Every finding on record at Briarwood at Timber Ridge

Based on observations, interview, and record review the facility failed to ensure food was stored and prepared in accordance with professional standards of safety. The failure to ensure: (1) open foods were labeled and dated, (2) kitchen fan and ice machines were monitored and cleaned, and (3) kitchen garbage/trash receptacles were covered as required placed residents at risk for ingesting expired and/or contaminated food and the development of food-borne illness.Findings included .<Facility Policy>The facility policy titled, Food Receiving and Storage, revised 03/2024, showed foods would be received and stored in a manner that complied with safe food handling practices. The policy showed dry foods that were stored in bins and all foods stored in the refrigerator or freezer would be covered, labeled, and dated ( use by date) appropriately. The policy showed food services staff would maintain clean food storage and preparation areas at all times.<Dry Storage>Observation on 12/10/2025 at 8:18 AM with Staff G (Sous Chef) showed six bottles of assorted sauces and cooking condiments and one bottle of chocolate syrup that were open but undated; several bottles had dried-up drips along the sides of the bottle cap. There were two packages of dry cashew and walnuts that were left open and uncovered.In an interview on 12/10/2025 at 8:36 AM, Staff G confirmed the foods observed to be opened, undated, and left uncovered and stated the dietary staff were expected to date opened foods and to cover them for resident safety in preventing foodborne illness.<Walk-In Refrigerator #1>Observation on 12/10/2025 at 8:55 AM showed three kinds of partially cut-up cheeses and one package of soybean paste that were opened and undated.In an interview on 12/10/2025 at 9:05 AM, Staff G stated it was important to label and date cheeses because they were moist, could grow molds, and was dangerous to eat especially if they expired. Staff G stated these items should be labeled and dated after opening, but they were not.<Freezer>Observation on 12/10/2025 at 9:13 AM showed one package of ground meat, one package of frozen pasta tortellini, and one package of freezer-burned salami that were open and undated. There were two slices of individually wrapped steak inside a grocery bag tucked behind the boxes of frozen foods that were unlabeled and undated.In an interview on 12/10/2025 at 9:19 AM, Staff E (Executive Chef) validated the food items observed and stated all opened food items in the freezer must be labeled and dated according to their facility policy. Staff E stated the individually wrapped steaks found inside the grocery bag were for a resident and they should be labeled, but they were not.<Kitchen Fan>Observation and interview on 12/10/2025 at 9:39 AM showed a short, stand-up fan was placed on top of metal table by the dishwasher; it was turned on, dirty, and heavily covered with black dust build-up along the blades and outer mesh cover blowing onto the dishes and utensils there were being air-dried. Staff E turned the fan off and stated it should be cleaned weekly by the kitchen staff for food safety.<Ice Machines>Observation and interview on 12/16/2025 at 10:34 AM showed the two ice machines located in the main kitchen had brownish, dirt build-up inside the upper chamber. Staff E stated they were unsure as to who was responsible for monitoring the machine's cleanliness.Review of the May 2025 - November 2025 Ice Machine Monthly Cleaning Log provided by Staff P (Facility Dietician) showed the protocol that was used in cleaning the ice machine located at the skilled nursing unit. The log outlined the ice machine's cleaning process, the date it was cleaned, and who was the person responsible.In an interview on 12/16/2025 at 10:42 AM, Staff F (Food and Beverage Director) stated there were no monthly cleaning logs for both the ice machines located in the main kitchen, [We] will start doing them moving forward.<Kitchen Trash/Garbage Bins>Observation on 12/10/2025 at 8:48 AM showed five garbage/trash bins were actively used in the kitchen during food preparation; three were round and two were rectangular lined with a black garbage bags and they were all without lids/cover.In an interview on 12/10/2025 at 8:51 AM, Staff G stated the facility was in the process of switching vendors and garbage lids were in order. Staff G stated it was important for trash/garbage bins to have a lid/cover to avoid cross-contamination during food handling and preparation, thus preventing foodborne illness.REFERENCE: WAC 388-97-1100 (3), -2980.

Based on observation, interview, and record review the facility failed to ensure essential equipment including the dishwasher, walk-in refrigerator, and freezer thermostat (a device that regulated a heating or cooling system to maintain a set temperature) located in the main central kitchen were maintained and kept in safe operating conditions. These failures placed the residents at risk for infection with using improperly sanitized dishes and utensils during meals, consuming foods stored in unsafe temperatures, and the development of foodborne illness.Findings included.<Facility Policy>The facility policy titled, Food Receiving and Storage, revised 03/2024, showed functioning of the refrigeration and food temperatures would be monitored at designated intervals throughout the day by the food and nutrition services manager or designee. The policy showed its monitoring would be documented according to state-specific requirements.The facility policy titled, Sanitization, revised 11/2022, showed dishwashing machines were operated according to the manufacturer's instructions. The policy showed dishwashing machines had preventative maintenance programs in place to monitor the equipment for proper operation.< Manufacturer's Instructions - Dishwasher>According to the 09/2024 CMA High-Temperature Conveyor Dish Machine manufacturer instructions manual provided by the facility, the safe operating temperatures specified for this essential equipment were 150-160 degrees Fahrenheit (F) for the Wash Cycle and 180-195F for the Final Rinse Cycle.<Main Kitchen Dishwasher>Observation and interview on 12/10/2025 at 9:48 AM during an actual run cycle of the main kitchen's dishwashing machine with Staff E (Executive Chef) and the dishwasher-on-duty showed the wash temperature registered at 145 F and the rinse temperature registered at 140 F after the run cycle was completed. Staff E stated the dishwasher was the high-temperature type of dish machine.Observation and interview on 12/10/2025 at 9:54 AM during a second-time actual run cycle of the main kitchen's dishwashing machine with Staff E and Staff H (Lead Cook-Kitchen Staff) showed both the wash and rinse temperatures registered at 148 F after the run cycle was completed and did not reach safe operating temperatures as specified in the manufacturer's instructions. The cleaning test strip indicator placed by Staff E on the test plate showed a gray color which indicated the plate was not cleaned and sanitized properly. Staff E stated Staff H was in charge of monitoring the dishwasher for safe operating temperatures.Review of the December 2025 Kitchen Dishwashing Temperature Log showed there was no monitoring completed on 12/10/2025 to confirm the dishwasher was within safe operating temperatures.In an interview on 12/10/2025 at 9:58 AM, Staff H stated it was important for the dishwasher to run at safe operating temperatures to ensure proper sanitation, .it is how germs and bacteria are killed.residents use these [dishes/utensils] to eat with during their daily meals, so it is necessary that the recommended temperatures are reached when washing to prevent foodborne illness.Review of the 12/11/2025 Preventative Maintenance Summary conducted by a third party service provider showed the dishwasher was malfunctioning as the equipment would not fill or heat. The summary showed repair by another company was advised and that parts needed to be replaced.In an interview on 12/11/2025 at 10:08 AM, Staff E stated they utilized the three-compartment sink (a dishwashing method that used chemicals as the sanitizing agent) for washing the dishes after the dishwasher malfunction was identified. Staff E stated the parts needed to repair the dishwasher were ordered.<Walk-In Refrigerator - Bakery>Review of the December 2025 Daily Temperature Log for the walk-in refrigerator where the desserts were stored before meal service showed the temperature was monitored twice during the day (AM) and in the afternoon (PM), and the kitchen staff were instructed to notify the supervisor if the temperature was over 40 F. The log showed on 12/04/2025, the PM temperature logged was 47 F; on 12/06/2025, 12/07/2025, and 12/08/2025, both the AM and the PM temperatures logged were 42 F; on 12/09/2025, the AM temperature logged was 42 F; and on 12/10/2025, the AM temperature logged was 41 F.Observation on 12/10/2025 at 8:40 AM showed dessert items were brought inside the walk-in refrigerator by a kitchen staff despite a temperature reading of 43 F as shown on the thermostat. Inside the refrigerator, ready-to-eat food items and several pans of baked cake were observed stacked up on metal racks.In an interview on 12/10/2025 at 9:08 AM, Staff G (Sous Chef) stated the walk-in refrigerator was broken and should not be in use because the temperature readings, both logged and observed, were above the parameters. Staff G stated there was a work service order sent to check and/or repair the refrigerator. Staff G stated it was important to keep foods stored at the right temperatures to avoid reaching the danger zone (40 F to 140 F- the range where bacteria multiply rapidly, causing foodborne illness).<Freezer Thermostat>Review of the December 2025 Daily Temperature Log for the freezer showed the temperature was monitored twice during the day (AM) and in the afternoon (PM), and the kitchen staff were instructed to notify the supervisor if the temperature was over 0 F. The log showed on 12/01/2025, the AM temperature logged was 2 F; on 12/03/2025, the AM temperature logged was 8 F and the PM temperature logged was 7 F; on 12/04/2025, the PM temperature logged was 1 F; on 12/05/2025, 12/06/2025, 12/07/2025 and 12/08/2025, both the AM and the PM temperatures logged were 6 F; and on 12/09/2025, the PM temperature logged was 3 F.On 12/10/2025 at 9:13 AM, observation of the freezer thermostat located by the wall adjacent to the door with Staff E showed the temperature registered at 2.5 F; the device was observed externally wired from the thermostat box, wedged between the freezer door and the door jam, and was threaded inside the freezer.In an observation and interview on 12/10/2025 at 9:19 AM, Staff E stated, [Freezer] has been opened and is probably defrosting.the temperature should be back to negative in 10 minutes. Staff E went inside the freezer and obtained a small, round thermometer located in one of the top shelf racks; the temperature reading on the thermometer was observed to be 2 F. At 10:01 AM, the freezer thermostat's temperature reading was 2.7 F and remained outside the safe parameters.In an interview on 12/16/2025 at 10:43 AM, Staff E stated it was important to ensure state-specific recommended temperatures were maintained at all times for food safety. Staff E stated the replacement of the freezer thermostat device was in the works but the process to have kitchen equipment replaced was a very slow process.REFERENCE: WAC 388-97-2100.

Based on observation, interview, and record review the facility failed to develop, implement and/or ensure residents' comprehensive care plans accurately reflected care needs for 2 of 12 (Residents 26 & 15) residents reviewed for care planning. These failures placed residents at risk for unidentified and/or unmet care needs, medical complications and a diminished quality of life.Findings included .<Resident 26>According to the 10/21/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 26 had clear speech, impaired memory, and was assessed to require substantial/maximal assistance from staff with grooming/personal hygiene.Review of the revised 10/20/2025 Activities of Daily Living (ADL) Care Plan (CP) showed Resident 26 needed assistance with their ADLs as they were unable to perform them independently. The CP did not show Resident 26 needed substantial/maximal assistance with their grooming/personal hygiene as assessed in their MDS.On 12/10/2025 at 10:36 AM, Resident 26 was observed with facial hair/stubbles, bushy eyebrows, and long unkempt hair. There were white flakes covering both the shoulders and upper chest portion of Resident 26's shirt.In an interview on 12/16/2025 at 2:31 PM, Staff B (Director of Nursing) reviewed Resident 26's CP and stated the resident's need for grooming assistance should be captured, but it was not. Staff B stated they expected resident CP's to be complete, accurate, and revised accordingly because it was what the staff goes by when providing daily care for residents. <Resident 15>According to the 10/01/2025 Quarterly MDS, Resident 15 had clear speech, impaired memory, and was assessed to require partial/moderate assistance from staff with eating. The MDS showed Resident 15 was dependent on staff for their oral hygiene.An 11/24/2025 dental visit note showed Resident 15 had a lower removable partial denture and the resident needed staff assistance with daily denture removal and cleaning.Review of the revised 01/30/2024 ADL CP showed Resident 15 needed assistance with their ADLs as they were unable to perform them independently due to limited mobility and weakness. The CP did not show Resident 15 required partial/moderate assistance from staff with eating as assessed in their MDS. The CP did not show Resident 15 had a lower partial denture and required staff assistance with putting them in and taking out.On 12/12/2025 at 12:14 PM, Resident 15 was observed receiving one on one eating assistance from Staff J (Certified Nursing Assistant) and the resident was not wearing their lower partial denture; it was observed left in the cup by the sink in Resident 15's room.In an interview on 12/16/2025 at 10:15 AM, Staff B reviewed Resident 15's CP and stated both the level of assistance needed by the resident while eating and their current use of a lower partial denture should be captured in the CP, but they were not.Refer to F677 - ADL Care Provided for Dependent Residents.REFERENCE: WAC 388-97-1020(1), (2)(a)(b).

Based on observations, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 3 (Resident 3, 14, & 6) of 12 residents whose CPs were reviewed. These failures left residents at risk for inappropriate care, unmet care needs, and other negative health outcomes. Findings included.<Facility Policy> Review of the facility's Care Plans policy, revised 03/2022, showed CPs would be revised as information about the resident and/or the resident's condition changed. <Resident 3> According to the 10/03/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 3 was able to make their needs known, had memory loss, clear speech, could make themself understood and usually could understand others. The MDS showed Resident 3 had limited range of motion to one leg, used a walker or wheelchair, and required moderate assistance with toileting, bathing, dressing, and personal hygiene. Observations made on 12/10/2025 at 9:25 AM ,12/11/2025 at 9:32 AM, and 12/15/2025 at 11:15 AM showed Resident 3 in a wheelchair with a hard boot on their left lower leg. In an interview on 12/15/2025 at 8:33 AM with Residents 3's Collateral Contact (CC), the CC stated Resident 3 wore a hard boot to the left lower leg and a regular shoe on the right foot. The CC stated Resident 3 could bear some weight to their left lower leg, but they barely put any weight on it when standing. Review of Resident 3's Pressure Wound CP, revised 05/30/2025, directed staff that the resident could not bear weight to their left lower extremity and to check the left foot every shift while Resident 3 was wearing the boot. The CP did not provide directions to staff on how to manage the hard boot, if staff should remove the boot, for how long, and how often the boot must be worn. During an interview on 12/16/2025 at 10:56 AM, Staff Q (Resident Care Manager) stated Resident 3 was non-weight bearing to their left leg because of the wound on the left foot. Staff Q stated the wound healed about four weeks ago and Resident 3 was now able to bear weight to the left foot. Staff Q stated the CP should be updated and revised to reflect the current weight bearing status for Resident 3 and directions for staff on how to manage the hard boot. <Resident 14> According to the 10/13/2025 Quarterly MDS, Resident 14 had severe cognitive impairment. The MDS showed Resident 14 required substantial/maximal assistance from staff with eating. Observation on 12/11/2025 at 11:30 AM showed Resident 14 seated at a table in the dining room for lunch. Staff served Resident 14 their lunch at 11:38 AM. Resident 14 was looking around at other residents and falling asleep. Staff were not observed to provide cueing or eating assistance to the resident. After continuous observation with no staff intervention, Resident 14 was approached by the surveyor at 11:57 AM. At this time, Staff M (Certified Nursing Assistant) stood up, cut up Resident 14's food, and gave the resident their first bite of lunch. Review of Resident 14's I need help with [activities of daily living] . CP, revised on 08/12/2025, showed the resident only required set up assistance from staff with their meals in the dining room. The CP did not show Resident 14 required substantial/maximal assistance from staff with eating. In an interview on 12/16/2025 at 9:45 AM, Staff B (Director of Nursing) stated they expected Resident 14's CP to be revised and direct staff to provide the level of assistance with eating the resident required. <Resident 6> According to the 10/06/2025 Quarterly MDS, Resident 6 had clear speech, impaired memory, and was assessed to require supervision or touching assistance with walking. The MDS showed Resident 6 had a fall and sustained a major injury during the assessment period. Review of the 08/12/2025 facility incident report showed Resident 6 fell at the parking lot of a restaurant while they were out with their family. The report showed Resident 6 was taken to the hospital and was diagnosed with a mildly displaced left collarbone. An 08/12/2025 nursing progress note showed Resident 6 was discharged from the hospital with an arm sling and had left arm non-weight bearing restrictions. Review of Resident 6's CP showed a 04/09/2025 fall CP indicating Resident 6 was at risk for falls and injuries due to their unsteady gait/balance and weakness. An 08/14/2025 CP intervention listed showed therapy recommended non-weight bearing to the left arm with continuous sling use. An 08/14/2025 fall incident CP outlined Resident 6's actual fall on 08/12/2025 and included a 12/09/2025 CP intervention indicating 25% weight bearing limitation on the resident's left arm. In an observation and interview on 12/11/2025 at 10:49 AM, Resident 6 was observed lying in bed and was not wearing a sling to support their left arm. Resident 6 stated they fell badly a while ago, could not recall exactly when, but was feeling much better. In an observation and interview on 12/11/2025 at 12:33 PM, Resident 6 was walking to their spot at the dining room for lunch; they were not wearing a sling. Resident 6 was using their left arm while eating their meal. When asked if they were supposed to be wearing a sling and not using their left arm, Resident 6 stated they did not need to put the sling on anymore and could now use their left arm but with caution. Review of Resident 6's physician orders showed the resident's left arm non-weight bearing restriction and sling use was discontinued on 09/26/2025. In an interview on 12/16/2025 at 2:31 PM, Staff B stated they expected resident CP's to be complete, accurate, and revised accordingly because it was what the staff goes by when providing care for residents. Staff B reviewed Resident 6's CP and stated the two weight bearing restrictions written in the CP were conflicting. Staff B stated Resident 6's CP should be revised when the sling use was discontinued, but it was not. Refer to F677 – ADL Care Provided for Dependent Residents. REFERENCE: WAC 388-97-1020(2)(c)(d).

Based on observation, interview, and record review the facility failed to ensure non-pharmaceutical interventions were in place, pain medications had parameters for residents receiving multiple pain medications, physician's orders were clarified, and staff followed post dialysis orders for 3 (Residents 8, 3 & 18) of 12 residents whose orders were reviewed. These failures placed residents at risk for ineffective treatments, medication errors, and delayed treatments.Findings included.<Pain Medication Parameters & Non-Pharmaceutical Interventions> <Resident 8> According to the 10/13/2025 Comprehensive Minimum Data Set (MDS - an assessment tool), Resident 8 was able to make their needs known, had memory impairment, had clear speech, was able to understand and be understood by others. The MDS showed Resident 8 had diagnoses including an upper arm fracture, pain, and muscle spasms. The MDS showed Resident 8 was assessed with occasional pain that interfered with therapy activities and activities of daily living. Review of the at risk for pain due to a left arm fracture care plan, revised 10/24/2025, directed staff to offer and administer pain medications according to the physician order. The care plan directed staff to encourage the resident to try different pain relieving measures, such as re-positioning and relaxation therapy. Review of Resident 8's December 2025 Medication Administration Record (MAR) showed a 10/10/2025 physicians order for an Over the Counter (OTC) pain medication to be administered every four hours as needed for pain. The order showed insert pain scale and no pain scale or parameters were observed. An additional physician order, dated 10/28/2025 showed a narcotic pain medication to be administered every six hours as needed for moderate to severe pain. The December 2025 MAR showed Resident 8 received narcotic pain medication on 12/05/2025 and 12/07/2025 for pain 4 out of 10, on a scale of 10. Review of December 2025 Treatment Administration Record (TAR) showed a physician order directing staff to observe for pain and offer non-pharmacological interventions to reduce pain. The TAR showed eight different interventions to offer, numbered one through eight. The TAR did not show what interventions were offered and what interventions were effective. In an observation and interview on 12/11/2025 at 10:24 AM, Resident 8 was observed in bed. Resident 8 stated they had pain to their left shoulder, the fracture was not surgically repaired, and they were anxious about having another fall. During an interview on 12/16/2025 at 10:21 AM Staff Q (Resident Care Manager) stated Resident 8's pain medication orders should have pain parameters in place to direct staff what pain medication to dispense for the pain level. Staff Q stated non-pharmacological interventions attempted and the outcome should be documented on the TAR. <Resident 3> According to the 10/03/2025 Quarterly MDS, Resident 3 was able to make their needs known, had impaired memory, and required staff assistance with toileting, dressing, and bathing. The MDS showed Resident 3 had diagnoses including non-traumatic brain disfunction, dementia, and anxiety. The MDS showed Resident 3 was assessed with no current pain. Review of a pain care plan, revised 07/25/2025, showed Resident 3 was at risk for pain due to arthritis. The care plan directed staff to assess pain every shift by using a pain scale, to attempt non-pharmacological methods for reducing pain, and to offer and document pain medications. Review of Resident 3's December 2025 MAR showed Resident 3 had a 04/04/2023 physicians order for an OTC pain medication to be administered every four hours as needed for pain. An additional physician's order showed a narcotic pain medication to be administered every four hours for moderate to severe pain. Review of December 2025 TAR showed a physician order directing staff to observe for pain and offer non-pharmacological interventions to reduce pain. The TAR showed eight different interventions to offer, numbered one through eight. The TAR did not show what interventions were offered and what interventions were effective. In an observation and interview on 12/15/2025 at 8:33 AM, Resident 3 was observed sitting in a chair. Resident 3 stated their left foot hurt at times but not frequently. During an interview on 1216/2025 at 10:21 AM, Staff Q stated when a a resident had multiple pain medications prescribed the nurse should administer the OTC medication for pain 1-3 out of 10 and administer the narcotic pain medication for pain 4-10 out of 10 on the pain scale. Staff Q stated there was a pain scale located on the nurses medication cart the nurse could use to assess pain. Review of the pain scale located on the nurses cart showed a pain scale that utilized facial expressions to assess pain for non-verbal residents who could not express their pain. When asked if Resident 3 could verbalize and express their pain, Staff Q stated, yes they could. When asked how the pain scale was determined for Resident 3, Staff Q stated each resident had a pain assessment completed and the results of the pain assessment determined what non-pharmacological interventions would be used. Staff Q stated Resident 3's pain medication orders should have parameters to direct nurses on which medication to administer for the pain level indicated and they would expect nurses to attempt and document non-pharmacological interventions before administering pain medications. In an interview on 12/16/2025 at 10:28 AM, Staff R (Licensed Practical Nurse), stated they did not use the non-verbal pain scale for residents who were able to verbally rate their pain on a scale and able to express pain or discomfort. Staff R stated the pain medication orders should have parameters to direct what pain medication to administer. <Clarifying Physician Orders> <Resident 3> Observations made on 12/10/2025 at 9:25 AM ,12/11/2025 at 9:32 AM, and 12/15/2025 at 8:33 AM and 11:35 AM, showed Resident 3 in a wheelchair with a hard boot on their left lower leg. In an interview on 12/16/2025 at 8:33 AM Resident 4's Collateral Contact (CC) stated Resident 4 could bare weight on their left foot. The CC stated Resident 4 wore the boot due to a wound on the left foot. Review of a 12/13/2025 Kardex (quick access to key resident information used by caregivers) showed Resident 3 was non weight bearing to the left lower extremity. Review of Resident 3's physician orders, showed an 11/13/2025 order directing staff to assess the resident's left foot condition when wearing the crow boot. The order directed staff to monitor the left foot twice daily for any signs of skin impairment. Review of the physician orders showed no order directing staff if Resident 3 was able bare weight on the left foot, able to take off the boot, for how long, or directions on how to manage the boot during showers. The physician orders showed no order directing staff what to do if the bandage to the left foot was dislodged or soiled, or orders for treatment to the left foot as needed. Review of Resident 3's At risk for skin breakdown care plan, revised 07/25/2025, directed staff to monitor the skin under the left boot for skin impairments. Review of the comprehensive care plan showed no other directions for staff on how to manage the crow boot During an interview on 12/16/2025 at 10:56 AM, Staff Q stated Resident 3 wore a boot to the left foot due to a wound. Staff Q stated Resident 3 was non-weight bearing but now could bare weight on the left foot as the wound healed. Staff Q stated there was not but should be a physician order and a care plan for Resident 3's boot that directed staff on how to manage the boot. Staff Q stated Resident 3's Kardex should reflect their current weight bearing status. <Resident 18> Review of Resident 18's 12/05/2025 admission MDS showed the resident had a diagnosis of kidney disease and received dialysis (life sustaining medical treatment that filtered waste products from the blood when the kidneys failed). Review of Resident 18's 12/09/2025 hemodialysis care plan showed the resident had dialysis three times weekly on Monday, Wednesday, and Friday mornings. Review of Resident 18's 12/2025 TAR showed a 12/05/2025 order directing staff to complete the pre and post dialysis assessment on Mondays, Wednesdays, and Fridays at 7:00 AM. The order included a space where staff documented the resident's vitals before leaving for dialysis. A second 12/05/2025 order directed staff to complete the pre and post dialysis assessment per dialysis schedule on [Monday, Wednesday, Friday every night shift on Tuesday, Thursday, Sunday]. This order showed staff were documenting on the TAR Resident 18's vitals at 11:00 PM the following evening on Tuesdays, Thursdays, and Sundays and showed staff were not assessing the resident's vitals upon their return from dialysis on Mondays, Wednesdays, and Fridays. Observation on Monday, 12/15/2025 at 12:59 PM, showed Resident 18 was back from their dialysis appointment and was lying in bed. In an interview on 12/16/2025 at 9:51 AM, Staff B (Director of Nursing) stated staff were supposed to monitor Resident 18's vital signs upon their return from the dialysis center. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the assistance they required for 3 (Residents 14, 26, & 15) of 3 residents and 1 (Resident 3) supplemental resident reviewed for assistance with ADLs. The failure to provide assistance with putting on compression stockings, eating assistance, and grooming/personal hygiene left residents at risk for embarrassment, poor hygiene, and other negative health outcomes.Findings included.<Facility Policy>According to the facility's Activities of Daily Living policy, revised 03/2018, care and services would be provided to residents who were unable to carry out ADLs independently. Staff would provide appropriate support and assistance with hygiene, mobility, using the restroom, dining, and communication. <Resident 3> According to the 10/03/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 3 was able to make their needs known, had memory loss, and required moderate staff assistance with toileting, bathing, dressing, putting on, and taking off footwear. Review of resident 3's edema (swelling caused by excess fluid) care plan, revised 07/25/2025, showed Resident 3 had swelling in both lower legs. The care plan directed staff to apply knee high compression stockings in the morning and remove the compression stockings at night. Observations on 12/10/2025 at 9:25 AM ,12/11/2025 at 9:32 AM, and 12/15/2025 at 8:33 AM and 11:35 AM showed Resident 3 in a wheelchair with a hard boot on their left lower leg and no compression stockings on their lower legs. In an interview on 12/15/2025 at 8:33 AM, Resident 3's Collateral Contact (CC) stated Resident 3 was not supposed to wear compression stockings because the resident had a wound to their left foot. During an observation and interview on 12/15/2025 at 11:01 AM, Resident 3 was observed sitting in a recliner after having a shower. Staff R (Licensed Practical Nurse) was observed assessing Resident 3's left foot wound, the wound was healed, and Staff R stated they observed swelling to Resident 3's ankles that was pitting (an indentation in the skin after being pushed indicating fluid retention in the lower legs). In an interview on 12/16/2025 at 10:56 AM, Staff Q (Resident Care Manager) stated Resident 3 wore compression stockings for swelling in their lower extremities. Staff Q stated Resident 3's wound healed three to four weeks ago, there was an active physician order, and care plan for compression stockings. Staff Q stated staff should assist Resident 3 with putting on and removing the compression stockings and they expected Resident 3 to be wearing compression stockings as ordered by the physician. <Resident 14> According to the 10/13/2025 Quarterly MDS, Resident 14 had severe cognitive impairment. The MDS showed Resident 14 required substantial/maximal assistance from staff with eating. Review of Resident 14's 05/12/2023 ADL care plan showed the resident required assistance from staff to set their meals up in the dining room. The care plan did not show Resident 14 required substantial/maximal assistance from staff for eating their meals. Observation on 12/11/2025 at 11:30 AM showed Resident 14 sitting at a table in the dining room with four other residents who were being assisted with their lunch meal. At 11:38 AM, host staff served the resident their lunch. Resident 14 was falling asleep and not touching their lunch. In an interview at 11:57 AM, Staff L (Certified Nursing Assistant - CNA) stated Resident 14 had behaviors and often declined assistance. In a continuous observation from 11:30 AM to 11:57 AM, facility staff did not assist or offer assistance to Resident 14 with their lunch. Observation on 12/12/2025 at 8:45 AM showed Resident 14 at a table with their breakfast tray. No staff were sitting with the resident. Resident 14 was not eating their breakfast and kept falling asleep. Most of Resident 14's breakfast remained on the plate. At 8:48 AM, Staff M (CNA) sitting at a nearby table, began calling for Resident 14 by name, attempting to wake the resident up. Staff M did not get up from the table or go over to Resident 14. At that time, Staff B (Director of Nursing) approached Resident 14 and woke the resident up. Staff M, who was still at another table, called to Resident 14 and stated eat your food from afar. In an interview on 12/15/2025 at 10:46 AM, Staff N (CNA) stated they were very familiar with Resident 14. Staff N stated Resident 14 needed help to eat stating the resident could drink on their own and did well with finger food but needed verbal cueing. Staff N stated We have to tell [them] to eat or [they] get distracted. In an interview on 12/16/2025 at 9:45 AM, Staff B stated Resident 14 used to be more independent with their meals, but staff recently noticed the resident was requiring more help with dining assistance. Staff B acknowledged staff should provide Resident 14 assistance with their meals as the resident required. <Resident 26> According to the 10/21/2025 admission MDS, Resident 26 had clear speech, impaired memory, and was assessed to require substantial/maximal assistance from staff with dressing, grooming, and personal hygiene. Review of the revised 10/20/2025 ADL care plan showed Resident 26 needed assistance with their ADLs including dressing. The care plan showed Resident 26 was unable to perform ADLs independently due to their limited mobility and weakness. The care plan did not show Resident 26 needed substantial/maximal assistance with their grooming/personal hygiene as assessed in their MDS. In an observation and interview on 12/10/2025 at 10:36 AM, Resident 26 was observed with facial hair/stubble, bushy eyebrows, and long unkempt hair. There were white flakes covering both shoulders and upper chest portion of their shirt. Resident 26 stated the staff did not help them with shaving but the resident would like to have assistance. In an observation and interview on 12/12/2025 at 9:07 AM, Resident 26 was sitting up in their room eating breakfast; their facial hair was noted to be more pronounced, and their eyebrows and hair were in the same condition as previously observed. Resident 26 stated they got their haircut from the first floor salon in the facility. Resident 26 stated they would like their eyebrows trimmed and have a haircut but could not do it on their own. In an interview on 12/12/2025 at 9:18 AM, Staff K (Unit Coordinator) stated Resident 26 received their last haircut from the first floor salon on 09/11/2025. In an interview on 12/12/2025 at 9:33 AM, Staff I (CNA) stated they used and referred to the care plan when providing ADL care to residents for safety. Staff I stated grooming/personal hygiene for male residents included giving showers, shaving the facial hair, and nail care. Staff I looked at Resident 26 inside their room and confirmed the resident needed grooming/personal hygiene care and their shirt changed. In an interview on 12/16/2025 at 10:26 AM, Staff B stated they expected the nursing staff to provide ADL assistance to residents who were assessed to need them for safety, dignity, and quality of life. <Resident 15> According to the 10/01/2025 Quarterly MDS, Resident 15 had clear speech, impaired memory, and was assessed to require partial/moderate assistance from staff with eating. The MDS showed Resident 15 was dependent on staff for their oral hygiene because the resident did not have the ability to insert and remove their dentures. An 11/24/2025 dental visit note showed Resident 15 had a lower removable partial denture and the resident needed staff assistance with daily denture removal and cleaning. Review of the revised 01/30/2024 ADL care plan showed Resident 15 needed assistance with their ADLs as they were unable to perform them independently due to limited mobility and weakness. The care plan did not show Resident 15 required partial/moderate assistance from staff with eating as assessed in their MDS. The care plan did not show Resident 15 had a partial denture that required staff assistance with putting on and taking off especially during meals. In an observation and interview on 12/12/2025 at 12:14 PM, Resident 15 was observed receiving one on one eating assistance from Staff J (CNA) and was not wearing their lower partial denture; it was observed left in the cup by the sink in Resident 15's room. Staff J stated they were aware Resident 15 had a lower partial denture. When asked if Resident 15 was wearing them, Staff J stated, I think so, I am not sure. Staff I confirmed Resident 15 did not have their denture in while eating. In an interview on 12/16/2025 at 10:15 AM, Staff B stated it was important to ensure residents were properly assisted by the nursing staff with putting their dentures on, especially before eating, so residents could tolerate their diet textures effectively and prevent any unnecessary chewing discomfort. Refer to F656 – Care Plan Development and Implementation. Refer to F657 - Care Plan Timing and Revision. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to ensure 3 (Resident 5, 8, & 7) of 12 residents reviewed received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure residents with diabetes (disease in which the body fails to control blood sugar levels) received appropriate monitoring and had orders in place for emergent changes in blood sugar levels for 1 (Resident 5) of 1 diabetic residents, failed to implement skin preventative measures for 1 (Resident 8) of 12 residents reviewed, and failed to follow the facility bowel protocol for 1 (Resident 7) of 12 residents reviewed. These failures placed all residents at risk for unmet care needs, uncontrolled diabetes, skin breakdown, prolonged constipation, pain, and a diminished quality of life. Findings included .<Facility Policy>According to the facility Diabetes- Clinical Protocol, policy revised 03/2025 showed residents prescribed insulin would have their blood glucose monitored three to four times daily. The policy showed the facility would monitor the resident's Hemoglobin a1C ((Ha1C)a blood test showing average blood glucose levels over the past three months) on admission and every six months after. The policy showed the staff and the provider would monitor for and manage any episodes of low blood sugar or high blood sugar by following the facility protocol and informing the provider as soon as possible.Review of the undated facility policy titled, Bowel and Bladder Management, showed all residents would be initially assessed for elimination status, including risk factors and care needs as part of the admission nursing assessment and it would be utilized by the staff to guide resident care. The policy showed the bowel management program included dietary interventions, evaluation of bowel movement patterns, and administration of bowel medications as ordered.<Diabetes Management> <Resident 5> Review of Resident 5's 10/17/2025, Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 5 had clear speech, was able to understand and be understood, and had memory impairment. The MDS showed Resident 5 had medically complex conditions, including diabetes, heart failure, and kidney disease. The MDS showed Resident 5 received insulin (an injectable medication used to treat diabetes) daily, during the look back period of the MDS assessment. Review of Resident 5's diabetes care plan, revised 05/23/2025, directed staff to monitor for signs and symptoms of low or high blood sugar. The care plan directed staff to monitor Resident 5's Ha1C (blood test that measured average blood sugar levels over 2 - 3 months) as ordered by the physician. Review of Resident 5's physician orders showed two orders for insulin and directed staff to hold the insulin if Resident 5's blood sugar was below 70 or greater than 350. The physician orders did not include as needed orders to direct staff how to manage a low or high blood sugar level. No orders were observed for emergency medications, such as glucagon (an injection that treats extremely low blood sugar) for an urgent situation when a resident could not swallow or was unconscious. No physician orders were found to perform Ha1C testing every six months per the facility policy or per Resident 5's care plan interventions. Review of Resident 5's lab results, showed a 04/30/2025 Ha1C blood test with abnormally high results. Review of Resident 5's record showed no follow-up testing or additional Ha1C tests every six months. In an observation and interview on 12/11/2025 12:56 PM Resident 5 stated they had their finger poked five times a day, sometimes their fingers hurt, and they took insulin before every meal and at night. During an interview on 12/16/2025 at 9:30 Am Staff B (Director of Nursing) stated they expected residents with diabetes to have Ha1C testing every six months. Staff B stated Resident 5's Ha1C should be re-tested and an Ha1C lab done at least every six months. Staff B reviewed Resident 5's physician orders and stated they expected a physician order to monitor and manage any episodes of low or high blood sugar levels. <Skin Preventative Measures> <Resident 8> According to 10/13/2025 Comprehensive MDS, Resident 8 was able to make their needs known, had clear speech, was able to understand others, and be understood. The MDS showed Resident 8 had medical diagnoses including an upper arm fracture, pain, anxiety, and muscle spasms. Review of the Skin Conditions section of the MDS showed Resident 8 had no current skin conditions. Review of a 10/27/2025, Braden Scale (an assessment tool used to determine risk for pressure injury) showed staff assessed Resident 8 to be at risk for skin issues due to occasional moisture, their ability to walk severely limited, and potential friction and shearing problems when in bed. Review of the at risk for skin breakdown care plan, dated 10/24/2025, showed a goal to maintain intact skin for Resident 8. The care plan interventions directed staff to educate the resident and representative on multiple factors to maintain skin integrity and directed staff to utilize pressure relieving surfaces. In an observation and interview on 12/11/2025 at 10:24 AM, Resident 8 was observed in bed on their back, with a tray table in front of them. When asked if they had any open wounds, Resident 8 stated they had a mole removed on their left front shin area about a year ago and it was very slow to heal. Resident 8's leg was observed with a dry circular area of scabbed skin and a small opened area. During an interview and observation on 12/15/2025 at 11:25 AM, Staff Q (Resident Care Manager) observed Resident 8's leg and stated they were not sure how the open area got missed on the admission and weekly skin checks. Staff Q was asked to observe Resident 8's heels that were resting on the bed. Staff Q stated the heels were a little red but were blanchable (skin turned white when pressed on and quickly returned to red indicating blood flow to the tissue). Resident 8's heels were observed to be red, soft, dimpled, and mushy. The right heel had a slight discoloration at the center of the heel bone and when Staff Q pressed on the area, Resident 8 winced in pain. In an interview on 12/16/2025 at 12:14 PM, Staff Q stated Resident 8 rarely got out of bed due to their anxiety and fear of falling. Staff Q stated there should be skin preventative measures in place, on the care plan, and the Kardex (quick directions to staff regarding specific resident care) to inform staff of Resident 8's risk and prevent pressure injuries. <Bowel Management> <Resident 7> According to the 10/07/2025 admission MDS, Resident 7 had clear speech, impaired memory, and frequent bowel incontinence. The MDS showed Resident 7 was assessed to require substantial/maximal assistance from staff with toileting. Review of Resident 7's active diagnosis list showed a 10/01/2025 diagnosis of unspecified constipation (a condition characterized by difficulty in emptying the bowels, usually associated with hardened feces). The 10/02/2025 bowel care plan showed Resident 7 was at risk for altered bowel elimination and a care plan intervention directed the nursing staff to administer bowel medications per the facility protocol if the resident did not have a bowel movement for two days. The 10/14/2025 pain care plan showed Resident 7 was taking pain medications and the staff were instructed to monitor the resident for side effects including constipation. In an observation and interview on 12/10/2025 at 10:50 AM, Resident 7 was observed bent over crooked in bed; restless and uncomfortable. Resident 7 stated they felt the urge and needed to have a bowel movement, but could not. Resident 7 stated they suffered from constipation and did not have a bowel movement in days but could not exactly recall how many. In an observation and interview on 12/10/2025 at 11:01 AM, Staff O (Registered Nurse) stated Resident 7 had ongoing constipation issues. Staff O went to Resident 7's room, gave the resident the bowel protocol medication, and documented the administration in the Medication Administration Record (MAR). Record review of Resident 7's 11/2025 bowel monitoring log showed the resident had no bowel movement for two days on 11/09/2025 – 11/11/2025, 11/15/2025 – 11/17/2025, and 11/22/2025 – 11/24/2025. Review of Resident 7's progress notes from 11/09/2025 until 11/24/2025 did not show the nursing staff evaluated the resident's bowel movement pattern and the lack thereof or notified the physician for further evaluation and/or treatment. Review of the November 2025 MAR showed Resident 7 received stool bulk-forming medication every two days to help with their bowel movement. The MAR showed the nursing staff did not administer any additional bowel medications per the facility protocol to address and manage Resident 7's lack of bowel movement for two days as care planned. In an interview on 12/16/2025 at 2:09 PM, Staff B stated it was important to follow the facility's bowel protocol because, when residents did not have a bowel movement within 48 hours, it could cause ill-effects such as abdominal pain, vomiting, and loss of appetite. Staff B reviewed Resident 7's MAR and confirmed the facility's bowel protocol was not provided to the resident when needed. Staff B stated they expect the nursing staff to administer bowel medications per the facility protocol and to document the administration in the MAR. REFERENCE: WAC 388-97-1060(1).

Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were completed monthly and recommendations were reviewed and acted upon for 2 (Resident 3 & 5) of 5 residents reviewed for unnecessary medications. This failure placed all residents at risk for delays in necessary medication changes and at risk for adverse side effects. Findings included . <Facility Policy> According to the facility's Medication Regimen Review policy, revised 03/01/2017, the facility would maintain each resident's highest practicable level of functioning by helping them utilize medication appropriately and prevent or minimize adverse consequences related to medication therapy. The pharmacist would provide the facility Director of Nursing and the Medical Director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions.<Resident 3>Review of a 10/03/2025 Quarterly Minimum Data Set (MDS - an assessment tool), showed Resident 3 was able to make their needs known, required assistance with decisions, had clear speech, impaired memory, could make self understood, and usually could understand others. The MDS showed Resident 3 had medical diagnoses including non-traumatic brain dysfunction, dementia (progressive memory and cognitive function loss disorder), anxiety, and depression. The MDS showed Resident 3 had indications for use of high risk medications and had received antipsychotics, antidepressants, and anticonvulsants within the last seven days prior to the MDS assessment. Review of Resident 3's medical record showed the facility pharmacist completed an MRR for 10/01/2025-10/31/2025 and made recommendations for medication changes on 10/19/2025. The MMR showed staff did not act upon the recommendations until 17 days later. Similar findings for Resident 3's pharmacist MRR for 11/01/2025-11/30/2025, showed the pharmacist made recommendations on 11/10/2025 that were not implemented by facility staff until 21 days later on 12/01/2025. <Resident 5>Review of a 10/17/2025 Quarterly MDS showed Resident 5 was able to make their needs known, had memory loss, was able to understand and be understood. The MDS showed Resident 5 had medically complex diagnoses including heart failure, high blood pressure, diabetes (inability for their body to regulate blood sugar levels), swelling, and kidney disease. The MDS showed Resident 5 had indications for and received injectable diabetes medications and medications to treat their swelling during the seven day look back period. Review of a facility provided binder showed no indication that Resident 5's MRR occurred for the month of October 2025. Review of Resident 5's medical record showed the facility pharmacist completed an MRR for 09/01/20255-09/30/2025, and made recommendations on 09/13/2025. These recommendations were not acted upon or implemented until 16 days later on 09/29/2025. Similar findings for Resident 5's MMR for 11/01/2025-11/30/2025, showed the pharmacist made recommendations on 11/10/2025 that were not implemented by facility staff until 21 days later on 12/01/2025. During an interview on 12/16/2025 at 9:46 AM, Staff B (Director of Nursing) stated they expected staff to inform the resident representatives of the recommendations before medication changes were made and this could create a delay if the resident representative did not respond timely. Staff B acknowledged the pharmacist recommendations were delayed for Resident 3 and Resident 5, and stated they would expect staff to act upon and implement pharmacist recommendations within a week to ten days. REFERENCE: WAC 388-97-1300(4)(c).

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 (Residents 34 & 3) of 12 residents whose records were reviewed. Staff failure to include interdisciplinary team notes from behavior meetings including physician documentation regarding Gradual Dose Reduction (GDR) decisions placed residents at risk for unmet care needs and risk for receiving unnecessary psychotropic medications.Findings included.<Resident 34> Review of Resident 34's 09/24/2025 Annual Minimum Data Set (MDS – an assessment tool) showed the resident had diagnoses including anxiety and depression. The MDS showed Resident 34 received an antianxiety and antidepressant medications during the assessment period. Review of Resident 34's 12/12/2025 order summary showed a 07/172024 physician's order directing staff to administer an antianxiety medication three times per day to the resident. A 09/30/2025 physician's order directed staff to administer an antidepressant medication to Resident 34 every morning. Review of a 10/20/2025 social services progress note showed a summary of Resident 34's psychotropic medications. The note showed a GDR recommendation of Resident 34's antianxiety medication was rejected on 03/24/2025. Review of Resident 34's comprehensive medical records showed no progress notes from a physician documenting the rejection of the GDR, there were no documents scanned in from the physician, or pharmacy recommendations that included documentation from the physician regarding rejection of the GDR for the antianxiety medication that occurred on 03/24/2025 per the 10/20/2025 progress note. In an interview on 12/16/2025 at 10:34 AM, Staff C (Social Services Director) stated the interdisciplinary team completed a Behavior Monitor/Medication Management form when the team discussed potential GDRs or medication changes for residents receiving psychotropic and other high-risk medications. Staff C reviewed their personal files and provided the 03/24/2025 Behavior Monitor/Medication Management form with the physician's signed rational for why a GDR of Resident 34's antianxiety medication was contraindicated. Staff C stated they missed scanning the document into Resident 34's record but stated the document should be part of the resident's record. In an interview on 12/16/2025 at 11:35 AM, Staff B (Director of Nursing) stated it was their expectation the Behavior Monitor/Medication Management form be scanned in and available in Resident 34's records. <Resident 3> According to a 10/03/2025 Quarterly MDS, Resident 3 was able to make their needs known, had memory loss, and required moderate staff assistance with toileting, bathing, and dressing. The MDS showed Resident 3 had medical diagnoses including non-traumatic brain dysfunction, dementia, anxiety, and depression. The MDS showed Resident 3 received antipsychotic and antidepressant medications during the seven day look back period of the MDS assessment. Review of Resident 3's physicians order's showed a 12/20/2024 order for an [NAME]-depressant medication directing staff to administer daily. A 09/09/2025 physicians order directed staff to administer an anti-psychotic medication to Resident 3 twice daily. Review of Resident 3's anxiety and depression care plan, revised on 07/25/2025, showed Resident 3's anti-depressant GDR was contraindicated and the dose remained the same for the last year since12/20/2024. Review of the care plan showed Resident 3's anti-psychotic medication GDR was rejected on 11/11/2025. Review of Resident 3's comprehensive medical record showed no progress notes from a physician documenting the rejection of the GDR, there were no documents scanned in from the physician, or pharmacy recommendations that included documentation from the physician regarding rejection of the GDR for the anti-depressant medication or the anti-psychotic medication. In an interview on 12/16/2025 at 1:01 PM, Staff C stated the facility intradisciplinary team discussed Resident 3's medications on 11/11/2025. Staff C printed a Behavior Monitor/Medication Management form from their personal file that showed on 11/11/2025 the physician agreed a GDR for the anti-psychotic medication was not recommended and provided a rationale. The form did not address the physicians rationale for not preforming a GDR for the anti-depressant medication in over a year. Staff C stated the behavior monitoring and medication management form should be scanned in and part of the resident's record. REFERENCE: WAC 388-97-1720 (1)(a)(i-iv).

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 2 (Residents 43 & 30) of 4 residents reviewed for hospitalization s. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> According to the facility's Transfer or Discharge, Facility Initiated policy, revised 10/2022, the facility would provide a notice of transfer as soon as practicable to residents who were transferred emergently to an acute care setting. This policy showed the notice would be provided in a manner the resident could understand. The notice would include the reason, effective date, location, and an explanation of the resident's rights for transfer. <Resident 30> Review of Resident 30's 03/05/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on 03/05/2024, with their return anticipated. Record review showed staff documented where and why Resident 30 was being transferred to the hospital on a 03/05/2024 Notice of Emergency Transfer form. At the bottom of this form was a statement that said to see the reverse side of the notice for information on appeal rights. The reverse side of the notice with the appeal rights was not found in Resident 30's records for the 03/05/2024 transfer to the hospital. <Resident 43> Review of Resident 43's 10/09/2024 Discharge MDS showed the resident was transferred to the hospital on 10/09/2024, with their return anticipated. Record review showed staff documented where and why Resident 43 was being transferred to the hospital on a 10/09/2024 Notice of Emergency Transfer form. At the bottom of this form was a statement that said to see the reverse side of the notice for information on appeal rights. The reverse side of the notice with the appeal rights was not found in Resident 43's records for the 10/09/2024 transfer to the hospital. In an interview on 10/23/2024 at 2:50 PM, Staff F (Social Services Director) stated the charge nurses were responsible for filling out an emergency packet, which included the Notice of Emergency Transfer form, and provide the paperwork to the resident upon transfer to the hospital. Staff F stated the transfer form should include the appeal rights for the resident. In an interview on 10/24/2024 at 1:06 PM, Staff G (Licensed Practical Nurse) stated they were one of the charge nurses that often completed transfer paperwork when a resident was sent to the hospital. Staff G pulled a packet from a drawer at the nurse's station and stated the form was what they completed and sent with a resident upon transfer to the hospital. In an interview on 10/24/2024 at 1:12 PM, Staff F reviewed the packet provided by Staff G and confirmed it was missing the second page of the Notice of Emergency Transfer form, which included the required appeal rights. Staff F stated they would have expected the appeal rights to be included in the packet, and stated they were unable to locate them for Resident 30 or 43. REFERENCE: WAC 388-97-0140(1)(a)(b)(c)(i-iii).

Based on observation, interview, and record review the facility failed to ensure 5 of 12 sample residents (Residents 33, 5, 26, 29, & 34) reviewed for care and services received the necessary care and services they required in accordance with professional standards of practice. The facility failed to monitor residents taking anticoagulant medications (Residents 33, 5, 26, &, 29) and assess, monitor, and apply compression stockings to residents with edema (Resident 34). These failures placed residents at risk for delays in treatment, potential declines in health, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Anticoagulation Protocol policy, updated 01/2018, showed the staff and the physician would monitor for potential complications such as excessive bruising, bleeding, or bloody urine for resident's who were receiving anticoagulant medications. Review of the facility's Edema policy, reviewed 03/01/2023, showed residents with edema would be routinely assessed to determine effectiveness of current treatments and/or worsening conditions. This policy showed interventions could include compression socks, elevating the extremity, medications management, and pharmacy review. <Resident 33> According to the 09/02/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 33 had mild cognitive impairment. The MDS showed Resident 33 had diagnoses including an abnormal heart rhythm and a disease in which arteries to the heart have a build up of fatty substances. This assessment showed Resident 33 took anticoagulant medication during the assessment period. In an interview on 10/21/2024 at 12:20 PM, Resident 33 stated they had nose bleeds almost daily. Resident 33 stated they were hospitalized on ce for having a nosebleed that would not stop. Review of a 09/01/2023 hospital discharge summary showed Resident 33 was discharged to the facility with orders for an anticoagulant to be taken twice daily. Review of a 05/11/2024 progress note showed Resident 33 returned to the facility after a hospital stay with a diagnosis of gastrointestinal bleeding. Review of a 09/12/2024 progress note showed Resident 33 was readmitted to the facility after a short hospital stay due to a nosebleed. Review of Resident 33's 10/25/2024 order summary showed a 09/16/2024 order directing staff to administer an anticoagulant medication twice daily to Resident 33. This summary showed a 10/03/2024 order directing staff to monitor Resident 33 for signs and symptoms of bleeding every shift related to the use of the anticoagulant medication. The 10/03/2024 order to monitor Resident 33 for bleeding was implemented 13 months after the initial order for the anticoagulant medication. <Resident 5> According to the 08/07/2024 Quarterly MDS, Resident 5 had mild cognitive impairment. This MDS showed Resident 5 had diagnoses including an irregular heart rhythm and high cholesterol. The MDS showed Resident 5 took anticoagulant medication during the assessment period. Review of a 10/22/2024 order summary showed a 06/12/2024 order for an anticoagulant medication to be administered to Resident 5 twice daily. This order summary showed no directions to staff to monitor adverse side effects such as bleeding for the anticoagulant medication. <Resident 26> Review of the 07/22/2024 Quarterly MDS showed Resident 26 was cognitively impaired. This MDS showed Resident 26 had diagnoses of high cholesterol and an irregular heart rhythm. The MDS showed Resident 26 was taking anticoagulant medication during the assessment period. Review of Resident 26's order summary showed a 07/26/2024 order directing staff to administer an anticoagulant medication to Resident 26 twice daily. This order summary showed no instructions for staff to monitor for side effects of the anticoagulant until over two months later, when a 10/01/2024 order was written, directing staff to monitor for bleeding. In an interview on 10/24/2024 at 11:55 AM, Staff B (Director of Nursing) stated nurses should be monitoring residents for side effects to anticoagulants such as bleeding. Staff B stated they would have to check if the monitoring should be documented in the resident's record. No further information was provided. 43642 <Resident 29> According to a 09/03/2024 Annual MDS, Resident 29 had multiple medically complex diagnoses including heart failure and required the use of anticoagulant medications during the assessment period. Review of Resident 29's order summary showed a 09/18/2023 order for an anticoagulant medication to be administered to Resident 29. This order summary showed no directions to staff to document if any possible adverse side effects such as bleeding for the anticoagulant medication occurred. In an interview on 10/24/2024 at 2:40 PM, Staff B stated it was important to monitor a resident who was taking an anticoagulant medication and stated, the resident was at risk for bleeding and bruising. Staff B stated it was their expectation staff would start monitoring a resident as soon as they started taking an anticoagulant medication. <Resident 34> According to a 09/11/2024 Annual MDS, Resident 34 had multiple medically complex diagnoses including a stroke, with the loss of strength or muscle weakness on one side of the body, and an abnormal heartbeat which required the use of anticoagulant medications during the assessment period. Review of Resident 34's records showed a 07/25/2024 provider progress note indicating the resident was being assessed related to weight gain and swelling to their lower legs. Mild edema was observed by the provider with recommendations for Resident 34 to wear compression stockings on both legs during the day and off at night. This progress note showed documentation if symptoms worsen or persist, staff were to contact the provider's office. Observations on 10/24/2024 at 1:14 PM showed Resident 34 without compression stockings on. Review of an 08/23/2024 dietician progress note showed documentation that nursing staff reported no edema when compression stockings were in place, but the dietician documented they observed edema to both lower legs. Review of a 09/17/2024 quarterly progress note written by staff, showed Resident 34 utilized compression stockings secondary to edema to both lower legs. Review of a 10/03/2024 dietician progress note showed Resident 34 was experiencing some edema, correlating with weight gain. According to a 10/03/2024 History and Physical document, Resident 34 was seen by the provider related to edema to their left lower leg more than their right lower leg and ordered a low dose of a medication to promote the excretion of water from the body. This document indicated Resident 34 was assessed to have symptoms of heart failure. Review of Resident 34's comprehensive care plan showed staff did not address the resident had heart failure and was placed on a medication for edema. In a joint interview on 10/25/2024 at 1:16 PM with Staff H (MDS Coordinator) and Staff I (Resident Care Manger), Staff H stated if a resident was placed on a medication to reduce edema, they would expect staff to utilize the compression stockings and to assess and document the status of the edema. Staff I stated it was important to monitor frequently to see if the resident's edema had stabilized and how they were responding to the medications. Staff I reviewed Resident 34's records for documentation of the edema by the nursing staff on the weekly skin checks. Staff I was unable to find documentation on the weekly skin checks from staff regarding the status of Resident 34's edema. 45720 REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 2 (Resident 7 & 26) of 12 sample residents. The failure to ensure resident bathroom door chime alarms were activated (Residents 7 & 26), ensure a maintenance cart containing tools and chemicals was supervised in resident common areas, and ensure kitchen pantry doors and storage rooms remained closed and/or locked, placed residents at risk for accidents, injury, and other negative health outcomes. Findings included . <Maintenance Cart> Observations on 10/21/2024 between 9:36 AM and 9:47 AM showed a maintenance cart unsupervised in the hallway between resident rooms [ROOM NUMBERS]. On this cart were several accessible tools, including a drill and a bottle of a drain opening compound with a layer of powder at the bottom. In an interview on 10/25/2024 at 1:16 PM, Staff H (Minimum Data Set - MDS - Coordinator) stated unsupervised sharps and tools posed a risk for resident safety, especially with residents who had dementia. <Storage Room> Observations on 10/24/2024 at 8:07 AM showed an unlocked storage room door next to the nurse's station. Inside the room were many shelves stocked full of supplies and four bottles of a liquid medication disposal system, visible from the door. The bottles showed a warning label that the product may be harmful if swallowed and to keep out of reach of children. In an interview on 10/25/2025 at 1:16 PM, Staff H stated the storage room was supposed to be locked and kept secured so the residents could not get a hold of anything dangerous to them. <Kitchen Pantry Door> Observation on 10/21/2024 at 9:37 showed the pantry door near the nurse's station was propped open. The pantry contained an oven, prep table, dried food storage, and dishwasher. There were no staff observed in the pantry when the door was propped open. The pantry door contained a keypad lock system. In an interview on 10/22/2024 at 8:20 AM, Staff D (Registered Nurse) stated the pantry door was usually only left open during mealtimes. Staff D stated kitchen staff usually closed the pantry door when the meal service was completed. In an interview on 10/25/2024 at 2:20 PM, Staff A (Administrator) stated the maintenance cart should not be left unsupervised when tools and sharps were accessible to residents. Staff A stated the storage room and kitchen pantry should be locked, with the door closed, if staff were not in the area and stated, you do not want confused residents to go into an unsafe space. <Fall Interventions> <Resident 7> According to a 07/19/2024 Quarterly MDS (an assessment tool) Resident 7 had multiple medically complex diagnoses including dementia with severe memory impairment and required substantial assistance from staff to transfer to the toilet. This MDS showed Resident 7 had three falls since the prior assessment, one with a major injury, and was utilizing alarms at least daily. Review of Resident 7's October 2024 Treatment Administration Records showed a 03/19/2024 order to ensure the bathroom chime alarm was in use and functioning every shift. Review of a revised 05/25/2023 fall Care Plan (CP) showed directions to staff that Resident 7 required assistance with toileting and to use a bathroom door chime alarm to alert staff when they tried to go to the bathroom. This intervention showed the bathroom door was to be kept closed at all times and staff were to check the function and presence of the bathroom door alarm every shift. Observations on 10/23/2024 at 11:27 AM showed Resident 7 lying in bed with their breakfast tray in front of them and their wheelchair at their bedside. Resident 7 stated, I need to use the bathroom. Observations at this time showed Resident 7's bathroom door was open, and the chime alarm was not activated. Similar observations of Resident 7 lying in bed with their bathroom door open and unarmed were noted on 10/24/2024 at 8:42 AM and 3:43 PM, and on 10/25/2024 at 7:52 AM. Review of Resident 7's fall incident reports from 05/09/2024, 05/18/2024, and 07/04/2024 showed staff identified the resident's falls occurred during self-transfers and staff were to continue to use a motion sensor and bathroom door chime alarm. In an interview on 10/24/2024 at 2:40 PM, Staff B (Director of Nursing) stated it was their expectation CP interventions and physician orders were followed as, that is the reason they are there. In an interview on 10/25/2024 at 1:16 PM, Staff H stated the best way to prevent falls was to follow the CP interventions staff put in place as a team. Staff H stated their expectation was for staff to keep Resident 7's bathroom door closed and have the alarm turned on to help prevent falls. 45720 <Resident #26> Review of the 07/22/2024 Quarterly MDS showed Resident 26 had a diagnosis including dementia and had severely impaired cognition. The MDS showed Resident 26 had one fall with no injury and one fall with injury during the assessment period. This MDS showed Resident 26 had a bed, chair, and other alarm in place and the alarms were used daily during the assessment period. Observations on 10/21/2024 at 10:21 AM and 2:29 PM showed Resident 26's bathroom door was open and the alarm on the bathroom door was disengaged. Observation on 10/22/2024 at 8:48 AM showed Resident 26's bathroom door was open, Resident 26 entered the bathroom and the alarm on the bathroom door did not trigger. Review of Resident 26's revised 08/05/2024 Fall CP showed Resident 26 fell on [DATE], 06/02/2024, 08/08/2024, and 09/15/2024. This CP showed Resident 26 had a door chime alarm on the bathroom door to alert staff when the resident tried to use the bathroom without assistance. During an interview on 10/25/2024 at 8:49 AM, Staff E (MDS Support Nurse) stated Resident 26 had a chime alarm on the bathroom door to alert staff when the resident went into their bathroom. Staff E stated the bathroom door must remain shut for the alarm to work. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive Care Plan (CP) for 3 of 12 sampled residents (Residents 34, 7, & 33) whose comprehensive CPs were reviewed. The failure to develop comprehensive, individualized CPs with resident-specific goals and/or interventions placed residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy> According to the facility's Care Plans, Comprehensive Person-Centered policy, dated 03/01/2023, the facility would develop and implement a comprehensive person-centered CP that included measurable objectives to meet the resident's physical, psychosocial, and functional needs. This policy showed the interdisciplinary team would review and update the CP for significant changes in the resident's condition, when the desired outcome was not met, upon readmission from a hospital stay, and quarterly. <Resident 7> According to a 07/19/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 7 had multiple medically complex diagnoses including dementia with severe memory impairment and required substantial assistance from staff for lower body dressing. Review of Resident 7's revised 05/25/2023 risk of skin breakdown CP showed directions to staff to apply compression stockings to both of Resident 7's lower legs in the morning and to remove in the evening. Observations on 10/23/2024 at 11:30 AM showed Resident 7 with a bandage wrapping to their left leg and no compression stockings on their right leg. In an interview on 10/25/2024 at 1:16 PM, Staff H (MDS Coordinator) stated their expectation was for staff to follow a resident's CP interventions and apply the compression stockings for Resident 7 as directed. <Resident 34> According to a 09/11/2024 Annual MDS, Resident 34 had multiple medically complex diagnoses including a stroke, with the loss of strength or muscle weakness on one side of the body, and an abnormal heartbeat which required the use of anticoagulant medications during the assessment period. Review of Resident 34's revised 04/21/2024 risk of skin breakdown CP showed directions to staff to apply compression stockings to both of Resident 34's lower legs in the morning and to remove in the evening. Observations on 10/24/2024 at 1:14 PM showed Resident 34 without compression stockings on. On 10/25/2024 at 8:00 AM, Resident 34 was wearing a compression stocking to their left leg but none on their right leg. In an interview at this time, Resident 34 stated, oh yeah, I am supposed to have on both legs, but they [staff] often cannot find the other one. Review of a 10/20/2022 COVID (a contagious respiratory illness) CP, showed Resident 34 was at risk for mood changes related to social isolation due to COVID. This CP gave directions to staff to provide Resident 34 with room activities as able and to provide alternative methods of communication with family and friends. In an interview on 10/24/2024 at 2:40 PM, Staff B (Director of Nursing) stated it was their expectation staff follow CP interventions as directed and update and revise a resident's CP with changes. Staff B stated Resident 34 did not currently have a COVID infection and should have been resolved off of the resident's CP. 46479 <Resident 33> According to the 09/12/2024 5-Day MDS, Resident 33 had mild cognitive impairment. This MDS showed Resident 33 had diagnoses of a urinary tract infection, lung disease, and elevated white blood cell count. This MDS showed Resident 33 was taking an antibiotic medication during the assessment period. Review of Resident 33's order summary showed a 09/11/2024 order for an antibiotic to be administered three times per week for an elevated white blood cell count. This order did not include a stop date for how long Resident 33 would be taking the antibiotic. On 10/24/2024, the antibiotic order was updated showing the indication for use was for a chronic lung infection and showed no stop date on the order, indicating long term use. Review of Resident 33's 09/01/2024 comprehensive CP showed no goals or interventions related to their lung infection. There were no goals or interventions related to Resident 33 receiving antibiotics since 09/11/2024. In an interview on 10/25/2024 at 9:31 AM, Staff C (Staff Development Coordinator/Infection Control) stated Resident 33 was being followed by a lung specialist. Staff C stated the facility and the lung specialist were going back and forth to determine if the antibiotic would long term and just recently the physician determined the medication would be long term. REFERENCE: WAC 388-97-1020(1), (2)(a)(b).

Based on interview and record review, the facility failed to ensure: physician's orders were followed for 1 (Resident 34); medications were administered within ordered parameters for 1 (Resident 38); and physician orders were clarified as needed for 1 (Resident 96) of 12 sample residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Facility Policy> According to the facility's Administering Medications policy, reviewed 03/01/2023, showed staff would administer medications in accordance with prescriber orders. <Medications Given Outside of Parameters> <Resident 38> According to an 08/09/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 38 had multiple medically complex diagnoses including high Blood Pressure (BP). Review of Resident 38's August 2024 Medication Administration Records (MAR) showed the resident was receiving three different medications (Medication A, B, and C) for high BP with directions to staff to hold the dose for the following parameters: Medication A was to be held if the Systolic BP (SBP - a measure of the pressure in your arteries when your heart beats) was less than 105; Medication B was to be held if SBP was less than 140; and Medication C was to be held if the SBP was less than 105. This MAR showed staff gave Medication B outside of parameters on eight occasions. Review of Resident 38's September 2024 MAR showed staff gave Medication B outside of parameters on five occasions. Review of Resident 38's October 2024 MAR showed staff gave: Medication A outside of parameters on one occasion; Medication B outside of parameters on nine occasions; and Medication C outside of parameters on one occasion. In an interview on 10/24/2024 at 2:40 PM, Staff B (Director of Nursing) stated their expectation was for staff to follow the medication parameters as ordered by the provider. <Clarifying Orders> <Resident 96> Review of Resident 96's October 2024 MAR showed the resident had a 10/18/2024 order for a laxative suppository medication to be given as needed for constipation. A second 10/18/2024 order for the same laxative suppository was also ordered to be given as needed for constipation. In an interview on 10/25/2024 at 1:16 PM, Staff H (MDS Coordinator) stated Resident 96 should not have two of the same laxative suppository orders and the orders needed to be clarified. <Following Orders> <Resident 34> Review of Resident 34's September 2024 MAR showed a 04/04/2023 order for a liquid laxative to be given as needed for constipation if the resident had no bowel movement in two days. This MAR showed staff administered the medication at 11:12 AM on 09/06/2024. Review of Resident 34's September 2024 bowel monitoring showed staff documented the resident had two bowel movements on 09/05/2024, the day before administering the medication with directions to give if no bowel movement in two days. In an interview on 10/25/2024 at 1:16 PM, Staff H stated it was their expectation staff follow the orders and only give medications as ordered. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

Based on observations and interview, the facility failed to ensure the Chlorine bleach test strips and QUAT test strips (Quaternary test used to verify the concentration level of sanitizers) were current (not expired) in the main kitchen and Health Center kitchen. This failure prevented kitchen staff from accurately monitoring cleaning solutions used to maintain kitchen counter and equipment sanitized. Findings included . Observation of the facility's main kitchen on [DATE] at 9:05 AM showed Staff M (dishwasher) doing dishes using the dishwashing machine. The documentation for dishwasher daily sanitization and temperature log was requested. Staff M stated they did not see the log and approached Staff K (Executive Chef) for this information. On [DATE] at 9:05 AM Staff K stated they did not keep a log for dishwasher sanitization and red bucket. Observation on [DATE] at 9:10 AM showed Staff K obtain test strips and demonstrate how the sanitization solution was tested . The bottle of Chlorine test strips showed an expiration date of [DATE]. QUAT check test strips showed an expiration date of [DATE]. Observation and interview on [DATE] at 9:39 AM in the second-floor health center kitchen showed staff removing dirty dishes from the dishwashing machine. Staff N (Assistant Director of Food and Beverage) stated the facility was out of sanitizer test strips and staff planned to wash the dishes in main kitchen. Staff N stated staff were to test dishwasher sanitization after every meal and QUAT test every two hours. Staff N stated the test strips were expired. In an interview on [DATE] at 10:08 AM, Staff L (Director of Food and Beverage) stated they did not know about the expired test strips. Staff N stated they should have checked the test strips for the expiration date but they did not. REFERENCE: WAC [DATE] (6).

Based on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 3 (Residents 35, 36, & 141) of 3 residents reviewed for hospitalization . Failure to ensure required notification was completed, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . According to a March 2023 facility Transfer or Discharge Notice policy, the facility would notify the resident and/or representative in writing regarding the resident's transfer or discharge and a copy of the notice would be sent to the LTCO. <Resident 35> According to a 05/26/2023 Discharge Minimum Data Set (MDS - an assessment tool), Resident 35 was discharged emergently to an acute care hospital on 05/26/2023 with return anticipated. Record review showed no documentation indicating the LTCO was notified of the 05/26/2023 transfer as required. <Resident 141> According to a 06/09/2023 Discharge MDS, Resident 141 was discharged emergently to an acute care hospital on 06/09/2023 with return anticipated. According to a 06/23/2023 Discharge MDS Resident 141 had a second discharge to an acute care hospital on 06/23/2023 with return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 06/09/2023 or 06/23/2023 transfers. <Resident 36> According to the 07/01/2023 Discharge MDS, Resident 36 was discharged emergently to an acute hospital on with return anticipated. Record review showed no documentation indicating the LTCO was notified of the 07/01/2023 transfer as required. In an interview on 07/10/2023 at 2:02 PM, Staff B (Director of Nursing) stated the facility's social worker did the LTCO notifications but no longer worked at the facility. Staff B was unable to locate any documentation of notification to the LTCO for Resident 35, 141, or 36 as required. REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii) 45941

Based on interview and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 4 (Resident 19, 243, 38 & 141) of 12 residents reviewed for unnecessary antibiotics and 3 (May 2023, June 2023, & July 2023) of 3 months of infection control documents reviewed. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of antibiotics. Findings included . According to the facility's revised 11/2016 Surveillance for Infections policy, the Infection Preventionist (IP) would conduct ongoing surveillance of infections that had a substantial impact on potential resident outcomes and could require transmission-based precautions and other preventative measures. The policy stated the purpose of the surveillance of infections was to identify both individual cases and trends of infections to guide appropriate interventions, and to prevent future infections. For residents with infections that met the criteria for surveillance, staff should collect the following data as appropriate: .admitted ; infection site; pathogens [infectious agent that causes disease]; .treatment measures and precautions. The policy directed staff to summarize monthly data for each nursing unit by site and by pathogen and to compare monthly/quarterly incidence of current infections to previous data to identify trends and patterns. <May Infection Surveillance Log (ISL)> Review of the facility provided ISL for May 2023 showed on 05/04/2023 Resident 19 was placed on an antibiotic for seven days for a suspected skin infection. According to the log staff identified Resident 19 had redness, pain, and heat to their skin. The log did not identify where the symptoms were located, if the infection was facility acquired, or if the resident admitted with the infection. The facility surveillance monitoring map provided for the month of May 2023 was blank and no summary of monthly data was completed by staff to identify trends or patterns. <June 2023 ISL> Review of the facility provided ISL for June 2023 showed staff only documented for one of six residents whether their infection was facility acquired or if the resident admitted with the infection. Resident 243 was identified on the log with a urinary tract infection. Staff did not document on the log what the infectious organism was identified or include the urine test results in the ISL binder for surveillance monitoring. The facility's surveillance monitoring map provided for the month of June 2023 was blank and no summary of monthly data was completed by staff to identify trends or patterns. <July 2023 ISL> Review of the facility provided July 2023 ISL showed two residents identified on the log. Resident 38 was identified on the log with having a urinary tract infection. Staff did not indicate if the infection was facility acquired or if resident admitted with the infection. Resident 141 was documented on the log for a contagious infection of the large intestine with an onset date for symptoms of 07/08/2023. The section of the log ACTION- Other than Standard Precautions for Resident 141 was left blank by staff and did not identify if the resident should be on contact precautions. Observations on 07/05/2023 at 9:02 AM showed a Contact Precaution sign was hung on the resident's door. Record review showed a 07/05/2023 progress note by staff identifying Resident 141 had loose stools and was placed on contact precautions. In an interview on 07/07/2023 at 2:04 PM, Staff I (Staff Development Coordinator/IP) confirmed Resident 141's onset date of symptoms was 07/05/2023, not the 07/08/2023 date identified on the log. Staff I stated the log should be complete and accurate to evaluate the surveillance of infections. In an interview on 07/11/2023 at 12:07 PM, Staff I stated they utilized the McGeer Criteria for infections (a set of criteria used to determine whether to treat an infection with antibiotics). Staff I reviewed the documented symptoms listed on the ISL for Resident 19 and the McGeer Criteria for skin infections and stated, Resident 19 did not meet the required criteria. Staff I stated staff should have but did not follow up with the provider to review the use of the antibiotic medication. Staff I stated they did not complete any monthly summaries, map location of infections to identify trends or patterns, or attend the facility's Quality Assurance and Performance Improvement meetings since March 2023 due to other obligations. REFERENCE: WAC 388-97-1320 (1)(a).

Based on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were followed for 3 of 13 sample residents (Residents 8, 6 & 35), or clarified for 2 of 13 sample residents (Residents 35 and 141) whose care was reviewed. These failures left residents at risk for not receiving the care they were ordered, and other negative health outcomes. Findings included <Following POs> <Resident 8> According to the 04/07/20/23 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 was assessed to required extensive assistance with toileting and personal hygiene. The MDS showed Resident 8 was assessed to be at risk for skin breakdown. Resident 8's POs included: a 04/06/2023 order to complete a weekly skin check scheduled for Thursday evenings; a 04/05/2023 PO for body powder to be applied to Resident 8's under arms and abdominal folds twice daily. There were no POs to treat Resident 8's groin skin. Review of the 04/02/2023 . at risk for skin breakdown . Care Plan (CP) showed staff should apply body powder to Resident 8's under arms and abdominal folds twice daily. The CP directed nursing staff to complete a skin check weekly, and as needed, and to report any concerns including areas of redness to Resident 8's nurse. In an interview on 07/05/2023 at 9:27 AM Resident 8 stated they sometimes had a rash in their groin. Resident 8 stated staff treated the rash with a powder. Resident 8 stated sometimes got a sore spot on their buttocks. According to the 07/06/2023 skin evaluation (skin check) Resident 8 had a new skin impairment of redness to their left groin area. The note stated to continue treatment as ordered. Record review showed a skin check was not completed the prior week, with the last skin check completed on 06/23/2023. In an interview on 07/11/2023 at 9:40 AM, Staff C (Resident Care Manager) stated it was important to conduct skin checks weekly, as ordered. Staff C stated a PO for skin powder was in place to treat Resident 8's groin skin. Staff C reviewed the PO and stated the skin powder did not include groin area, and the order needed to be updated. <Resident 6> According to the 05/22/2023 MDS, Resident 6 required set up assistance with eating, and had diagnoses including malnutrition. The MDS showed Resident 6 was assessed with verbal behavior directed toward others that impacted the safety and activity of Resident 6 and others. The MDS showed Resident 6's behaviors worsened since the prior MDS. Resident 6's POs included a 05/25/2023 order for a bedtime snack. The order stated staff should provide either half a sandwich or a fortified (protein-rich) pudding. The 05/23/2023 . at risk for weight loss . CP showed Resident 6 was intolerant to [ .] bananas . The CP directed staff to offer half a sandwich or a banana with pb [peanut butter] for a bedtime snack. In an interview on 07/10/2023 at 2:36 PM with Staff C and Staff D (MDS Coordinator) Staff C stated the . at risk for weight loss . CP needed to be updated so that it reflected the 05/25/2023 PO. Staff C and Staff D stated given Resident 6's behavioral issues, offering an unwelcome snack could cause an avoidable behavior. 43642 <Resident 35> According to a 04/24/2023 Admission MDS Resident 35 had multiple medically complex diagnoses including a respiratory infection and lung disease. Review of Resident 35's July 2023 Treatment Administration Record (TAR) showed the resident had a PO for oxygen to be given at 3 Liters Per Minute (lpm) continuously for a respiratory infection. Observations on 07/05/2023 at 9:51 AM and on 07/07/2023 8:05 AM showed Resident 35's oxygen was set to 3.5 lpm. On 07/10/2023 at 8:41 AM, Resident 35's oxygen was observed to be set to 2.5 lpm. In an interview on 07/10/2023 at 9:00 AM, Staff H (Licensed Practical Nurse), confirmed Resident 35's order for oxygen was to be at 3 lpm. Staff H checked the oxygen flow rate and raised the level of oxygen up to 3 lpm. On 07/11/2023 at 1:45 PM, Staff C stated nursing staff should follow the POs and always check the oxygen flow rate at eye level when setting the correct oxygen dose. <Clarifying Physician Orders> <Resident 35 - Pain Medications> According to a 04/24/2023 Admission MDS Resident 35 had multiple medically complex diagnoses including fractures and required the use of a narcotic pain medication during the assessment period. Review of July 2023 Medication Administration Records (MAR) showed Resident 35 had an order for a non-narcotic pain medication to be given every four hours as needed for pain. Resident 35 had additional orders for narcotic pain medications to be given every twelve hours as needed. These orders directed staff to give five milligrams (mg) of the narcotic pain medication for moderate pain, and to give 10 mg of the narcotic pain medication for severe pain. There were no directions to staff to indicate what parameters should be used when administering the non-narcotic pain medication, or what pain scale parameter to use for moderate or severe pain for the narcotic pain medications. In an interview on 07/11/2023 at 1:45 PM, Staff C stated the facility standard for pain medication parameters was for the non-narcotic pain medication to be given for mild pain and should be used for a pain level less than four. Staff C stated the narcotic pain medication parameters should be four to six for moderate pain and seven to ten for severe pain. Record review of the May 2023 MAR showed staff documented they gave Resident 35 the five mg dose of the narcotic pain medication for a pain level of 6 on 05/06/2023 and on 05/08/2023 for a pain level of 4. On 05/26/2023 staff documented they administered the non-narcotic pain medication for a pain level of 6 and indicated it was not effective in decreasing the resident's pain. Review of the June 2023 MAR showed staff documented they administered the five mg dose of the narcotic pain medication for a pain level of 7 on 06/08/2023 to Resident 35, rather than the dose for severe pain as indicated by Staff C. According to Resident 35's July 2023 MAR staff administered the non-narcotic pain medication for a pain level of 5 at 5:03 AM and the five mg dose of the narcotic pain medication for a pain level of 4 at 2:07 PM on 07/08/2023. In an interview on 07/11/2023 at 1:45 PM, Staff C stated the pain medication orders for Resident 35 should be clarified with the provider with clear directions given to staff on the pain level parameters for each medication. < Resident 35 - Probiotic Orders> According to July 2023 MAR, Resident 35 received a probiotic medication (a supplement to help balance the friendly bacteria in the digestive system when taking antibiotics) twice daily for the use of antibiotics. Review of this MAR showed no antibiotic orders were currently in place for Resident 35. Record review showed Resident 35 completed an antibiotic treatment for a respiratory infection on 06/08/2023. In an interview on 07/11/2023 at 1:45 PM, Staff C stated this order should have, but was not clarified with provider to determine if it should continue after the antibiotic order was completed. <Resident 141> According to a 06/22/2023 Admission MDS, Resident 141 had multiple medically complex diagnoses including an infection of the large intestine and required the use of antibiotics during the assessment period. Review of July 2023 MAR showed Resident 141 had an order for a probiotic medication twice daily. On 07/08/2023 a second order was added by staff for the same probiotic medication twice daily. Staff were documenting they were administering both medications. In an interview on 07/11/2023 at 1:45 PM, Staff C stated Resident 141 should not receive both doses of the probiotic medication and stated, it was a duplicate order. Staff C stated the orders should have been but were not clarified with the provider. In an interview on 07/11/2023 at 2:00 PM, Staff I (Staff Development Coordinator/Infection Preventionist) stated both medications should not be given together and stated the medication nurse stated they only administered one dose. In an interview on 07/11/2023 at 2:00 PM, Staff B (Director of Nursing) stated POs should be followed, have parameters, and be clarified as needed with the providers. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i)

Based on observation, interview, and record review the facility failed to ensure new skin issues were identified, assessed, or treated for 1 of 3 residents (Resident 11) reviewed for non-pressure skin and failed to ensure treatments were provided as ordered for 2 of 2 residents (Residents 35 & 29) reviewed for edema (fluid retention that causes swelling). These failures placed residents at risk for discomfort, untreated skin impairments, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 07/10/2023 Skin Management- Non Pressure Related and Skin Tears policy, upon discovery of a new skin impairment such as a skin tear, abrasion, or bruise, staff must complete an Event/Skin Report. The policy directed staff to report any new impairment to the resident's responsible family member and physician. <Resident 11> According to the 04/24/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 11 had no speech and rarely understood others in conversation. The MDS showed Resident 11's memory was assessed to be severely impaired and required extensive assistance with most care. The MDS showed Resident 11 had diagnoses including non-traumatic brain injury and dementia and had no skin impairment. According to the 05/05/2023 . at risk for skin breakdown . Care Plan (CP) staff were to evaluate Resident 11's skin on a daily and weekly basis. Observation on 07/05/2023 at 1:33 PM showed a small skin abrasion on the right side of Resident 11's nose. There was no dressing on the skin abrasion. Observation on 07/07/2023 at 10:07 AM showed the skin abrasion was still present on Resident 11's nose. Record review showed no nurses or aides documented the skin abrasion in Resident 11's record. There was no documentation demonstrating nursing staff completed an Event/Skin Report, or notified Resident 11's responsible family member or physician. In an interview and observation on 07/10/2023 at 10:00 AM, Staff C (Resident Care Manager) observed Resident 11's abrasion on the right side of their nose and stated no staff informed them of the impairment to the resident's skin but should have so the appropriate notifications and processes could be completed. Review of the 07/10/2023 weekly skin evaluation, time stamped at 11:07 AM showed no skin impairment for Resident 11. 43642 <Resident 35> According to a 04/24/2023 Admission MDS Resident 35 had multiple complex diagnoses including heart failure and required the use of diuretic medication during the assessment period. This MDS identified Resident 35 had no rejection of care. Review of Resident 35's Physician Orders (POs) showed the resident was assessed to require knee high compression stockings to be put on in the morning and removed at bedtime for swelling to their feet/ankles. According to the July 2023 Medication Administration Records (MAR) Resident 35 was taking a medication once daily to treat the swelling to both feet. Observations on 07/05/2023 at 9:38 AM, 07/07/2023 at 8:05 AM, and on 07/10/2023 at 2:12 PM showed Resident 35 only wearing yellow nonskid socks. Resident 35 was not wearing the compression stockings. In an interview on 07/11/0223 at 11:00 AM, Staff D (Certified Nurse's Aide - CNA) stated they worked with the residents on the unit for a long time and indicated they knew who wore compression stockings. Staff D listed residents that required compression stockings but did not identify Resident 35 to require compression stockings. In an interview on 07/11/2023 at 11:05 AM, Staff J (Registered Nurse) stated they oversaw the care provided by the CNAs and when refusals occurred a progress note was made, staff followed up as needed. Staff J stated if a resident had an order for compression stockings, staff would be expected to assist the resident with putting them on. Staff D stated they were not aware of any refusals for compression stockings for Resident 35. 46479 <Resident 29> Review of a 03/29/2023 Quarterly MDS showed Resident 29 had a diagnosis of unspecified swelling and did not reject care. Review of Resident 29's 07/05/2023 PO summary showed the resident had a 06/29/2023 PO to receive a medication to treat their swelling daily. This order summary showed a 07/05/2023 PO that instructed staff to apply knee high compression stockings to Resident 29's legs in the morning and remove the compression stockings before bedtime in the evening. In an interview and observation on 07/07/2023 at 10:05 AM, Resident 29 was being assisted to their room from the dining room. Resident 29 was not wearing compression stockings. Resident 29's lower legs were red with notable swelling around their ankles. Staff D stated Resident 29 was not wearing the compression stockings because they refused to have them put on. Staff D stated they documented in the record when a resident refused their compression stockings. Record review on 07/10/2023 at 12:33 PM, showed no documentation of Resident 29 refusing their compression stockings. In an observation and interview on 07/10/2023 at 11:23 AM, Staff E (CNA) and Staff F (CNA) were assisting Resident 29 to get dressed after a shower. Staff E stated they did not put compression stockings on Resident 29 and there was nothing in their computer system showing staff to put compression stockings on Resident 29. Staff F verified there was nowhere for the CNAs to document putting on or taking off Resident 29's compression stockings. In an interview on 07/10/2023 at 12:33 PM, Staff B (Director of Nursing) stated it was their expectation staff followed orders to put compression stockings on Resident 29. Staff B acknowledged the PO as written did not allow staff to document completion or resident refusal of the task. Staff B stated refusals should be documented in Resident 29's records. REFERENCE: WAC 388-97-1060(1).

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in accordance with food service safety standards. Facility failure to maintain a clear division between the handling of clean and soiled dishes, safely store dry and cold foods, and maintain a kitchen free of cross-contamination sources left residents at risk for consuming contaminated or spoiled foods. Findings included . Sanitary Workflow Observartions of lunch food service on 03/23/2022 from 12:00 PM to 12:45 PM revealed the following: staff served the residents in the dining room from an adjacent Pantry. This Pantry had a door opening directly to the dining room. This door had a handle on the dining room side and opened out from the Pantry to the dining room. The Pantry had a second door that opened into hallway. Throughout lunch service dietary staff and CNAs (Certified Nursing Assistant) were observed to handle both dirty dishes and clean dishes without performing hand hygiene between and/or wearing gloves during these tasks. Staff used the exterior handle of the dining room-side door to enter the Pantry also without performing hand hygiene, wearing gloves, or sanitizing the door handle. Examples included: At 12:00 PM, an unidentified CNA entered the Pantry through the dirty side, opening the door using the handle and without performing hand hygiene (HH), returned with a coffee for a resident; at 12:07 PM Staff R (Dietary Lead) enetered the Pantry on the dirty side, using the handle to open the door bare handed, and returned immediately with a resident's lunch tray without performing HH; at 12:10 PM and at 12:31 PM Staff R was observed to readjust their facemask while serving residents lunch without performing HH; at 12:13 PM, an unidentified CNA was observed to enter the dirty side of the Pantry with a used coffee cup, after comforting a resident by holding their hand, Staff S (Unit Coordinator) was observed to enter the Pantry on the dirty side using the handle; at 12:15 PM, after a touching a male resident on the arm, Staff I was observed to enter the Pantry using the dirty door handle without performing HH, and immediately exited the same door where they served a bowl of soup from a pot while still not having performed HH; at 12:34 Staff R entered the dirty side of the Pantry using the handle without performing HH; at 12:37 PM Staff R was observed to wipe down a table and return dirty dishes to the Pantry using the dirty door handle and return to the Dining Room without performing HH; at 12:48 PM Staff I was observed to enter the pantry on the carrying soiled dishes, using the dirty door handle and not performing HH. On 03/24/2022 at 10:38 AM in the Third Floor Kitchen, Staff O was observed preparing resident meals while wearing gloves Staff O stopped preparing trays and took a blender from the left side of the dishwasher which had just completed a washing cycle. Staff O rinsed the blender in the sink to the left of the dishwasher. The sink was observed to be soiled with food waste. Staff O then took the blender, while still wearing the same gloves and began preparing to blend a pureed meal. In an interview on 03/24/2022 at 10:47 AM, Staff H stated the left side of the dishwasher was the dirty side and the right side was the clean side. Staff I stated Staff O should have taken the blender from the clean side rather than the dirty side. In an interview with Staff H and Staff I on 03/24/22 03:16 PM, Staff H stated Staff O should not have taken the blender out of the dishwasher in the dirty side and did not need to rinse it before use as it was already clean. Staff I described the workflow in the Pantry between clean and dirty dishes should be as follows: The door between the Pantry and the 100 Hall with no handle on the outside was the dirty side and staff should take all dirty dishes through that door and that the door between the Pantry and the Dining Room was the clean side. Dry Storage On 03/21/2022 at 9:06 AM, during an initial tour of the facility's kitchen, a bag of pasta was observed to be opened and wrapped in plastic wrap with no date noted when the pasta was opened was not recorded. Staff L (Kitchen Assistant) confirmed the lack of date and stated that all opened food packet should be dated to ensure the contents were used timely. On 03/21/2022 at 9:30 AM, in the facility's 3rd floor pantry area, a bag of rice and a bag of orzo pasta were observed opened, resealed with plastic wrap and not dated. On 03/24/2022 at 9:52 AM, in the facility's main first floor kitchen, a bottle of wok sauce was observed to be undated and opened. Staff M (Executive Chef) confirmed the bottle was not but should have been dated when opened. Cold Storage On 03/21/2022 at 12:50 PM, a bottle of lemon flavored, thickened water (water with thickener ordered for residents with swallowing difficulties) was observed to be opened and not dated in the Pantry by the dining room from which resident meals are served. Staff I, (Assistant Dietary Manager) stated the thickened lemon flavored water was open and should have been, but was not dated. Dirty Fans On 03/21/2022 at 9:07 AM, two fans were noted in the third floor kitchen, a large black standing fan and a small white fan with a small water cannister with corresponding nozzles that allowed the fan to generate a mist. The black standing fan had a build up of cobwebs and dust on the fan blades and wire housing. The black fan was positioned so the flow of air from the fan would blow directly towards the food when resident meals are being plated. The small white fan had observable dust and cobwebs on the blades and was also positioned where the flow of air from the fan would carry to the food during plating. In an interview on 03/24/2022 at 3:16 PM, Staff H stated the facility did not have a fan cleaning schedule or policy. Staff H stated the fans were brought to the third floor kitchen by other staff without approval and that they removed the black fan on 03/22/2022 but had not removed the white fan. Staff H stated that the white fan with the water cannister was not suitable for the kitchen; it should be removed. It could spray over the food. Hair Nets On 03/21/2022 at 09:00 AM, when surveyors sought to enter the third floor kitchen, Staff L (Kitchen Assistant) stated there were no hair nets available for use. On 03/24/2022 at 9:33 AM, Staff M was observed in the first floor main kitchen not wearing a hairnet. When asked why the were not wearing a hair net at that time, Staff M, who was standing in the kitchen at that time, stated they generally worked from their office (located within the main kictchen) were they did not require a hair restraint. During lunch preparation on 03/24/2022 at 09:35 AM, two unidentified service staff were observed repairing equipment in the main kitchen and were not wearing hairnets, and Staff N (First Floor Kitchen Staff) was observed sanitizing counter tops without a hair restraint. Staff N left after a conversation with Staff M and returned immediately after with a hairnet. In an interview on 03/24/2022 at 09:39 AM Staff N stated Staff M directed them to put on a hairnet. Staff N stated that they normally don't use a hairnet; I am cleaning - normally it's just the food preparation staff that wear them. On 03/24/2022 at 11:12 AM, Staff H was observed in the kitchen without a hair restraint. Staff H expressed surprise and stated they had put on a hair net earlier that day. On 03/24/2022 at 10:42 AM, Staff O (cook) was observed wearing a baseball cap and no other hair restraint while preparing residenty lunches. Staff O's baseball cap did not cover the lowest part of Staff O's head and did not prevent hair from falling into food. Refer to F880 Infection Prevention and Control REFERENCE: WAC 388-97-1100 (3), 2980.