated [DATE] at 2:00 PM, showed the resident had a poor appetite. Review of the facility progress note dated [DATE] at 7:52 AM, showed the resident had been found in sitting in a chair in the bathroom not feeling well, appeared to have labored breathing and sweating. Review of the facility progress note dated [DATE] at 10:00 PM, showed the resident had difficulty walking, appeared weak to the nurse, and had labored breathing. Review of the facility progress note dated [DATE] at 7:24 AM, showed that at 11:40 PM the night before, the resident had a blueish color to their nail beds, labored breathing above their normal baseline. The resident continued to have labored breathing throughout the shift per the nurse. At 4:00 AM on [DATE], the resident was found to have no vital signs and was pronounced dead. RESIDENT 114 Resident 114 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Admission MDS assessment dated [DATE], showed the resident had intact cognition, had not received supplemental oxygen, and did not require hospice services. The resident was able to ambulate with the assist of one person using a walker and ate meals with set up assist. Review of the facility progress note dated [DATE] at 8:46 PM, showed the resident had tested positive for COVID-19 virus. Review of the facility progress note dated [DATE] at 11:25 PM, the resident had complained of a cough and was producing thick yellow sputum and reported a sore throat. Review of the facility progress note dated [DATE] at 1:37 PM, the resident reported a cough, with greenish colored sputum. Review of the facility progress note dated [DATE] at 10:23 AM, the resident had an elevated body temperature above base line, blood pressure was below their normal baseline, had an increased heart rate, increased respirations, and required supplemental oxygen. Review of the facility progress note dated [DATE] at 1:48 PM, resident was declared deceased at 10:42 AM. <Personal Protection Equipment> Review of Center for Disease Control (CDC) policy titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 2, 2022, stated: - Residents with confirmed or suspected COVID-19 requires a National Institute of Occupational Safety and Health (NIOSH) approved respirator as PPE and should be removed and discarded after the patient care encounter and a new one should be placed on; and - Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting including residents. Review of CDC policy titled, How to use your N95 Respirator, updated [DATE]th, 2022, showed the N95 respirator must fit snug against the face, with no gaps or items in the way. Do not crisscross the straps ensure the straps lay flat and are not twisted. In the event there are gaps or improper use of straps the N95 respirator was not worn correctly and was not an effective respirator for use with COVID-19 positive residents. Review of the CDC policy titled, Strategies for Optimizing the Supply of Eye Protection, updated [DATE], ensured appropriate cleaning and disinfection after each use if reusable face shields or goggles are used. Review of the facility policy titled, Novel Coronavirus Prevention and Response, dated [DATE], stated staff are educated on proper use of personal protective equipment for standard, contact, droplet, and airborne precautions, including eye protection. In a continuous observation on [DATE] at 2:29 PM, Staff G, Licensed Practical Nurse (LPN), was observed to enter room [ROOM NUMBER], a known COVID-19 positive resident room wearing a surgical mask underneath a N95, eye protection, gown, and gloves. Staff G then exited the room removing gloves, and gown and discarded into the waste basket. Staff G performed hand hygiene with alcohol-based hand gel (ABHG) and proceeded back to their medication cart down the hall. Staff G did not change their N95 after a resident encounter with a COVID-19 positive resident and did not disinfect their eye protection. In an interview on [DATE] at 2:35 PM, Staff G confirmed that the resident in room [ROOM NUMBER] was positive with COVID-19. Staff G stated they had not had any education regarding disposing of their N95 after resident encounters with COVID-19 and replacing with a new N95. Staff G stated they had not had any education on proper use of the eye protection and were unaware they were to disinfect they eye protection after they provided care to a COVID-19 positive resident. Staff G stated they thought they were providing themselves extra precaution by applying a surgical mask under their N95. Staff G confirmed they were providing care with COVID-19 positive and negative residents. In an observation on [DATE] at 3:06 PM, Staff Z, Registered Nurse (RN), was observed to exit a resident room wearing their eye wear on top of their head. Staff Z continued to wear eye protection on top of their head while they assisted a resident in the hallway apply their surgical mask to their face, adjust the resident's jacket and push the resident in the wheelchair down to the nurse's station. In an interview on [DATE] at 3:17 PM, Staff Z continued to wear the eye wear on top of their head during the interview. Staff Z stated they were to always wear eye protection with all resident encounters. Staff Z never acknowledged they had their eye wear on ineffectively. In an observation on [DATE] at 1:39 PM, Staff O, LPN, was observed to provide closed contact care to a resident in room [ROOM NUMBER]. The signage outside of the room indicated aerosol contact precautions. Staff O was observed to exit the room and remove their gloves and gown, performed hand hygiene with ABHG and walk down the hallway and place a lunch lid at the nurse's station. Staff O did not remove their N95 and replace with a clean one. Staff O did not disinfect their eye protection. In an interview on [DATE] at 1:41 PM, Staff O confirmed the resident in room [ROOM NUMBER] was COVID-19 positive. Staff O stated they were the nurse for both COVID-19 positive residents and negative residents. Staff O stated they were supposed to discard their N95 anytime they were in close contact with a COVID-19 positive resident and replace with a new one. Staff O stated they were supposed to disinfect their eye protection anytime they were in close contact with a COVID-19 positive resident. Staff O stated I guess I forgot when asked why they did not replace their N95 or why they did not disinfect their eyewear after caring for the COVID-19 positive resident in room [ROOM NUMBER]. In an observation on [DATE] at 9:11 AM, Staff AA, Physical Therapy Assistant (PTA), was observed in a COVID-19 positive residents' room with the door open. Staff AA was observed to be less than 6 feet from the resident while assisting with therapy exercises with the resident and was wearing a gown, gloves, eye wear and a surgical mask. In an interview on [DATE] at 9:19 AM, Staff AA stated they were instructed to wear a N95 respirator for all COVID-19 positive residents. Staff AA stated the reason for only having a surgical mask on was I forgot this time, I thought I was already wearing one. In an observation on [DATE] at 12:57 PM, Staff L, Nursing Assistant Certified (NAC), was observed exiting the room of a COVID-19 positive resident. Staff L was observed to not remove their N95 when they removed their PPE, Staff L did not replace their N95 after providing care to a COVID-19 positive resident. In an observation and interview on [DATE]at 9:06 AM, Staff DD, NAC, was observed to enter a COVID-19 positive room to provide care not wearing a N95 respirator. Staff DD, then exited the room, removed the mask, and placed another one on their face. Staff DD stated they were unaware they were not wearing a N95 as the PPE bin outside of the COVID-19 positive room was stocked with those type of masks. In an observation on [DATE] at 11:40 AM in the South Unit common room there were seventeen residents sitting and only one resident was wearing a surgical mask. Eight of the residents were seated closely together within one to two feet apart. Staff were observed to walk past the residents and did not make efforts to have residents wear a mask. In an observation on [DATE] at 9:11 AM, Resident 50 was observed to not be wearing any source control (face mask) and was observed to be coughing repeatedly and wiping their runny nose with bare hand. Resident 89 was seated less than six feet away. In an observation on [DATE] at 11:01 AM, Staff B, Nurse Manager (NM), was observed to enter a COVID-19 positive resident room with their N95 straps were crisscrossed which is incorrect placement. Staff B then exited the COVID-19 positive room and placed a new N95 on with the straps worn incorrectly. In an observation on [DATE] at 11:41 AM, Resident 50 was observed to not be wearing any source control (face mask) and was observed to be coughing repeatedly and wiping their runny nose with bare hand. Resident 89 was seated less than six feet away. In an observation on [DATE] at 1:20 PM, there were sixteen residents sitting in the common area on the South unit with no source control. There were six residents seated closely together with in one to two feet apart. Staff were observed to walk past the residents and did not make efforts to have residents wear mask. In an observation on [DATE] at 2:14 PM, Resident 50 was observed in the common area of South Unit coughing and wiped their runny nose with a bare hand. In an interview on [DATE] at 8:50 AM, the DNS entered the South Unit and reported that Resident 50 was now positive for COVID-19 virus. <Hand Hygiene> In a review of facility document titled, Glove Use, dated [DATE] stated: - Perform hand hygiene prior to placing gloves on; - Hand hygiene is to be performed immediately after removing gloves; - Gloves are to be changed if they are damaged, soiled following a task, moving from a soiled body site to clean; and - Reference procedures from the CDC. In a review of facility policy titled, Infection Control and Prevention, updated [DATE], stated hand hygiene shall be performed in accordance with the facility established hand hygiene procedures. In a review of the CDC policy titled, Hand Hygiene Guidance, reviewed [DATE], stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove removal. In an observation on [DATE] at 2:38 PM, Staff G was observed to exit a COVID-19 positive resident room, at 2:39 PM they touched the front of their N95 and lifted it away from their face and pulled out the surgical mask underneath the N95. Staff G discarded the surgical mask into the garbage, adjusted their N95 by touching the front of the mask. Staff G did not perform hand hygiene, reached into their shirt pocket, retrieved keys, and unlocked the medication cart. In an observation on [DATE] at 2:54 PM, Staff FF, NAC, was observed to perform incontinent care on a resident. Staff FF performed hand hygiene and placed gloves on their hands and prepared wash clothes to clean resident. Staff FF then approached the resident removed blankets, pants, and opened the resident's adult incontinent brief. Staff FF then stated they needed more items and placed the soiled front of adult incontinent brief over the resident's private area, walked away from the bed, touched the privacy curtain, and went to sink to grab trash bags and more wash clothes. Staff FF did not remove their gloves and did not perform any hand hygiene. Staff FF then reapproached the resident and began to clean the front private area, then tucked the soiled adult incontinent brief under resident and rolled resident on to their side. Staff FF cleaned the backside of the resident where stool was present on the incontinent brief. Staff FF then stated they needed more washcloths, left resident exposed, removed gloves, and grabbed more wash clothes and clean clothes out of the closet. Staff FF did not perform hand hygiene and placed new gloves on. Staff FF returned to finish cleaning the resident, applied a new clean brief and clean pants. Staff F then covered the resident, performed hand hygiene, and went to obtain clean linens to change the bedding. In an interview on [DATE] at 3:38 PM, Staff FF stated they did not perform hand hygiene properly and stated they knew better. Staff FF did not offer a reason as to why they did not perform hand hygiene effectively. <Transmission Based Precautions> Review of the facility isolation sign for Transmission Based Precautions (TBP), titled Aerosol Contact Precautions, undated, stated directions for TBP for COVID-19 positive residents. The sign instructed healthcare workers to keep the door closed. In an observation on [DATE] at 9:40 AM, room [ROOM NUMBER] had visible aerosol contact isolation instructions posted on the door. Resident 99 was visible in room, the door to the room was open. In an observation on [DATE] at 9:52 AM, staff were observed to walk past the room [ROOM NUMBER], and the door was open. In an observation on [DATE] at 11:30 AM, room [ROOM NUMBER] had visible aerosol contact isolation instructions posted on the door. Resident 99 was visible in room, and the door to the room was open. In an observation on [DATE] at 10:32 AM, the room [ROOM NUMBER] had visible aerosol contact isolation instructions posted on the door. Resident 99 was visible in room, and the door to the room was open. <Universal Medical Equipment> Review of the facility policy titled, Novel Coronavirus Prevention and Response, dated [DATE] stated that all non-dedicated medical equipment used for a resident, needs to be cleaned and disinfected before use on another resident. In an observation and interview on [DATE] at 3:06 PM, Staff Z was observed to exit a resident room with a vitals machine cart (which included a blood pressure cuff, thermometer, oximeter, which tests the amount of oxygen in the blood), they walked to the nurse's station with the cart documented in a red binder, then plugged the vitals cart into the electrical outlet on the wall. Staff Z stated the process for reusable medical equipment was to wipe them down with the disinfectant wipes. Staff Z stated they only wiped the vitals cart down with a paper towel in the room and did not offer a reason why they did not follow policy. <Catheter Care> Review of the facility policy titled, Urinary Indwelling Catheters, dated [DATE], sated Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Maintain resident dignity by covering the urinary bag. In an observation on [DATE] at 9:42 AM, Resident 67's catheter bag was visible lying on the ground. The resident was unable to state when the last time the staff were in to care for their catheter bag. In observations on [DATE] at 2:12 PM and [DATE] at 10:30 AM, Resident 31's catheter was not covered under the wheelchair (w/c) and was dragging along the ground with dependent loops. The tubing was close to being caught in the wheels of the w/c. In an observation on [DATE] at 12:44 PM, Resident 79's catheter bag was three quarters full, and bag was attached to bed at head level with no privacy bag. In an observation on [DATE] at 8:54 AM, Resident 79's catheter bag was visible lying on the ground, part of the bag was under the wheels of the over the bed table. The resident was unable to state when the last time the staff were in to care for their catheter bag. In an observation on [DATE] at 9:14 AM, Resident 79's catheter bag was attached to the bed, no privacy bag visible. In an observation on [DATE] at 10:59 AM, Resident 79's catheter bag was attached to the bed, no privacy bag visible. In an interview on [DATE] at 1:30 PM, Staff A, Assistant Director of Nursing/Infection Prevention, stated that during an outbreak they try to encourage residents to wear surgical mask and stay in their rooms as it was an ongoing process all the time. The expectation was staff were disinfecting their eye wear after they care for a resident who has tested positive for COVID-19, and all universal equipment such as vitals carts should be wiped and disinfected after every use regardless of COVID-19 status. Staff A stated that they educate staff on infection control practices at general orientation, and then do competency checks, rounding and on the spot education. Staff A stated they attempt to educate on hand hygiene quarterly. Staff A did not offer a reason as to why staff were not disinfecting their eye wear, changing out their N95, not performing hand hygiene, and disinfection of equipment. In an interview on [DATE] at 2:10 PM, Staff GG, Staff Development Coordinator (SDC), stated they conduct general orientation once a month, but this month was cancelled due to the annual survey. They stated seven staff members were scheduled to attend, and they have already started working in their respected departments. Review of facility documentation packet for newly hired employees provided by the facility on [DATE] at 2:20 PM, had no documentation related to infection control prevention and procedures. The facility failed to ensure staff were wearing the appropriate PPE with working with COVID-19 positive residents, failure to properly disinfect eye protection after contact with a COVID-19 positive resident, there was failure by staff to perform proper hand hygiene during and after care of residents, failure to properly disinfect universal equipment after direct contact with a resident, and failure to ensure appropriate placement of a urinary catheter bag in accordance with infection control standards of practice. These breaches in infection prevention and control practices led to the spread of COVID-19 virus throughout the facility that subsequently led to the outbreak of 35 residents with COVID-19, which resulted in the hospitalization of Resident 110, and the death of Resident 110, Resident 113, and Resident 114. Reference WAC [DATE] (1)(a)(c)(5)(c)(e)

Based on observation, interview and record review, the facility failed to ensure hazardous chemicals were secured on three of six units including the secured Dementia Unit (South). These failures placed cognitively impaired resident's unsecured access to hazardous chemicals. The failure to safely secure hazardous chemicals caused an unsafe environment and placed residents at risk for serious injury, impairment, or death from ingestion of inappropriate substances. An Immediate Jeopardy (IJ) was called on 05/17/2022 at 4:49 PM. The IJ was removed on 05/23/2022 at 2:47 PM, after chemicals were secured and staff was educated on the dangers of unsecured chemicals. Findings included . According to the Safety Data Sheet (SDS), revised 07/22/2020, identified the Q.T. Plus, a disinfectant/cleaner as a dangerous combustible liquid that causes respiratory and skin sensitization, severe skin [CONDITION(S)] and eye damage, and [CONDITION(S)] could result. The hazards included that Q.T. Plus may cause an allergic skin reaction, allergy, asthma symptoms or breathing difficulties if inhaled. The SDS directed staff to store the Q.T. Plus in a well-ventilated place or wear a respirator, store locked up and do not eat or drink when using. The SDS included a warning to store the disinfectant/cleaner in the original container in areas inaccessible to children. <SOUTH UNIT> In an observation on 05/16/2022 at 9:30 AM, the PPE (Personal Protective Equipment) cart outside of room 204 had a container of [MEDICATION(S)] wipes on top of the cart. The wipes were at wheelchair height and accessible to wandering residents in the secured dementia unit. The label read Keep Out of Reach of Children (KOROC). In an observation on 05/16/2022 at 9:38 AM, there was a Sani hand sanitizer wipes container on top of PPE cart outside room 228, containing 70% alcohol. The label showed, if swallowed, get medical help, or contact the Poison Control Center Immediately, the label stated KOROC. At this time, there were two residents observed wandering the halls independently without assistive devices. In an observation on 05/16/2022 at 10:37 AM, 11:00 AM, 11:47 AM, 12:15 PM, 2:35 PM and 3:20 PM, the Sani hand sanitizer wipes remained on top of the PPE cart outside of room 228. In an observation on 05/16/2022 at 10:37 AM, a container of Sani hand sanitizer wipes remained on top of the PPE cart outside of room 228. In an observation on 05/16/2022 at 11:47 AM, a container of Sani hand sanitizer wipes remained on top of the PPE cart outside of room 228. There was one unidentified resident observed nearby wandering in unit with staff accompanying them. In an observation on 05/16/2022 at 12:15 PM, a container of Sani hand sanitizer wipes remained on top of the PPE cart outside of room 228. In an observation on 05/16/2022 at 2:35 PM, a container Sani hand sanitizer wipes remained on top of PPE cart outside of room 228. In an observation on 05/16/2022 at 3:20 PM, Sani hand sanitizer wipes container remained on the top of PPE cart outside of room 228. In an observation and interview on 05/17/2022 at 12:39 PM, Staff M, Housekeeper, left the housekeeping cart unattended to go into the South pantry without their cart. On top of the cart was a one-gallon bucket with a side label indicating it was Q.T. Plus by [NAME]. The lid over the chemicals showed Shoppers Value Strawberry Swirl Ice Cream. Resident 102 was observed to wander out of their room in front of the housekeeping cart. There were no staff present. Review of Resident 102's, 04/29/2022 Quarterly Minimum Data Set (MDS) assessment, showed the resident had severe cognitive impairment and wandering behaviors. The resident was ambulatory and required supervision and used no assistive devices. When Staff M returned to their housekeeping cart at 12:44 AM, they were asked about the unsecured chemicals. Staff M stated it contained Q.T., a cleaner and they always left it on their cart as it was used to clean high touch areas. Staff M stated they were unable to get a new container of Q.T. and needed a lid so they replaced it with the strawberry ice cream one. Staff M stated most of the residents stayed away from their housekeeping cart except (Resident 42). Staff M stated they had to keep Resident 42 away from their cart and mop bucket. Review of Resident 42's 03/28/2022 Quarterly MDS assessment, showed severe cognitive impairment and wandering behaviors that put the resident at risk for physical illness or injury. The resident was able to self-propel around the unit in their wheelchair. In an observation on 05/17/2022 at 12:48 PM, Staff M left their housekeeping cart once again to go out of the secure unit, leaving the Q.T. Plus chemicals unattended. Resident 102 had wandered back into their room and then wandered out of their room again in front of the unsecured chemicals. In a continuous observation on 05/17/2022 at 12:55 PM, seven minutes later, Staff M returned to the unit with a new QT Plus label to put on the top of the chemicals. Staff M stated Staff X, Environmental Services, was going to get the housekeeping staff new Q.T. Plus containers. In a similar observation on 05/17/2022 at 1:03 PM and 1:10 PM, Staff M, left their housekeeping cart with unsecured unattended chemicals on top of the cart while two residents wandered on the unit near the cart without direct supervision. Review of a requested dementia unit audit of cognitive status, and ambulatory status was received on 05/17/2022 at 3:28 PM, revealed there were twenty-five residents with significant cognitive impairment on the South unit. Thirteen of the twenty-five residents were able to ambulate, and nine residents could self-propel in their wheelchair and would have access to unsecured chemicals. An Immediate Jeopardy (IJ) was called on 05/17/2022 at 4:49 PM. In an observation on 05/20/2022 at 11:51 AM, Resident 87 was up in their wheelchair in their room. A container of Sani hand sanitizer wipes was located at the sink. Staff K, Licensed Practical Nurse (LPN), was informed there were unsecured chemicals at the resident's sink. Staff K stated they would let the aide know. <NORTH> In an observation on 05/16/2022 at 10:01 AM, there were two medication cups containing an unknown white substance on the nightstand of Resident 74. In an observation on 05/16/2022 at 11:50 AM, the treatment cart on the North B hallway had Clorox [MEDICATION(S)] Wipes and Sani Cloths containers unsecured and accessible to residents. In an observation on 05/16/2022 at 12:03 PM, there was a jar of Tri-Derma pain reliever cream and a bottle of antifungal powder unsecured on Resident 7's bedside table. The bottles contained the warning of KOROC. <CENTRAL> In an observation on 05/16/2022 at 9:34 AM, the PPE cart outside room 204 had [MEDICATION(S)] wipes on top of the cart. In an observation on 05/17/2022 at 1:41 PM, there was a container labeled Germicidal on the unattended housekeeping cart in the hall between rooms 203 and 205. In an observation on 05/17/2022 at 2:44 PM, Clorox Wipes were on top of the isolation cart outside room 217. On 05/18/2022 at 9:10 AM, there was an in-service posted at the South nurse's station dated 05/17/2022 that showed, Do not leave chemicals unattended. All chemicals must be secured inside the housekeeping cart and or inside the PPE drawers, including disinfectant wipes, hand sanitizers, and chemicals with a label keep out of children. Carts must be locked at all times when unattended including housekeeping carts. PPE bin drawers must be closed after removing an item. In an observation on 05/20/2022 at 9:31 AM, Clorox [MEDICATION(S)] wipes were left unattended on top of housekeeping cart outside room 227. The housekeeper was in the room mopping. There were six residents with cognitive impairment seated nearby. In an observation on 05/20/2022 at 9:33 AM, Staff L, Nursing Assistant Certified (NAC), walked past the housekeeping cart with the unsecured Clorox Wipes on top of the cart. At 9:34 AM, Staff K and Staff L walked past the wipes. At 9:37 AM, Staff K threw a medication cup into the housekeeping cart garbage bin and walked past without securing the chemicals. In an observation on 05/20/2022 at 9:40 AM, Staff N, Housekeeper, was asked about the unsecured and unattended Clorox Wipes located on top of their cart while they were in a room mopping. They stated chemicals should have been locked up. In an interview on 05/23/2022 at 1:52 PM, Staff M, Housekeeper stated they had been in serviced on chemical security and they were not to use ice cream containers for chemical storage. In an interview on 05/25/2022 at 3:15 PM, the Director of Nursing Services (DNS) stated the facility did not have a chemical security or storage policy In an interview on 05/26/2022 at 10:45 AM, Staff B, Nurse Manager, stated the expectation was to secure chemicals and to be alert to residents on the unit and, look out for staff to ensure chemicals were locked up. In a joint interview on 05/17/2022 at 4:49 PM, the Administrator, DNS, and Staff A, Assistant Director of Nursing Services (ADNS), were notified of the identified failure to secure hazardous chemicals, labeled with the warning, Keep out of the reach of children in the South, secured dementia unit and on the North and Central resident hallways. They were informed one resident was observed wandering by the unsecured chemicals covered with a strawberry ice cream lid and staff confirmed another resident (42) had tried to get into their housekeeping cart and mop bucket. Of immediate concern, was the South unit was comprised of twenty-five residents with significant cognitive impairment, thirteen of which could walk around the unit while nine were able to self-propel in their wheelchair. The DNS stated that the health department had advised them to have the wipes accessible for use. In an interview on 05/25/2022 at 3:15 PM, the DNS stated the facility had no policy for securing chemicals. Reference: (WAC) 387-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure that residents were free from abuse for one of three sampled residents (109) reviewed for abuse. This failure placed residents at risk of being abused and the facility not identifying the potential for vulnerable residents being abused. This caused harm to Resident 109 when staff physically and forcibly removed their hands, fingers from an over the bed table as Resident 109 attempted to keep hold of it. Findings included . Review of facility policy titled Abuse, neglect, abandonment, financial exploitation and misappropriation of resident property, revised January 2017, policy purpose stated to ensure prevention, protection, prompt reporting and interventions in response to alleged, suspected or witnessed abuse/neglect/exploitation, misappropriation of resident property and injuries of unknown sources. The policy definition of abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult with resulting physical harm or pain or mental anguish. This also includes inappropriate and/or unauthorized photographing/recording of a resident which may demean or humiliate the resident. Resident 109 was admitted to the facility on [DATE], with most recent admission 10/09/2020, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment of care needs, dated 05/09/2022, indicated the resident had memory issues, with inattention (lack of attention/distraction) and disorganized thinking. The MDS showed the resident required extensive assistance with activities of daily living (ADL's) including bed mobility, dressing, toileting, transfers, personal hygiene, and bathing. Review of the resident's care plan showed interventions that included the resident needed 1:1 supervision when restless, agitated, or exhibited unsafe behavior. The care plan directed the staff to seat the resident at the activity table with hot chocolate, cookies, and a snack. Staff were to anticipate the resident's needs, provide physical and verbal cues to alleviate the resident's anxiety and to reapproach when indicated. In an observation on 05/17/2022 at 12:18 PM, Resident 109 was awake, in their wheelchair slightly tilted back in the common area of the secure unit, rolling their over the bedside table back and forth in front of their wheelchair, holding on to it with both hands. In a continuous observation on 05/17/2022 at 12:38 PM, Resident 109 was continuing to roll their over the bedside table back and forth in front of them, while seated in their wheelchair in the units common area. Resident 109 raised their left hand to staff as they walked by. Three staff members were observed to walk by the resident and did not acknowledge the resident. At 12:47 PM Staff O, Licensed Practical Nurse (LPN), moved the resident's wheelchair slightly in the common area as they were holding on to the over bedside table in front of the resident. Staff O was observed to forcefully remove the resident's hands from the over the bedside table multiple times. On 05/17/2022 at 1:50 PM, the Administrator was informed of the observation regarding Staff O and Resident 109. In an interview on 05/20/2022 at 11:40 AM, Staff K, LPN, stated that they try to lay the resident down in their room when they were waving their arms, attempting to grab at staff or attempting to get up from their wheelchair. Staff K stated that the resident did not like to be alone. In an interview on 05/20/2022 at 1:23 PM with Staff EE, Nursing Assistant Certified, stated that interventions were in place for Resident 109 if they were reaching out, restless, or agitated. We have access to fidget toys, snacks, cookies, hot chocolate, and one to one interaction. On 05/24/2022 at 01:33 PM the surveyor demonstrated to the Director of Nursing Services and Staff A how Staff O forcibly removed the resident's hands and fingers from the over the bedside table. WAC Reference 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to protect 3 of 24 cognitively impaired residents (10, 9, and 3) who resided in a secured dementia unit from physical abuse from Resident 4. The facility failed to take action to protect residents from Resident 4's aggressive behaviors to prevent continued resident to resident physical altercations. This failure resulted in harm to the residents who experienced pain and emotional distress and placed all the residents residing in the secured unit at risk of potential harm from Resident 4. Findings include: RESIDENT 4 Resident 4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 resided in the secured dementia care unit of the facility, the resident ambulated independently and was not interviewable. Resident 4 was observed walking around or watching television in the living room area where all the residents congregate. RESIDENT 10 Resident 10 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation report dated 11/18/18, indicated Resident 10 was standing in front of the television, in the living room, dancing. Resident 4 asked Resident 10 to move out of the way but due to Resident 10's dementia, he did not understand and did not move. Resident 4 then pushed Resident 10 to the floor, Resident 10 received a 1 cm x 0.5 skin tear to the right elbow, and the resident complained of pain to his lower back. The facility determined to prevent re-occurrence, staff were educated to not leave Resident 4 in the common area unattended. RESIDENT 9 Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided in the secured dementia unit of the facility. The resident was observed sitting in the living room common area, and was speaking out loud in an incoherent manner. The resident was not interviewable. Review of a facility investigation report dated 1/08/19, indicated, staff heard yelling from the living room. Resident 4 was observed sitting next to Resident 9 and had a hold of Resident 9's left arm. Resident 4 would not let go, even after 3 staff members assisted. Staff documented that Resident 9 was upset and crying and she sustained 2 nail indentations to her left wrist, and it was noted red and sore. The facility determined to prevent re-occurrence Resident 4 was not to be left alone with other residents when in the common area. RESIDENT 3 Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided in the secured dementia unit of the facility, the resident was observed sitting in the living room area. The resident was not interviewable. Review of a facility investigation report dated 1/12/19, indicated a nurse heard a loud slap. She looked up, to see Resident 4 standing over Resident 3. Resident 3 was holding the left side of her face stating, He hit me hard. The facility documented to prevent re-occurrence. Staff were to continue with current interventions of, when the resident was in the common area, not to be left unattended with other residents. In addition, there was to be a consultation with the pharmacy and the provider during an interdisciplinary meeting. Record review revealed no evidence that the interdisciplinary meeting, consultation with the pharmacy and the provider had occurred. In an interview on 01/22/2019 at 2:54 PM, Staff D, the resident care manager for the dementia unit, stated Resident 4 had been living in the facility since (MONTH) and had not had any signs of aggressive behaviors. Staff D stated, these incidents have all come as a surprise because there had been no warning, they happened so fast. Staff D was asked what was being done to ensure the residents were safe from Resident 4's abuse, Staff D, stated, Resident 4 is not being left alone with any residents. At this point we don't know what else to do. When asked if an interdisciplinary meeting had occurred to discuss Resident 4's abusive behaviors, Staff D, stated, No, we have a care conference scheduled for later this week. In an interview on 01/23/19 at 9:08 AM, Staff E, a nursing assistant, that works in the memory care unit, stated, Resident 4 was very unpredictable, staff are always working on the floor, we try to keep the residents safe from him (Resident 4), but he is so quick, you just never know when he is going to strike. In an interview on 01/23/19 at 10:15 AM, Staff F, the Social Services Director, was asked about Social Services involvement with Resident 4 who has had various resident to resident physical altercations. Staff F stated he did not know much about it. When asked if social services had been involved in assessing the resident's aggressive behaviors, triggers, interventions that had been attempted and worked or not worked etc. Staff D stated no, not that he was aware. In an interview with the facility Administrator on 1/23/19 at 10:22AM, the Administrator verified the meeting had not occurred. When asked what the facility was doing to ensure the residents living in the secured unit were safe from abuse from Resident 4, the Administrator stated, he was not sure and would have to speak to the Resident Care Manager of the unit. The facility failed to take actions in (MONTH) of (YEAR) to keep all resident, who lived in the dementia unit safe from Resident 4's aggressive and physical behaviors. In addition, the facility failed to complete an interdisciplinary resident assessment and develop care planning interventions to address Resident 4's behavior of physical aggression. Without having completed this, the facility was unable to provide sufficient protection to prevent resident to resident abuse. WAC Reference 388-97-0640(1)

Based on observation, interview and record review the facility failed to prevent an accident for one of four residents reviewed (1). The failure to supervise/assist Resident 1 with consuming hot beverages in bed resulted in harm. Resident 1 sustained a second degree burn to the left thigh and had the potential to place other residents at risk for injury and a diminished quality of life. Findings included . Review of the facility's undated policy and procedure titled, Hot Liquid Spills, showed coffee brewing stations temperature would be set at 165 degrees. If a resident was noted to have difficulty or unsafe use of regular cups then an assessment will be done for needed interventions which may include a two handled cup, a lidded cup or an Occupational Therapy evaluation. Resident Care Guides would reflect individual safety measures needed to promote safety in drinking hot liquids. Resident 1 admitted to the facility on [DATE]. The resident was on hospice care following a stroke and showed a continued decline in her condition. Review of the quarterly Minimum Data Set assessment dated [DATE], showed Resident 1 had severe cognitive impairment. The resident required extensive assistance of 2 persons for bed mobility, and extensive assistance of 1 person for transfers, dressing, personal hygiene, toileting, bathing, locomotion, and eating. Review of the resident's typed Resident Care Guide (guide for resident care for Nursing Assistant (NA) use), dated 01/29/18, revealed the resident had short-term memory problems, needed cues/supervision, had difficulty paying attention at times, experienced periods of lethargy, and had varying mental function. Review of the handwritten Resident Care Guide dated 03/2018, revealed the resident required set-up to extensive assist for meals and required increased assistance when weaker/tired. Review of a facility investigation dated 04/25/18, revealed Staff B, NA, served Resident 1 coffee in a sippy cup at 7:30 AM, then left the room to pass coffee to other residents. Staff B returned to Resident 1's room at 7:45 AM, and found the coffee cup was turned over on the resident's lap. Staff B removed the bedding and discovered a reddened area on top of the resident's left thigh. Resident 1 told Staff B she she had spilled her coffee. The red area measured 17.5 centimeters (cm) by 11 cm. The facility concluded the reasonable cause of injury was the resident spilled coffee and did not realize she needed to call for help or move the cup to prevent further damage. The facility identified the resident's cognitive status was oriented to person only and predisposing factors included confusion and weakness. There was no documentation found indicating the temperature of the coffee at the time of the spill. Review of the investigation notes dated 05/01/18, revealed the resident can feed herself during the start of meals and requires encouragement and assistance with feeding for completion depending on her level of fatigue. There was a reddened area on top of the left thigh that measured 17.5 cc by 11 cm, with a 14.5 cm by 2.5 cm clear fluid filled blister. Review of Advanced Registered Nurse Practitioner note dated 05/01/18, revealed the resident sustained [REDACTED]. The wound measured 14.5 cm by 2.5 cm by 0.1 cm. On 05/03/18 at 1:35 PM, observations of Resident 1 revealed a wound to her left upper posterior thigh measuring approximately 7 inches by 2 inches. The wound bed was primarily whitish slough (yellow or white tissue that adheres to the wound bed in strings or thick clumps) surrounded by reddened tissue. During an interview on 05/04/18 at 12:10 PM, Resident 1 stated I think I just fell asleep and dropped my coffee, I sleep through everything. I even slept through getting my nails cut yesterday. At 1:30 PM, the Director of Nursing Services (DNS) stated hot beverage temperatures were done by the kitchen. The DNS stated the kitchen put the coffee out on the units in thermos carafes at approximately 6:55 AM every day and the temperature was at 160 degrees. The DNS stated the facility did not have any formal screening/assessments to determine resident safety with hot beverages. The DNS stated if staff observed a resident had difficulty with handling their cup they should report it so changes could be initiated and/or occupational therapy evaluation could be ordered. At 2:06 PM, Staff C, Licensed Nurse, stated he was not aware of specific monitoring of Resident 1 or any assessments staff completed for safety with hot beverages prior to the coffee spill. Staff C stated the only safety intervention in place for Resident 1 was the use of a sippy cup with 2 handles. On 5/18/18 at 2:41 PM, the DNS confirmed the facility did not have a form/process for assessment of resident safety with hot liquids. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure effective pharmaceutical services procedures were in place to ensure accurate resident identification prior to administering medications for 1 of 7 residents (246) observed during medication pass. This failure resulted in Resident 246 receiving 10 medications that were ordered for another resident with the same first name. Additional failed practice included 7 licensed nurses (Staff V, Q, W, S, F, R, E ) being unfamiliar with specific facility policy regarding resident identification prior to medication administration, and a facility failure to implement the name tag policy regarding residents with the same first names. These failures resulted in an Immediate Jeopardy (IJ) related to pharmaceutical services on 06/08/17. The facility reviewed/revised their policies and procedures and provided training to licensed nurses, which led to the removal of the IJ on 06/09/17. Findings include: RESIDENT 246 The resident was admitted to the facility in April 2017 with [DIAGNOSES REDACTED]. Review of the resident's Resident Care Guide, print date 06/09/17, revealed I need cues and supervision I have difficulty finding words and difficulty finishing thoughts. I have severe cognitive deficits with deficits in memory and attention. During an observation of a medication pass on 06/08/17 at 9:26 AM, Staff C, Licensed Nurse (LN), was observed to have administered 10 medications to Resident 246, that were ordered for Resident 43, who had the same first name. Staff C was observed to address Resident 246 by her first name, but she did not ask her what her name was, and she was not observed to otherwise verify the resident's identity. Resident 246 was not wearing an identification arm band and the name tag outside the resident's room door only included her first name. Review of the resident's 06/08/17 progress notes revealed she complained of nausea and vomited at 2:43 PM, and then she refused dinner due to nausea. In an interview on 06/09/17 at 10:43 AM, Resident 246 was able to state her first and last names. Review of a Medication Error Report, dated 06/08/17, revealed the Reason for Error(s) was Failure to identify resident. Review of the Client Summary (Resident Roster) form, dated 06/05/17, revealed the facility had 33 residents with first names that were the same or similar to other residents. There were also 3 other residents with the same first name as Resident 246. Review of Staff C's personnel file and training records revealed no specific documentation she had received training or had a competency evaluation related to how the facility expected her to accurately identify residents prior to administration of medications. FACILITY POLICY/PROCEDURES Review of the facility policy Procedure for Medication Administration, dated 03/09/11, revealed Never, Never . Administer a medication or treatment without identifying the Patient by an arm band or photo I.D Ask resident to tell you their name. Review of the Licensed Staff Forms and Procedures Orientation packet, undated, revealed: 1. Page 1b, Follow the basic 5 rights for medication administration - identify the resident, . (It did not state how to identify the resident). 2. Page 22, Rights of Medication Administration for Nurses (2012), 1. Right patient: Use 2 Identifiers. (It did not state which identifiers to use). Review of the Resident Door Photos and Name Tags Procedure, dated 01/13/12, revealed: Procedure: 1. Each new admit must have a name tag and a photo next to their room. 2.a name tag must be written with the patient's first name (and last initial if first name is same as another patient). SAME/SIMILAR FIRST-NAME RESIDENTS AND OBSERVATIONS In an observation on 06/08/17 at 1:46 PM, outside of Resident 60's room, the name tag had the resident's first name with last name initial, however, no picture was posted. In an observation at 2:07 PM, outside of Resident 127's room, there was a name tag with the same first name as Resident 60, and there was a picture, but there was no last name initial. In an observation on 06/08/17 at 1:51 PM, outside Resident 11's room, there was a name alert posting, however there was no picture or last name initial. In an observation outside of Resident 78's room at 1:52 PM, there was a name tag with the same first name as Resident 11, there was a name alert present with the resident's picture, but no last name initial was present. In an observation on 06/08/17 at 1:53 PM, the following rooms on the South locked unit had name alert signs on the room doors with the following information posted or missing: 1. Resident 9 had no last name or last name initial on door name tag, this resident had the same or similar first name as 2 other residents in the facility. 2. Resident 110 had no last name initial on door name tag, this resident had the same first name as 3 other residents in the facility. 3. Resident 83 had no last name initial on door name tag, this resident had the same or similar first name as 2 other residents in the facility. 4. Resident 170 had no last name initial on door name tag, this resident had the same or similar first name as 2 other residents in the facility. In an observation made on 06/08/17 at 1:36 PM outside of Resident 43's room, the name tag near the door had the resident's photo and first name, but no last name initial. Resident 246's room name tag had the resident's photo and first name listed, but no last name initial. Residents 246 & 43 had the same first names. In an additional observation in the north hall on 06/08/17 at 1:36 PM, the room name tags outside of Resident 85's room and Resident 152's room were noted to have the same first name. The resident's photos and first names were posted on the name tags outside of the doors, however no last name initials were used. The name tags did have name alert stickers next to their names. In a walking tour of the North Hall on 06/08/17 at 2:42 PM, 3 residents were observed sitting near the nurse's station. No wrist bands were observed on the residents. During this walking tour, 12 residents were observed in the Sunflower Dining Room playing bingo. No wrist bands were observed on the residents. In observations on 06/08/17 at 2:31 PM, Resident 116's room name tag had the same first name as Resident 13. Resident 116's room name tag had the first name and last initial, but Resident 13's room name tag had only the first name and not the last name initial. And, on the same hallway, there were 2 more residents with the same first names, Resident's 185 & 92, both residents room name tags had only their first names, and not the last name initial. LICENSED NURSE INTERVIEWS In an interview on 06/08/17 at 11:00 AM, the Director of Nursing Services (DNS) stated Licensed Nurses (LN) were to identify residents prior to administering medications by looking at the MAR (Medication Administration Records) and the picture on the door, and residents ought to be able to say their name. The DNS stated Staff C, LN, had been immediately sent home and was suspended pending completion of the investigation. In an interview on 06/08/17 at 11:30 AM, Staff S, Resident Care Manager/LN, stated medication nurses were to identify residents using the 5 rights, look at pictures on door, or look at resident wrist bands (if residents had them - some residents may not have them due to resident preference). She stated facility policy was to look at the resident's wrist band or the picture in the electronic record. She stated the facility had a name alert system for residents with the same name, there should be a name alert outside resident's door and on the spine of the paper chart at nurse's station. In an interview at 11:30 AM, Staff Q, Resident Care Manager/LN, stated nurses should use the 5 rights when identifying a resident prior to administering a medication (right person, medication, route, dose, time). We do have a policy for identifying residents but I don't know what it says, I would have to look it up and I can get it for you. She went on to state the facility's name alert system was a name alert sticker on the spine of the resident's paper chart and just now they added a name alert notification to the electronic charting record so now it will alert the nurse of residents with same/similar names. In an interview on at 11:32 AM, Staff F, LN, was asked how nurses identify residents before administering a medication, she stated, On the computer there is a picture of the resident. On the door is another picture, residents do not wear bracelets or nametags, or don't like to wear them. Staff nurses usually call the resident by first name and last name. When asked about what the facility policy for identifying residents before giving medication was, Staff F said 5 rights. When asked if there was a name alert system or process in place, Staff F stated On paper chart is a sticker. I have not seen a name alert system in the computer. In an interview at 11:35 AM, Staff R, LN, stated when he was delivering medications, he looked at resident's wristbands (if they had one), he tried to catch residents in their rooms, or he asked the resident to tell him their name. He stated the facility policy to identify a resident for medication pass was to look at the electronic chart picture, wrist band, or to ask resident to state their name. Staff R stated the name alert system for residents with the same name was there was something on spine of paper chart at nurse's station or a flag on outside of resident's door to let others know that there was another resident with same first name. In an interview at 11:41 AM, Staff V, LN, stated to identify a resident when administering medications: I ask for their name; first and last, date of birth and make sure the name on the medication card matches and the picture on the electronic medication administration record (MAR) matches. Staff V stated she did not know specifically what the facility policy stated on how to identifiy a resident, but she was trained by her nurse manager to follow the procedure that she just stated, and she received training on the electronic charting system from her nurse manager too, there is a formal manual and at the end of the training we signed off. She stated there was nothing that showed up on the MAR to alert the nurse their name was the same or similar to another resident. In an interview at 11:47 AM, Staff W, LN, stated she identified a resident prior to medication pass by their first name and checked their photos on the computer and the door. If I am not familiar with the resident I would ask another staff member who has worked more with the resident. I would look at their photos on the MAR and the door, but sometimes they do look different. She stated she was not sure what the facility policy for identifying residents prior to medication pass was and she would have to check on that. When asked about the facility's policy on a name alert system for residents with the same/similar names she stated there was a name alert sticker on the paper chart and she believed they put it at the door but was not 100% sure of that. In an interview 11:51 AM, when asked how nurses identified residents before giving a medication, Staff E, LN, said Nurses are expected to double check names, room numbers to the medication order in the computer, picture on the computer, paper chart and door. When asked what the policy was for identifying residents as a whole, Staff E said I'm not sure, but there should be one and I could get it for you. I will have to look. Regarding a facility name alert system or process, Staff E stated Double checking the charts and adding names into the computer charts. I think they have a name alert system, I have not seen a name alert system. In an interview on 06/09/17 at 9:55 AM, with the Assistant Director of Nursing Services (ADNS), she provided a copy of Licensed Staff Forms and Procedures Orientation, she referenced the page for protocol to identify a resident, it stated to use two identifiers (the identifiers were not defined). She stated, Many of our residents have bracelet identifiers, but many choose not to wear them. When asked how the facility alerted staff of residents with the same or similar names, the ADNS stated they did not have a process for that; but the DNS was working on it. Upon comprehensive review of facility policy, and policy implementation, it was concluded the facility did not have effective safeguards in place to prevent future resident identification failures. Facility policy failed to provide staff with specific guidance on how to ensure accurate resident identification in a setting with many residents with the same/similar names, varied cognitive abilities, changing physical appearances/pictures, and varied utilization of resident identification name bands/room name tags. Reference: WAC 388-97-1300(1)(b)(ii)(3)(a)(4)(a)(i) Refer to: F332, CFR 483.45(f) - Medication Errors

Based on interview and record review, the facility staff failed to recognize and evaluate environmental hazards in the building and intervene to maintain safety for Resident 2. Failure to assess the area of damp carpet as a potential safety hazard, adequately supervise and consistently implement nursing interventions to protect residents resulted in a fall with harm of a fractured arm and pelvis for Resident 2 and placed other residents at risk of falls. Findings include: Resident 2 was admitted in September in 2008 with multiple [DIAGNOSES REDACTED]. She needed one person assistance for transfer, standing and walking. She used a walker as a mobility device. Her care plan identified a history of falls and a continuing risk for falls. During the morning of 09/09/13, Staff A and Staff B entered the special care unit and cleaned a large area of soiled hallway carpet. The carpet was damp after the cleaning process was completed. About 4:45 p.m. that afternoon, Resident 2 was found lying on the floor with her walker sideways on the ground and her legs under it. Nursing assessment identified an abrasion, about 3 centimeters (cm) x 3 cm on her left shoulder and another bruise on her left forehead. Additionally, Resident 2 complained of pain in her right shoulder. Resident 2 told staff she slipped on the "wet carpet." Resident 2 reiterated she slipped on the carpet, including pointing to the carpet, to other staff members later that same day. The next morning, 09/10/13, Resident 2 complained of pain in her right should and refused to get out of bed for breakfast. Resident 2 was sent to the hospital where x-ray identified a fracture to her right humerus and pelvis. She returned to the building with an arm immobilizer (sling) on the right arm. On 10/10/13 at 10:10 a.m., Resident 2 was observed seated in a chair in the hallway wearing a sling/arm immobilizer on her right arm. She was able to recall she fell , but she was unable to provide any details. She advised the investigator to be careful when the investigator prepared to walk away down the hallway. On 10/15/13 at 10:20 a.m., Staff A reported she was one of the two staff who cleaned the hallway carpet on 09/09/13. A staff person told her of Resident 2's fall a couple of days after it happened. Staff A recalled there were multiple spill stains on the hallway carpet over a large area. It was very dirty in many places. Staff A stated usually housekeeping cleaned only part of the carpet and left part for later cleaning. In this instance, because of the spills, the hallway carpet was very dirty. On 09/09/13, Staff A explained to the nursing staff she and Staff B would clean the entire hallway carpet, a larger area than usual. Staff A stated nursing staff said this was ok. Staff A and Staff B placed signs cautioning the damp carpet at the ends of the hallways and around the living room area after the cleaning was completed. They also placed mats at the entrance to each resident room, so when a person stepped from the freshly cleaned carpet, they would step onto the mat to wipe/dry their feet and then onto the linoleum flooring of the rooms. This was a safety precaution against slipping on the floors with wet footwear. Staff A stated they told the nurses the carpet was wet. Staff A reported she saw Resident 2 stand up from the chair in the hallway and she told the nurses to remind Resident 2 of the wet carpet. Resident 2 independently entered her room, used the bathroom facility and returned to the chair in the hallway that was surrounded by damp carpet. Staff A was concerned Resident 2 used the chair in that hallway where they had cleaned the carpet. She told the nurses to watch Resident 2 and be careful. Staff A stated the nurses acknowledged her statement and told her Resident 2 was fine. At 11:10 a.m., Staff C reported she was in the unit where Resident 2 resides on 09/09/13. Staff C stated housekeeping should do "only half of a half of hallway" when cleaning carpet. Generally, they clean sections only, not such a large area. Staff C stated a couple of other staff told her the carpet seemed "wetter" than usual and Staff C noticed this as well. She wondered whether the equipment worked properly when the carpet was cleaned, but she did not ask anyone about it. Staff C reported Resident 2 consistently told different staff members that she slipped on the "wet" carpet. On 10/16/13 at 12:15 p.m., the Administrator reported he reenacted the carpet cleaning procedure and found the equipment worked as it should, extracting the moisture as expected. He stated the carpet was slightly "damp" after the cleaning. Review of the facility investigation revealed evidence of documentation Resident 2 and multiple staff wrote Resident 2 slipped on "wet" carpet. Review of the care plan for Resident 2, dated 06/19/13, revealed Resident 2 required "extensive assist" with transfer as well as walking at times. She used a walker for ambulation. Additionally, Resident 2 had a history of [REDACTED].

Based on interview and record review, facility staff failed to implement their process to prevent an accident for 1 of 4 sample residents (Resident 5). The failure of nursing staff to communicate new interventions to protect Resident 5 from reoccurence of a fall resulted in harm when she fell and fractured her right leg. Findings include: Resident 5 entered the facility in July 2013 with multiple [DIAGNOSES REDACTED]. Her care plan identified staff needed to remind her to use her call light and ask for assistance rather than attempt to perform tasks independently. Additionally, she was a one assist with either a walker or wheelchair for mobility. On 08/18/13 at 2:40 p.m., staff found Resident 5 on the floor in the doorway to the bathroom. Her wheelchair was close to her. Resident 5 stated she wheeled herself to the bathroom. When she attempted to self-transfer back into the wheelchair, she fell down on the floor. Assessment found a 1 centimeter laceration on her left wrist. Resident 5 complained of pain in her back and head. Review of the facility investigation revealed staff cleansed and dressed the laceration on Resident 5's left wrist. The next day small bruises were noted along her back. The facility placed Resident 5 on alert charting and monitored her vital signs (blood pressure, temperature, pulse, respirations) and level of consciousness. The plan to prevent future incidents instructed staff to not leave Resident 5 alone in her wheelchair whenever she was up in her room. This new intervention was added to her care guide for safety on 08/23/13. Review of the clinical record revealed on 08/19/13 nursing noted Resident 5 had to void every 2-3 hours during the day and evening. She "requires extensive assist to toilet for safety." On 08/25/13 at 12:40 p.m., Resident 5 was found on the floor of her bathroom. She attempted to transfer from the toilet to her wheelchair. Assessment found her right leg turned "inward" and she complained of pain in the right leg/ankle area. Resident 5 went to the hospital where an x-ray identified a fracture of her lower right leg. On 09/18/13 at 3:50 p.m., Staff 2 reported the facility policy directed all staff who changed/updated a resident's care guide to also fill out a care guide change form and place it on the dedicated location where each shift, all staff reviewed it for new updates to residents' care guides. Staff 3 failed to follow the process and appropriately place a care guide change form in the dedicated location for all staff review. Review of the facility investigation revealed Staff 3 failed to follow the facility process of communicating the new safety intervention - do not leave Resident 5 alone in her wheelchair - added to the care guide on 08/23/13 to all other staff. Without that information, staff followed the known interventions and left Resident 5 alone in the bathroom on 08/25/13 when she fell .

Based on interview and record review, the facility failed to prevent significant medication errors for one of eight sample residents (#1). This failure resulted in harm for Resident #1, who had to be hospitalized due to a decreased level of consciousness. Findings include: Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Along with the admission paperwork from the hospital was a notation the resident was allergic to [MEDICATION NAME]. This was also indicated by a large sticker placed on the outside jacket of her chart at the nursing home. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, there was no mention of the allergy to [MEDICATION NAME]. On 12/3/11 at approximately 8:00 p.m., Staff A, an LPN, administered another resident's medications to Resident #1, including 100 milligrams of [MEDICATION NAME]. Once the error was acknowledged, the nurse contacted the physician and an order for [REDACTED]. The resident was placed on alert charting, which included frequent checks. According to documentation in the facility's investigation, the resident was sleepy, but alert and responded to her name during the night. On the following morning at 11:00 a.m., Resident #1 failed to respond to verbal stimuli or to a sternal rub. The physician was again contacted and an order for [REDACTED]. 911 was called and the resident was admitted to a local hospital. According to the hospital admission notes, the resident was "slow to clear" and was experiencing hallucinations. Several more doses of [MEDICATION NAME] were administered. As of 12/14/11, the resident remained in the hospital. A review of the facility investigation dated 12/4/11, found Staff A acknowledged she had prepared medication for another resident, but the resident was not able to take his medication at that time. The nurse placed the medications back in the medication cart in a labeled cup. Staff A then prepared to give medication to Resident #1, but the nurse was called away from her medication cart. She placed Resident #1's medication in a labeled cup and locked it in her cart. Upon returning, the nurse picked up the wrong, previously prepared cup of medication and gave it to Resident #1. The investigation concluded the nurse did not follow facility policy and procedure which included the right medication, the right route, the right time, the right dose, and the right resident. She was in-serviced on the correct procedures and received disciplinary action. During observations on 12/13/11 at 8:20 a.m., the surveyor watched four nurses administer morning medications to residents. When asked, all four nurses informed the surveyor there had been recent in-servicing to the nursing staff as the result of a recent medication error. .

Based on record review and interview, the facility failed to maintain a supply of Narcan, an emergency medication stocked by the facility for use in treating emergent adverse side effects of narcotics. This failure resulted in harm to one of eight sample residents (#1) when the resident had to be hospitalized due to a decreased level of consciousness associated with a medication error. Findings Include: Resident #1 was given the wrong medication which included morphine, a narcotic, on 12/3/11 at approximately 8:00 p.m. Once the error was made, the facility gave two doses of Narcan from the emergency kit, leaving no remaining medication. The facility did not have a policy pertaining to the reordering of emergency medications. The pharmacy was not contacted by the facility to have additional Narcan delivered. The following morning, the resident was nonresponsive. an order for [REDACTED]. During an interview with the facility Administrator on 12/13/11 at 11 a.m., he concurred the facility failed to obtain a supply of Narcan from the pharmacy. Refer to CRF 483.25(m)(2) F 333 Residents free of significant med errors