Every finding on record at Everett Transitional Care Services

Based on observation, interview and record review the facility failed to prevent an accident for 1 of 1 sampled resident (Resident 1) reviewed for burns. Resident 1 experienced harm when facility staff heated food and then failed to ensure safe temperatures prior to serving the resident, resulting in second degree burns. The facility failed to report to the appropriate state agencies at the time of the incident. This failure also placed other residents at risk of serious injury and a diminished quality of life. Findings included.Review of a facility policy titled Microwave Reheating Guidelines updated 10/01/2022 showed; Policy Statement: Foods and fluids heated in the microwave are served to residents at safe temperatures- 7. Temperature is taken prior to service to the residents. Hot beverages and hot foods are served to residents at less than or greater than 145 degrees. <RESIDENT 1>Resident 1 was re-admitted to the facility on [DATE] with diagnoses to include Rheumatoid arthritis, diabetes, kidney disease dependent on dialysis, pain in the left and right shoulder, chronic pain, and abnormalities of gait and mobility, below the knee left and right amputations, and lack of coordination. According to the Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], documented Resident 1 had no cognitive impairment.Review of Resident 1's electronic medical record (EMR) showed the resident is dependent on 2 staff for transfers with a mechanical lift, dependent on 1 staff for bed mobility, toileting, and dressing, and required set up assistance for meals and could feed themself.Review of the facilities State reporting log dated February 2026 showed documentation that Resident 1 sustained a burn on 02/26/2026 at 12:00 AM. In an interview on 05/13/2026 at 4:27 PM, Staff C stated an investigation had not been completed. Review of a progress note dated 02/26/2026 at 2:02 AM documented the Resident 1 had spilled a bowl of hot soup onto themself. Upon arrival, this LN observed the resident lying on his right-side shouting in pain. A skin assessment was performed and there was a great area of redness that covered the left groin area, the lower left abdomen, the left hip, and a portion of the left lower back. There were 4 dime sized blisters that had formed in various areas. Documentation showed first aid was provided and pain medication was administered.Review of a wound consultant progress note dated 03/04/2026 at 10:18 AM showed Resident 1 had a circumferential second degree burn on their left lower leg, mainly on the thigh, some blisters partially open and draining, some blisters are intact, some epidermis (outer layer of skin) already gone. Wound measurement was documented as 15 centimeters (cm) by 58 cm by 0.1 cm. Documentation showed given the large area of the burn and comorbidities (medical conditions that coexist alongside a primary diagnosis, affecting health, treatment, and prognosis), orders were given for antibiotic ointment to prevent infection as the resident was at high risk.Review of Resident 1's Medication Administration Record (MAR) dated February 2026 showed the resident was administered as needed pain medication on 02/26/2026 at 12:40 AM, for a documented pain level of 10.Review of Resident 1's EMR did not show a skin check or pain evaluation completed for the burn incident on 02/26/2026.Review of Resident 1's Kardex and care plan for eating, was revised on 03/02/2026 showed staff to allow food/liquids to cool before placing in reach and ensure resident is covered with a towel/apron when necessary. Ensure resident is positioned in upright position as tolerated.Review of Resident 1's Care Plan showed a focus initiated on 03/23/2026 that Resident 1 had burn wounds, placing them at risk for infection, pain, impaired skin integrity, and delayed healing. Review of Resident 1's physician orders did not show wound care orders from 04/14/2026 through 04/17/2026. Resident 1's burn wound was resolved on 05/06/2026.Review of Resident 1's MAR and Treatment Administration Record dated April 2026 did not show documentation of wound care provided from 04/14/2026 through 04/17/2026.In an interview on 05/13/2026 at 2:54 PM, Resident 1 stated on 02/26/2026, an NAC had heated up a bowl of soup and placed the bowl at the edge of the bedside table and left the room to get a towel for their lap. The resident stated they started to eat the soup and their hand twitched and the bowel fell and spilled on them. The resident stated the soup was hot and they were yelling for help. The resident stated the hot soup caused burns to their left upper leg and left hip to the edge of their left buttock.In an interview and observation on 05/13/2026 at 3:10 PM, Staff D, Certified Nursing Assistant, stated the Kardex provides information about how to care for residents. Staff D stated that staff can heat food for residents and staff should check the temperature and not serve to the resident until the temperature is between 135 to 145 degrees, there is a thermometer next to the microwave. Staff D stated temperatures for food heated for residents are not documented. This writer observed a thermometer next to the microwave in the fifth-floor nourishment room.In an interview on 05/13/2026 at 4:27 PM, Staff C, Registered Nurse (RN), Director of Clinical Operations (DCO) stated an investigation was not completed and there were no statements from staff. Staff C stated they were gathering information and were attempting to contact and obtain statements from staff.In an interview on 05/14/2026 at 10:21 AM, Staff E, RN, stated staff can heat food for residents but it cannot be served if the temperature is above 145 degrees. Staff E stated nurse managers enter wound care orders, update care plans and complete incident investigations.In an interview on 05/14/2026 at 10:56 AM, Staff F, Dietary Manager, stated staff can heat food for residents and they should follow directions for the food item but staff should temp the food and should not serve to residents until the temperature is between 135 to 145 degrees. Staff F stated there had been binders on the fourth and fifth floors with instructions for heating food, but they were unable to find them. Staff F stated staff were educated but they do not remember the date and cannot find documentation.In an interview and record review on 5/15/2026 at 1:15 PM, Staff G, RN, Nurse Manager, stated the nurse managers and the Director of Nursing (DNS) complete incident investigations. Staff G stated they did not complete an investigation or interview staff for Resident 1's burn. Staff G reviewed Resident 1's EMR and acknowledged there were no wound care orders for Resident 1 from 04/14/2026 through 04/17/2026. Review of a statement dated 02/25/2026 and obtained on 05/14/2026, Staff H, Certified Nursing Assistant, documented Resident 1 had asked them to make noodles. Staff H stated they made the noodles and gave them to the resident and told the resident to be careful because the noodles were hot. Staff H documented they went to get the resident a towel to use as a clothing protector and the resident had spilled the noodles, was hurt and had pain. Review of a statement dated 05/14/2026 at 3:15 PM, Staff C documented an interview with Staff H who stated they heated Resident 1's soup according to the directions and allowed it to sit for one minute prior to serving to the resident. Staff H stated staff had previously offered to add ice to the residents soup, but the resident declined so staff stopped offering.In a joint interview and record review on 5/15/2026 at 12:15 PM, with Staff A, Administrator, Staff B, RN, DNS, and Staff C, RN, DCO, Staff C stated during an interview with Staff H, Staff H could not recall if they had temped Resident 1's soup prior to serving to the resident. Staff C stated heated food should be temped prior to serving residents. Staff A stated food and beverages cannot be served unless the temperature is between 135 to 145 degrees. Staff C stated that an investigation was not completed and confirmed there were no wound care orders for the resident from 4/14/2026 through 4/17/2026. Staff C stated resident care plans should be updated immediately for changes to residents skin and acknowledged that the residents care plan for burn wounds was not initiated until 3/23/2026.Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review the facility failed to ensure respiratory care and services were provided in accordance with accepted professional standards of practice for 3 of 4 sampled residents (Residents 14, 15, and 41) reviewed for respiratory care. Failure to change oxygen (O2) tubing routinely, failure to have appropriate orders for O2 administration and failure to have warning signs posted on resident's doors placed residents at risk for respiratory complications, unmet needs, and a diminished quality of life.Findings included.Review of the facility's policy titled, Oxygen Administration, dated 2025, documented that O2 is administered to residents who need it and consistent with professional standards of practice. Staff shall perform infection controls measures that include changing O2 tubing and nasal cannula (NC - medical tube that delivers supplemental O2 to the nose) weekly. Nebulizer (medical device that turns liquid medication into a breathable mist to be inhaled deep to treat respiratory conditions) tubing and delivery devices are to be changed every 72 hours. O2 delivery devices are to be kept covered in plastic bag when not in use. The policy documented that O2 warning signs must be placed outside the door of the resident's room where O2 is in use.<RESIDENT 14>Resident 14 admitted to the facility on [DATE] with diagnoses to include chronic lung diseases.In an observation on 12/08/2025, at 9:58 AM, Resident 14 was wearing O2 via NC. No label or date was observed on the O2 tubing. There was a nebulizer unit on their nightstand. O2 tubing and mask were connected to the nebulizer unit hanging off of the nightstand. The nebulizer unit was not in a bag, was not labeled, or dated. There was no sign observed on the resident's door indicating O2 was in use in the room.In an observation on 12/09/2025, at 9:27 AM, Resident 14 was not in their room and their O2 tubing was observed on the bed. The tubing was not in a bag, was not labeled, or dated. The nebulizer unit was observed with tubing connected, was hanging off the nightstand, not in a bag, not labeled or dated. Resident's door was observed without an O2 in use sign posted.In an observation on 12/10/2025, at 8:50 AM, Resident 14 was wearing O2 via NC. No label or date was observed on O2 tubing. Resident's door was observed without an O2 in use sign posted.Review of Resident 14's physician orders, dated 12/10/2025, documented no orders to show when the O2 tubing should be changed.In an interview on 12/12/2025, at 1:21 PM, Staff G, Licensed Practical Nurse/Resident Care Manager, stated that Resident 14 did not have an active physician order directing staff when to change their O2 tubing. Staff G stated O2 tubing should be changed weekly and labeled/dated when changed. Staff G stated that an O2 in use sign should be posted outside the room for anyone who was on O2. <RESIDENT 15>Resident 15 was admitted to the facility on [DATE] with diagnoses to include obstructive sleep apnea (sleep disorder where the airway gets blocked during sleep).In an observation on 12/08/2025, at 1:39 PM, Resident 15 was wearing O2 via NC. No label or date was observed on the O2 tubing. The resident's door was observed without an O2 in use sign posted.In an observation on 12/09/2025, at 9:25 AM, Resident 15 was wearing O2 via NC. No label or date was observed on the O2 tubing. The resident's door was observed without an O2 in use sign posted.In an observation on 12/12/2025, at 10:27 AM, Resident 15 was wearing O2 via NC. No label or date was observed on the O2 tubing. The resident's door was observed without an O2 in use sign posted.Review of Resident 15's physician orders, dated 12/09/2025, documented to date and change the resident's O2 tubing twice a month.Review of Resident 15's November 15th-30th 2025 Treatment Administration Record (TAR), the Licensed Nurse (LN) documented on the TAR with a checkmark indicating the O2 tubing was changed everyday. In an interview on 12/12/2025, at 11:52 AM, Staff H, agency Registered Nurse (RN), stated O2 tubing was normally changed weekly. Staff H stated that Resident 15 did not have a label or date on their O2 tubing and there was no O2 in use sign posted. In an interview on 12/12/2025, at1:21 PM, Staff G stated that Resident 15's physician orders directed the LN to change the resident's O2 tubing twice a month from November 15th to the end of the month. Staff G reviewed Resident 15's November 15th to the 30th, 2025 TAR and stated the checkmarks meant the O2 tubing was being changed daily. Staff G stated that the order was put into the Electronic Medical Record incorrectly and the O2 tubing should be changed weekly to include a label and date when the LN changed it. Staff G stated that a O2 in use sign should be posted outside the room for anyone who is on O2.<RESIDENT 41>Resident 41 was admitted to the facility on [DATE].In an observation on 12/08/2025, at 2:38 PN, Resident 41 was wearing O2 via NC. No label or date was observed on the O2 tubing. Resident's door was observed without an O2 in use sign posted.In an observation on 12/09/2025, at 9:57 AM, Resident 41 was wearing O2 via NC. No label or date was observed on the O2 tubing. Resident's door was observed without an O2 in use sign posted.In an observation on 12/10/2025, at 8:52 AM, Resident 41 was wearing O2 via NC. No label or date was observed on the O2 tubing. Resident's door was observed without an O2 in use sign posted.In an observation on 12/12/2025, at 10:28 AM, Resident 41 was wearing O2 via NC. No label or date was observed on the O2 tubing. Resident's door was observed without an O2 in use sign posted.Review of Resident 41's physician orders, dated 12/09/2025, documented no orders directing staff when to change the resident's O2 tubing.In an interview on 12/12/2025, at 1:21 PM, Staff G stated the Resident 41 did not have a physician order to change the O2 tubing. Staff G stated O2 tubing should be changed weekly and should include a label and date when the LN changed it. Staff G stated that an O2 in use sign should be posted outside the room for anyone who is on O2. In an interview on 12/12/2025, at 2:52 PM, Staff B, Registered Nurse/Director of Nursing, stated that their expectations would be for a resident on O2 to have physician orders for changing O2 tubing weekly and as needed. Staff B stated that resident's on O2 should have an O2 in use sign outside of their door. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview and record review, the facility failed to ensure proper storage and labeling of insulin (a medication that controls blood sugars) in 1 of 4 medication carts (Cart 4) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life. Findings included.Review of a facility policy titled, Medication Storage - Storage of Medications, dated 01/25, documented insulin products should be stored in the refrigerator until they were opened. The date is noted on the label of the insulin vials and pens (a device to inject insulin) when first used. Opened insulin vials may be stored in the refrigerator or at room temperature. Open insulin pens should be stored at room temperature. The policy directed the staff member to refer to the specific product labeling for additional details. Review of Lispro (a rapid-acting insulin) and Glargine (a long-acting insulin) insulin vial and pen manufactures recommendations, documented the insulin was good for 28 days once opened and stored at room temperature. On 12/09/2025 at 9:07 AM, Medication Cart 4 was observed with Staff F, Licensed Practical Nurse. The following was observed:-Resident 60's glargine insulin pen was observed with no date indicating when it was first used.-Resident 16's lispro insulin was opened and dated 11/06/2025, 34 days prior. In an interview on 12/09/2025 at 9:07 AM, Staff F stated that insulin was good for 28 days after it was removed from the refrigerator, opened and store at room temperature. Staff F stated Resident's 60 and 16 still were receiving these insulins. In an interview on 12/09/2025 at 1:03 PM, Staff B, RN/Director of Nursing Services, stated that the facility followed the manufacturers recommendations regarding how long insulins were good after they were opened and removed from the refrigerator. Staff B stated most insulins were good for 28 days after they were opened. Reference WAC 388-97-1300(2)

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans to include all provided nursing services for 2 of 3 sampled residents (Resident 41 and 15) reviewed for oxygen (O2) and 1 of 5 sampled residents (Resident 41) reviewed for unnecessary medications related to mental health. These failures placed residents at risk of unmet care needs, decline in condition, and diminished quality of life.Findings included.Review of the facility's policy titled, Comprehensive Care Plans, dated 2025, documented that the facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs. All Care Area Assessments (CAAs - triggered care areas from the MDS) triggered by the Minimum Data Set (MDS - an assessment tool) will be considered in developing the care plan.Review of the facility's policy titled, Oxygen Administration, dated 2025, documented that resident's care plan should identify the interventions for O2 therapy, based on the resident's assessment and orders, such as: - The type of O2 delivery system. - When to administer and/or discontinue O2. - Equipment setting for the flow rates (the amount of O2 delivered to a person per unit of time). - Monitoring of O2 levels (how much O2 is traveling through the body in the red blood cells). - Monitoring for complications associated with the use of O2. <OXYGEN>RESIDENT 41Resident 41 was admitted to the facility on [DATE].In an observation on 12/08/2025, at 2:38 PM, Resident 41 was wearing oxygen via nasal cannula (NC - a medical tube that delivers supplemental O2 to the nose) at 2 liters per minute (lpm).In an observation on 12/09/2025, at 9:57 AM, Resident 41 was wearing O2 via NC.In an observation on 12/10/2025, at 8:52 AM, Resident 41 was wearing O2 via NC.In an observation on 12/12/2025, at 10:28 AM, Resident 41 was wearing O2 via NC.Review of Resident 41's comprehensive MDS assessment, dated 10/28/2025, documented the use of O2. The CAAs were triggered for O2 use under pressure ulcer/injury and documented Resident 41 was on O2 and would be addressed in the care plan. Review of Resident 41's physicians orders, dated 12/09/2025, documented to apply O2 via NC continuously on 2 lpm that had an active order date of 10/14/2025.Review of Resident 41's care plan, dated 11/10/2025, documented no resident focus areas, goals or interventions for respiratory care.In an interview on 12/12/2025, at 1:21 PM, Staff G, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated that there was no respiratory care plan for Resident 41. Staff G stated they would expect a care plan for a resident on O2. RESIDENT 15Resident 15 was admitted to the facility on [DATE] with diagnoses to include obstructive sleep apnea (sleep disorder where the airway gets blocked during sleep).In an observation on 12/08/2025, at 1:39 PM, Resident 15 was wearing O2 via NC at 1.5 lpm.In an observation on 12/09/2025, at 9:25 AM, Resident 15 was wearing O2 via NC.In an observation on 12/12/2025, at 10:27 AM, Resident 15 was wearing O2 via NC. Review of Resident 15's comprehensive MDS assessment, dated 11/06/2025, documented the use of O2.Review of Resident 15's physicians orders, dated 12/09/2025, documented to apply O2 via NC at 2 lpm continuously to keep O2 rates above 92% and change and date O2 tubing twice a month were active with an order date of 10/31/2025.Review of Resident 15's care plan, dated 10/31/2025, documented no resident focus areas, goals or interventions for respiratory care.In an interview on 12/12/2025, at 1:21 PM, Staff G, stated that there was no respiratory care plan for Resident15. Staff G stated they would expect a care plan for a resident on O2. In an interview on 12/12/2025, at 2:52 PM, Staff B, Registered Nurse/Director of Nursing, stated that they would expect a care plan related to O2 use for residents who were on O2.<MENTAL HEALTH>Resident 41 was admitted to the facility on [DATE] with diagnoses to include dementia (a loss of mental functioning), anxiety, and major depressive disorder (chronic, serious depression).Resident 41's comprehensive MDS assessment), dated 10/28/2025, documented they had antianxiety (medications that calm your nervous system to help feel more relaxed) and antidepressant medications (medications that help balance mood regulating chemicals in the brain). The CAAs documented psychotropic (medications that change brain chemistry to help manage mental health conditions) drug use triggered and documented there was a care plan in place. Review of the level II Preadmission admission Screening and Resident Review (PASRR - an assessment to screen individuals for mental illness), dated 10/22/2025, documented Resident 41 had serious mental illness. The assessment also stated that Resident 41 met the criteria of a severe cognitive impairment.Review of Resident 41's care plan, dated 11/10/2025, showed no resident focus areas, goals or interventions for dementia or mental health needs.In an interview on 12/12/2025, at 2:52 PM, Staff B, stated that mental health was not addressed in Resident 41's care plan. Staff B stated they would expect mental health to be addressed in the resident's care plan since it was triggered on the CAAs. Reference: WAC 388-97-1020(1)(2)(a)

Based on interview and record review the facility failed to ensure 2 of 5 nurse aides (Staff P and S) had their required 12 hours of in-service training, and 5 of 5 nurse aides (Staff J, P, Q, R and S) failed to receive the required dementia training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training and required dementia training placed residents at risk of less than competent care and services from staff. Findings included . In a review of the nursing aides' training hours showed Staff P and S, Certified Nursing Assistants, (NAC), had did not have receive a minimum of 12 hours of training within the year. In a review of the nurse aides' dementia training, showed Staff J, P, Q, R and S, NACs, did not receive dementia training. In an interview on 02/13/2024 at 3:28 PM Staff T, Registered Nurse/Staff Development, stated they were new to the position, and they were in the process of putting in structures to ensure required trainings and skills checks were completed for NAC's. In an interview on 02/14/2025 at 10:09 AM, Staff A, Administrator stated they were aware of annual trainings had not been completed as required. Staff A stated they had recently begun to develop a new system to ensure education would be completed as required. WAC 388-97-1680(2)(a-c)

Based on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and at a palatable temperature on 1 of 2 floors (5th Floor). Failure to ensure timely meal delivery could negatively impact the residents' nutritional status, appetite, and meal acceptance. Findings included . Record review of the posted hall mealtimes for the 5th floor showed: - Breakfast 8:35 -8:45 AM, - Lunch 1:10-1:20 PM, - Dinner 6:35-6:45 PM. In an observation on 02/10/2025, a meal cart with breakfast trays was delivered to the 5th floor at 9:05 AM. In an observation and interview on 02/10/25 at 1:26 PM, Resident 9's meal was delivered. Resident 9 stated their soup was cold and the staff does not heat up their cold food, at 2:49 PM Resident 9's meal tray was still sitting in front of them. In an observation on 02/10/2025 at 1:27 PM, Resident 57's lunch tray was delivered to their room. In an observation on 02/10/2025 at 1:31 PM, the second tray cart was delivered to the 5th floor. Staff began passing the trays from the second cart at 1:37 PM. In an observation on 02/10/2025 at 1:43 PM, one hallway had not had trays delivered. The trays were observed to be delivered and completed at 2:10 PM. In an observation and interview on 02/10/25 at 2:09 PM, Resident 30 stated their meal tray was just delivered and stated, every one of these meals are cold, breakfast lunch and dinner .cold, maybe they can explain why these lunches are so (expletive) late. In an interview and observation on 02/10/2025 at 2:35 PM, Resident 57 was lying in their bed then sat up with marked tremors all over. Their lunch tray was on their overbed table untouched. When asked if they were going to eat lunch, the resident stated they were waiting for an aide to come in because they needed to be fed. At 2:43 PM, Staff G, Registered Nurse, went into Resident 57's room and began assisting them with eating. In an observation and interview on 02/11/2025 at 1:31 PM, Resident 30 was observed to have received their meal tray. Resident 30 stated it was a food item they liked, but then complained that the portion was small, it was not hot, and the kitchen must be slow again. In an interview on 02/11/2025 at 1:37 PM, Resident 31 stated sometimes lunch arrived at 12:30 PM and sometimes not until 2:00 PM. In an interview on 02/14/2025 at 9:25 AM, Staff M, Certified Nursing Assistant, NAC stated they felt the issue with trays being delayed was due to the meal carts arrive late from the kitchen and stated the floor staff pass them out as fast as they can. In an interview on 02/14/2025 at 10:09 AM, Staff A, Administrator and Staff B, Director of Nursing stated they were not aware of an issue with timely meal delivery. Refer to WAC 388-97-1100(1)(2) 36787

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for five of five employees (J, P, Q, R, and S) reviewed, who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs, and the quality of care provided to residents. Findings included . Review of the staff roster provided on 02/13/2025, showed Staff J was hired on 02/25/2022, Staff P was hired on 06/13/2022, Staff Q was hired on 02/02/2022, Staff R was hired on 06/28/2021 and Staff S was hired on 07/11/2023. In an interview on 02/13/2024 at 3:28 PM, Staff T, Registered Nurse/Staff Development, stated they were new to the position, and they were in the process of putting in structures to ensure evaluations were completed for NAC's. There were no evaluations provided by Staff T for the NAC's identified. In an interview on 02/14/2025 at 10:09 AM, Staff A, stated they were aware of annual evaluations had not been completed as required. Staff A stated they had recently begun to develop a new system to ensure education would be completed as required. Refer to WAC 388-97-1680 (2) (a-c)

Based on observation, interview and record review, the facility failed to review and revise care plans for four of 14 residents (Residents 3, 11, 43 and 57) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for weight loss, dehydration, unmet care needs and a diminished quality of life. Findings included . <RESIDENT 57> Resident 57 admitted to the facility on [DATE] with diagnosis to include essential tremor and gait and mobility abnormalities. Review of the Minimum Data Set Assessment (MDS, an assessment tool) assessment dated [DATE] showed Resident 57 required supervision or touching assistance for eating. Review of Resident 57's care plan on 02/11/2025 at 1:09 PM, showed the resident had an activities of daily living (ADL) self-care performance deficit related to tremors in their upper extremities. The care plan directed staff to use a cup with lid for hot liquids. The care plan did not include the feeding assistance needed for Resident 57. In an observation on 02/10/2025 at 1:27 PM, Resident 57's lunch tray was delivered to their room. In an interview and observation on 02/10/2025 at 2:35 PM, Resident 57 was observed lying in bed then sat up with marked tremors all over their body. Their lunch tray was on their overbed table untouched. When asked if they were going to eat lunch, the resident stated they were waiting for an aide to come in because they needed assistance with eating. At 2:43 PM, Staff G, Registered Nurse (RN) went into Resident 57's room and began assisting them with eating. In an observation on 02/11/2025 at 9:06 AM, Resident 57's lunch tray was delivered to the resident. At 9:26 AM, Staff H, Nurse's Aide Certified (NAC) stated they needed to help feed Resident 57. In an interview on 02/14/2025 at 9:34 AM, Staff B, Director of Nursing Services was informed of the lack of directive on the care plan for Resident 57's meal assistance. 51551 <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses to include dementia, depression and psychosis (a condition when people lost contact with reality). According to quarterly MDS, dated [DATE], Resident 43 showed severe cognitive impairment and took antidepressant and antipsychotic (A medication that affects mood, perception and thinking) medications. Review of Resident 43's February 2025's Medication Administration Record (MAR) showed Resident 43 was taking medications antidepressant since 12/19/2024 and antipsychotic since 06/14/2024. Review of Resident 43's care plan, copy date 02/11/2025 showed no focus, no goals or any intervention of antidepressant or antipsychotic medications. The care plan did not include monitoring of medication side effects or target behaviors for these medications. In a record review and interview on 02/12/2025 at 1:34 PM, Staff I, RN stated they get information of how to take care of resident from care plan. Staff I stated resident care manager was responsible to update and revise the plan of care. Staff I stated the care plan should include psychotropic medications with target behaviors and side effects monitoring. Staff I confirmed Resident 43's care plan did not include interventions for the antidepressant or antipsychotic medications, side effects or target behavior monitoring. In a record review and interview on 02/12/2025 at 3:15 PM, Staff F, Licensed Practice Nurse/Resident Care Manager, stated nurse obtain directive of resident care from the care plan. Staff F stated psychotropic medication side effects and target behavior monitoring should be included in the care plan but it had been missed for Resident 43. Staff F stated they should update and revise the care plan. 44110 <RESIDENT 11> Resident 11 admitted to the facility on [DATE], with diagnoses to include morbid obesity, muscle weakness, heart failure, and depression. The modified admission MDS dated [DATE], showed the resident had intact cognition. The MDS showed the resident had an active pressure ulcer, was a high risk for pressure ulcers, and at the time had one unstageable pressure wound (a full thickness wound where the base of the injury is obscured by dead tissue). Review of Resident 11's physician orders showed an active order dated 02/01/2025 for wound care to the resident's sacrum that read; to cleanse the area with normal saline, pat dry, apply a skin prep to inside of the wound, apply collagen (a protein that provides structural support and promotes the formation of new tissue grow) to wound bed and cover with a hydrocolloid (a self-adhesive, waterproof bandage that was used to protect and heal wounds) dressing. The orders instructed the licensed nurse to change the dressing every three days and as needed in the event of accidental removal and soiling. Review of Resident 11's wound care notes dated 02/07/2025 showed the wound to the sacrum was classified as a Stage 4 (full-thickness tissue loss exposing underlying muscle, tendon, or bone) that measured 2.5 centimeters (cm) in width, 5 cm in length, and 0.2 cm in depth. In an observation and interview on 02/10/2025 at 2:00 PM, Resident 11 stated they had admitted to the facility with a wound to their sacrum. The resident stated they felt the facility was doing a great job managing the wound, and that it had improved. The resident was observed to be lying on an air mattress, and had a trapeze grab bar above their bed to assist in self-repositioning. Review of Resident 11's care plan on 02/11/2025 had no reference that the resident admitted with an unstageable pressure wound, the wound had been classified at a Stage 4. The care plan did not address any individualized goals of care for the active stage 4 wound or list any resident-centered interventions to prevent worsening or aid in improvement of the wound. The air mattress and trapeze bar were not on the plan of care for the resident. <RESIDENT 3> Resident 3 admitted to the facility on [DATE] with diagnosis to include urinary retention, obstructive uropathy (a condition where urine flow was blocked or hindered, leading to backup of urine in the urinary tract), and benign prostatic hyperplasia (BPH) (enlargement of the prostate gland which can cause urinary retention). The quarterly MDS dated [DATE] showed the resident had a urinary catheter (tube inserted into the bladder to drain urine) and had occasional incontinence (loss of control of bladder elimination). Resident 3 was hospitalized on [DATE] and readmitted to the facility on [DATE] after diagnosis of septic shock (life-threatening condition that occurs when an infection spreads throughout the body) related to urinary infection caused by urinary retention. The significant change in condition MDS dated [DATE] showed the resident readmitted with a urinary catheter. Review of Resident 3's physician orders dated 12/03/2024 showed an order for Finasteride a medication which treats BPH and reduce risk for urinary retention. Review of Resident 3's hospital discharge summary dated 12/02/2024, showed there was difficulty placing a urinary catheter, and unable to place at bedside, and that surgical guidance was required to place the catheter. Recommendations included keeping the catheter in place after discharge, with urology follow-up. Review of Resident 3's care plan on 02/11/2025 showed no reference to the resident's urinary retention, or their enlarged prostate that could cause urinary retention. There was no individualized goals of care or interventions to prevent or treat the resident's urinary retention. In an interview on 02/13/2025 at 9:13 AM, Staff C, NAC stated that they rely on the electronic medical record to access the care plan to determine what level of care to provide to residents. In an interview on 02/13/2025 at 10:38 AM, Staff D, NAC stated they determine what level of care to provide to the residents by reviewing the residents care plan. Staff D stated that Resident 11 required assistance for repositioning, and that they had a bandage on their sacrum but was not aware of any interventions for care of the wound, as it was managed by the nurse. Staff D stated that Resident 3 used a urinal and was not aware the resident had any issues with urinary retention. In an interview on 02/13/2025 at 12:12 PM, Staff E, RN stated they had worked at the facility since October of 2024 through an agency service. Staff E stated that the care plan was how they obtained the residents care directives. Staff E stated they review the care plan every shift to familiarize themselves with what level of care each resident required. Staff E stated that the nurse managers were usually responsible for updating and revising the plan of care. Staff E stated that Resident 11 was repositioned, and used a trapeze for reposition in bed. Staff E confirmed that there were no interventions for the Stage 4 pressure wound to their sacrum on the care plan. Staff E stated they were not aware that Resident 3 had urinary retention concerns or that the resident had difficulty with catheter placement due to their BPH. Staff E confirmed that information should be in the care plan. In an interview on 02/13/2025 at 2:10 PM, Staff F stated all the staff used the care plan to direct their care for residents. Staff F stated the licensed staff and themselves were responsible for updating and revising the care plan. Staff F confirmed that Resident 11 had a Stage 4 pressure ulcer to their sacrum. Staff F confirmed that the care plan should reflect resident centered goals and interventions for staff to implement to reduce and assist in healing of Resident 11's stage 4 pressure ulcer. Staff F was asked to look at Resident 11's care plan and was unable to locate any information for their pressure ulcer on their sacrum or any goals or interventions. Staff F confirmed that Resident 3 had urinary retention, and that placing a catheter was difficult for the resident. Staff F confirmed that the urinary retention for the resident and monitoring for retention should be on the care plan and confirmed that it was not. In an interview on 02/13/2025 at 10:53 AM, Staff K, LPN stated the nurse managers and Director of Nursing Services (DNS) update the care plans. In an interview on 02/13/2025 at 3:04 PM, Staff O, MDS nurse stated they worked with the care managers to make sure the care plan matched the data collected. In an interview on 02/14/2025 at 10:09 AM, Staff B, DNS, stated they had been at the facility now for about 90 days, and had become aware recently that updates and revisions to the resident's care plans had not been getting completed timely. They were working with the nurse managers on educating the staff more on care plan revisions. Reference WAC 388-97-1020(2)(a)(5)(b)

Based on observation, interview and record review the facility failed to ensure 1 of 5 sampled residents (Resident 460) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors and update the care plan. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care. Findings included . Review of the facility policy titled; Use of Psychotropic Medication(s) undated showed the intent of the policy was to ensure residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. The policy explained the effects of psychotropic use would be evaluated on an ongoing basis to include physician evaluation, pharmacist medication reviews, Minimum Data Set (an assessment tool) reviews, and nursing assessments and the resident's care plan. Resident 460 admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (a disorder of the central nervous system affecting movements), stroke, dementia without behaviors (memory loss), and depression. Review of Resident 460's February 2025 Medication Administration Record on 02/13/2025, showed they were prescribed Abilify (an antipsychotic) 5 mg at bedtime for dementia starting 01/22/2025. Review of Resident 460's February 2025 Treatment Administration Record on 02/13/2025, showed no behavior monitor or interventions associated with the use of an anti-psychotic medication. Review of Resident 460's electronic medical record on 02/13/2024, showed no Abnormal Involuntary Movement Scale (AIMS) assessment was completed for the use of an antipsychotic. Review of Resident 460's care plan dated 01/28/2025, showed no indication they were taking an antipsychotic and had no behavior monitors or interventions found to document symptoms or behaviors associated with the use of an anti-psychotic medication. Review of the January monthly medication review (MMR), conducted by the pharmacist on 01/30/2025, showed Resident 460 was reviewed with a recommendation to check the indication for the use of Abilify. The pharmacist notated the diagnosis in the electronic health record showed a diagnosis of dementia for the use of Abilify, and a supporting diagnosis would be needed for the use of the antipsychotic medication. Review of Resident 460's Care Area Assessment (CAA- an assessment of a specific resident care or medical issue) dated 01/28/2025, showed they would remain free of complications related to their psychotropic medication use. The CAA lacked details regarding Resident 460's use of an antipsychotic medication, behavioral interventions, symptoms, or indications for use. In a review of Resident 460's provider note dated 02/03/2025, showed they met with the resident and reviewed the use of Abilify to which they endorsed a history of hallucinations related to their Parkinson's medication. Additionally, the note showed Resident 460 was not sure what the Abilify was being used for and a discussion of discontinuing it. In an interview on 02/13/2025 at 1:35 PM Staff N, Social Services Director, stated they meet with new residents as soon as possible, gather information about them, complete assessments and set up care conferences. Staff N stated they refer residents who take psychotropic medication if needed, ensure medications and diagnoses are reviewed, and review their medical record to gather as much information as possible. Staff N stated Resident 460 had diagnoses that included dementia, anxiety and depression. Staff N stated Resident 460 had a diagnosis of dementia as the indicator for use of Abilify. Staff N stated they did not know if dementia was an indication for use of an antipsychotic. Staff N stated they had not had any concerns about Resident 460 regarding psychosis and had not discussed with them their medication use, mental health diagnoses, or the reasons they were taking psychotropic medications. Staff N stated Resident 460 had no monitor in place for psychotic symptoms. In an interview on 02/13/2025 at 3:04 PM Staff O, Minimum Data Set (MDS) Coordinator, stated they completed the CAA for Resident 460's psychotropic medication use. Staff O stated they interviewed Resident 460 regarding their psychotropic medication use and signs/symptoms of not taking the medication. Staff O stated Resident 460 stated if they did not take their psychotropic medication, they get quiet and not participate in activities. Staff O stated they documented Resident 460's information on a form in which they kept internally. Staff O stated part of the admission process included reviewing a resident's medications and completing consents as needed with residents. Staff O stated the facility just recently started weekly meetings to review the care plans of residents and work with the nurse managers to ensure all the data complied matches a resident's care plan. Refer to WAC 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Resident 43) reviewed for unnecessary medication use. This failure placed the resident at risk for experiencing medication related complications and a decreased quality of life. Findings included . Resident 43 admitted to the facility on [DATE] with diagnoses to include diabetes (a chronic condition that affects how the body uses sugar for energy), and long-term kidney disease. Review of the monthly MMR note to attending physician/prescriber for Resident 43, dated 08/28/2024, showed recommendation to consider starting dapagliflozin (antidiabetic medication) 5miligram(mg) daily and to increase to 10mg daily next month if tolerated well. The provider agreed with recommendation on 08/29/2024. Resident 43's MMR showed recommendation of ensuring orthostatic hypotension monitoring was evaluated due to antipsychotic use and frequency determined by the facility policy and protocol. The provider ordered to monitor orthostatic hypotension weekly. Review of Resident 43's monthly MMR dated 11/29/2024 and 12/20/2024, showed repeated recommendation of ensuring that regular orthostatic hypotension monitoring was being evaluated due to antipsychotic use and frequency determined by facility protocol and policy. Review of Resident 43's February 2025's Medication Administration Record (MAR) showed an order of dapagliflozin 5 mg by mouth one time a day for diabetes if tolerated well increase to 10mg daily in October. Review of Resident 43's electronic medical record showed no documentation of orthostatic hypotension monitoring. Review of documentation from advanced registered nurse practitioner, dated 02/12/2025, under history of present illness showed Resident 43 was on dapagliflozin 10 mg daily. In an interview on 02/13/2025 at 9:10 AM, Staff I, Registered Nurse, confirmed Resident 43 was taking dapagliflozin 5mg currently. Staff I stated they were not sure why the dosage was not increased in the following month. In an interview on 02/13/2025 at 9:10 AM, Staff I, confirmed Resident 43 had no orthostatic hypotension monitoring on the MAR. In an interview on 02/13/2025 at 10:14 AM, Staff F, Licensed Practice Nurse/Resident Care Manager, stated they were not sure why the dosage of dapagliflozin did not increase in the following month after the medication started and there was no provider's documentation of the rationale to keep the 5mg dosage. Staff I stated as a part of the order, they did not know how to decide if Resident 43 tolerated the medication well or not. Staff F stated there was no documentation of orthostatic hypotension monitoring after August and they were not aware of this recommendation. In an interview on 02/13/2025 at 11:40 AM, Staff B, Director of Nursing, stated they did not work for the facility in August and did not know why the medication dosage was not increased for the dapagliflozin, or why orthostatic hypotension monitoring was not implemented. Reference: WAC 388-97-1060 (3)(k)

Based on observation, interview and record review, the facility failed to provide the necessary assistance for eating, and drinking, for 2 of 2 residents (Residents 16 and 57) dependent on staff to ensure their needs were met. The failed practice placed residents at increased risk for medical complications, poor quality of life and psychosocial harm. Findings included . <RESIDENT 57> Resident 57 admitted [DATE] with diagnoses to include essential tremors, muscle weakness and lack of coordination. Review of the Minimum Data Set Assessment (MDS) dated [DATE] showed the resident required supervision or touching assistance for eating. Review of the care plan on 02/11/2025 at 1:09 PM, showed the resident had an ADL self-care performance deficit related to tremors in their upper extremities. The care plan directed staff to use a cup with lid for hot liquids. The care plan did not include the feeding assistance needed for Resident 57. In an observation on 02/10/2025 at 1:27 PM, Resident 57's lunch tray was delivered to their room. In an interview and observation on 02/10/2025 at 2:35 PM, Resident 57 was lying in bed then sat up with marked tremors all over. Their lunch tray was on their overbed table untouched. When asked if they were going to eat lunch, the resident stated they were waiting for an aide to come in because they needed to be fed. At 2:43 PM, Staff G, Registered Nurse went into Resident 57's room and began assisting them with eating. In an observation on 02/11/2025 at 9:06 AM, Resident 57's lunch tray was delivered to Resident 57. At 9:26 AM, Staff H, Nurse's Aide Certified (NAC) said they needed to help feed Resident 57. In an observation on 02/12/2025 at 8:38 AM, Resident 57's breakfast tray was placed on the nurse's station counter. At 9:09 AM, Resident 57 walked to their doorway independently and tremors were noted. The resident asked, Where is (Staff H)? I am hungry and I need someone to help feed me. Can you get (Staff H) for me At 9:12 AM, Staff C, NAC went into assist the resident. In an observation on 02/12/2025 at 1:20 PM, Resident 57's lunch tray was dropped off in their room. In an observation on 02/13/2025 at 8:35 AM, Resident 57's tray was delivered to their room. At 8:49 AM, the tray remained covered in their room. At 8:56 AM, Resident 57 received eating assistance from Staff H. At 11:02 AM, the resident stated they got help with breakfast earlier and they often have to wait to get help to eat long after their meal had been delivered. In an observation on 02/14/2025 at 9:03 AM, the breakfast tray was delivered to Resident 57. Resident 57 asked Staff K, NAC if they were going to help him eat now. Staff J said, Not yet, I have to get the other trays passed first. Resident 57 stated their tremors were really bad today. Staff M, NAC commented that sometimes other staff will help them pass trays. At 9:20 AM, Staff J, NAC knocked on the resident's door and said they were there to help them eat. The phone rang seconds later, and Staff J left to answer the phone. At 9:27 AM, Resident 57 came out of their room and stood up against the wall and stated their tremors were real bad today and they were waiting for their aide to help them eat. Staff J, returned to assist Resident 57 at 9:31 AM. <RESIDENT 16> Resident 16 admitted to the facility 06/07/2024 with diagnoses to include stroke, dementia and need for assistance with personal care. According to the most recent quarterly MDS assessment dated [DATE], the resident had severe cognitive impairment. The resident required extensive assistance of one to two staff members for all activities of daily living (ADL) including eating. The resident had vision impairment and limited range of motion both upper extremities. Review of Resident 16's Kardex (tool to alert nursing assistants how to provide care) revealed Resident 16 was totally dependent on staff for eating requiring one to one feeding assistance. The care plan for Resident 16 showed the resident was totally dependent on staff for eating. In an observation on 02/11/2025 at 1:11 PM, Resident 16's lunch tray was delivered. Meal assistance was provided at 1:33 PM. In an observation on 02/12/2025 at 8:34 AM, Resident 16's breakfast tray was delivered. Staff H, Nurse's Aide Certified (NAC) went to assist the resident with their meal at 9:12 AM. In an observation on 02/12/2025 at 1:11 PM, Resident 16's lunch tray was delivered to them. Staff H, NAC went to assist Resident 57 with their meal at 1:30 PM. In an observation on 02/13/2025 at 8:37 AM, Resident 16's breakfast tray was delivered. Staff H, NAC went to assist Resident 57 with their meal at 8:53 AM. In an interview was done on 02/14/2025 at 9:34 AM with Staff B, Director of Nursing Services (DNS) were made aware the facility failed to provide timely ADL services to Resident's 16 and 57. The DNS stated Resident 57 needed weighted utensils, and they were getting an Occupational Therapy evaluation for that. Staff B stated they would address the eating assistance concerns for Resident 16 and 57. No additional information was provided. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 21) reviewed for dialysis services received consistent, ongoing communication and collaboration with the dialysis facility regarding care and services for dialysis residents. These failures failure had the potential to cause unmet care needs, medical complications, inadequate quality of care, and a diminished quality of life. Findings included . A review of the facility's policy, titled Hemodialysis dated August 2024, showed that the facility will assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice to including the ongoing assessment of the resident's condition and monitoring for complications before or after dialysis treatments. <RESIDENT 21> Resident 21 was admitted to the facility on [DATE] with a diagnosis of end stage renal (kidney) disease (stage of renal impairment that is irreversible and permanent), dependent on dialysis (a procedure that substitutes for the functions of the kidneys). Record review of Resident 21's care plan, revised on 04/26/2024, revealed the care plan lacked resident centered interventions and collaboration of dialysis care by the nursing home and dialysis staff. The care plan did not indicate what care or medications the facility would provide, nor what care the dialysis center would provide. Review of the form titled ECTS Dialysis Communication Form dated from 10/01/2024 through 02/11/2025 showed Resident 21 had twenty missing communication forms and five incomplete assessment information, excluding their refusals: - 10/01/2024 absent from medical record - 10/03/2024 absent from medical record - 10/05/2024 absent from medical record - 10/07/2024 absent from medical record - 10/12/2024 incomplete with no kidney center information - 11/12/2024 absent from medical record - 12/03/2024 absent from medical record - 12/04/2024 vital signs only post treatment - 12/06/2024 missing condition post dialysis - 12/10/2024 absent from medical record - 12/12/2024 absent from medical record - 12/19/2024 no post treatment assessment - 12/21/2024 absent from medical record - 12/24/2024 absent from medical record - 12/28/2024 absent from medical record - 12/31/2024 absent from medical record - 01/02/2025 absent from medical record - 01/04/2024 absent from medical record - 01/09/2025 no post treatment assessment - 01/11/2025 absent from medical record - 01/14/2025 absent from medical record - 01/16/2025 absent from medical record - 01/18/2025 absent from medical record - 01/28/2025 absent from medical record - 01/30/2025 vital signs only post treatment - 02/01/2025 absent from medical record In an interview on 02/14/2025 at 9:49 AM, Staff B, Director of Nursing stated the facility had a communication form that the nurses fill out their portion of the sheet, and then the kidney center fills out their portion. Residents on dialysis were to be assessed pre and post dialysis. Staff B was informed there was missing or inconsistent documentation from either kidney center or facility for Resident 21. Staff B stated the kidney center did not always send the form back and they should fax the report to us due to Resident 21's impaired vision. Reference: WAC 388-97-1900 (1),(6)(a-c)

Based on interview and record review, the facility failed to ensure 1 of 5 residents (Resident 21) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to assess and alert the physician of elevated blood sugar levels and hold medications as directed for abnormal vital signs. This placed the residents at increased risk of unmet care needs. Findings included . Review of the facility's Medication Administration General Guidelines, dated January 2025, directed nurses to administer medications in accordance with written orders of the prescriber. The guidelines directed staff to obtain and record any vital signs as necessary prior to medication administration. The American Heart Association, dated April 21, 2017, considered a blood pressure to be within the normal range when both systolic and diastolic numbers were in these ranges: a normal reading would be any blood pressure below 120/80 mm Hg (millimeters of mercury) and above 90/60 mm Hg. Additionally, hypotension was the medical term for low blood pressure (less than 90/60). <RESIDENT 21> Resident 21 was admitted to the facility on [DATE] with cardiac diagnoses to include congestive heart failure, hypertension and diabetes. Review of Resident 21's current physician's orders showed directives for the nurses to give Hydralazine (medication to treat hypertension) twice daily and hold the medication if the heart rate (HR) was less than 60 beats a minute or hold for systolic blood pressure (SBP- the first number, called systolic blood pressure, measures the pressure in your blood vessels when your heart beats) less than 110 or diastolic (DBP)-the second number) was less than 60. The physician's order showed the provider was to be notified of blood sugars less than 60 or over 400. Review of Resident 21's December 2024 Medication Administration Record (MAR) showed Hydralazine was not held on 12/19/2024 at 9:00 AM when the DBP was 58 and on 12/20/2024 at 6:00 PM, when the DBP was 48. On 12/04/2024 at 6:00 PM, Resident 21's blood sugar level was 429 and at 9:00 PM, the blood sugar was 412. Review of Resident 21's December 2024 progress notes showed the provider was not notified of the elevated blood sugar levels. Review of Resident 21's January 2025 MARs showed their blood sugar on 01/07/2025 at 6:00 PM was 430, on 01/18/2025 at 9:00 PM it was 431 and on 01/26/2025 at 1:00 PM it was 412. Review of Resident 21's January 2025 progress notes showed the provider was not notified of the elevated blood sugars. Review of Resident 21's February 2025 MARs showed their blood sugar on 02/02/2025 at 1:00 PM was 580 and at 9:00 PM it was 420. Further review showed that the medication Hydralazine had not been held on 02/01/2025 for a DBP of 54. On 02/08/2025 Hydralazine was administered when the SBP was 108 and DBP was 50. Review of Resident 21's February 2025 progress notes showed the provider was not notified of the elevated blood sugars. In an interview on 02/14/2025 at 9:56 AM, Staff B, Director of Nursing Services stated the nurses may not have documented notifying the providers of the elevated blood sugars and should have followed physician orders and document these in the medical record. In an interview on 02/14/2025 at 10:04 AM, Staff I, Registered Nurse stated medications are to be held per physician's order. Staff I stated they were to notify the provider and document when blood sugars are below 60 or over 400. Reference WAC: 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and to ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (Fourth floor and Fifth floor) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Findings included . <FIFTH FLOOR> During an observation and interview on 03/28/2024 at 10:10 AM, the Fifth -floor medication refrigerator contained 20 packets of Veltassa (a medication that treats high levels of potassium in the blood), 10 Insulin (manages sugar in the body) pens, 16 insulin vials, one Procrit (a medication to treat low red blood cells), six individual flu vaccines, two multi dose flu vaccine vials, two RSV (a respiratory virus) vaccination vials, and two multi-dose Tubersol (a prescription solution to test for Tuberculosis which was a potentially serious infectious disease that mainly affect the lungs) vial, and one Emergency Kit containing nine insulin pens, and three Ativan (a medication used to treat anxiety) vials. Staff I, Licensed Practical Nurse (LPN), stated resident medications, Tubersol, and vaccines were stored in the refrigerator. Review of Fifth floor's medication room temperature log, dated March 2024, showed only documentation for the AM shift and no PM documentation. <FOURTH FLOOR> During an observation and interview on 03/28/2024 at 11:00 AM, the Fourth-floor medication refrigerator contained 36 insulin pens, eight insulin vials, one RSV vaccination, 20 individual use flu vaccinations, two multi-use flu vaccine vials, three multidose COVID vaccine vials, and one Emergency Kit containing 10 insulin pens. There was a refrigerator temperature log, dated March 2024, taped to the front of the medication refrigerator, showed five missing readings for the AM shift and ten missing readings for the PM shift. Staff J, LPN, stated vaccinations and resident medications were stored in the refrigerator. Staff J was unsure of who was responsible for documenting and checking documentation of refrigerator temperatures. In an interview on 03/28/2024 at 11:25 AM, Staff C, Infection Preventionist/Assistant Director of Nursing Services, stated vaccinations were stored in the medication room refrigerators, and temperatures should be documented two times daily by a nurse. Staff C reviewed the refrigerator temperature log for the Fifth floor and stated the log should have a place to document for AM and PM shifts, and stated the log was incorrect and refrigerator temperatures were only being documented on the AM shift. When reviewing the Fourth-floor log, Staff C stated there were a lot of holes. In an interview on 03/28/2024 at 2:06 PM, Staff B, Registered Nurse/Director of Nursing Services, stated medication refrigerator logs should be documented two times daily. Staff B stated vaccinations and medications may be compromised. Refer to WAC 388-97-1300 (2)

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan, for 3 of 4 sampled resident (Residents 38, 152 and 248) whose care plans were reviewed for dialysis (medical procedure to purify the blood) care. Failure to establish care plans that were timely, individualized, accurately reflected assessed care needs, and provided direction to staff placed residents at risk for unmet care needs. Findings included . <RESIDENT 38> Resident 38 was admitted to the facility on [DATE], with diagnoses including but not limited to end stage kidney disease dependent on dialysis. Review of the comprehensive care plan on 03/29/2024, showed a focus area that Resident 38 has end stage renal disease. The interventions in place on the care plan did not include when (times) and where the resident received dialysis, contact information for the dialysis center or transportation information, specific care information for nursing assistants such as which arm, they should not obtain blood pressures on. In an interview on 04/01/2024 at 9:34 AM, Staff J, Licensed Practical Nurse (LPN)/Nurse Manager, stated dialysis specific care plans should include specific information on where the residents go for treatments, contact information for dialysis center and doctors, monitoring of the site before and after treatments, where it was safe to take blood pressure on a resident, fluid or diet restrictions, days/times and appropriate labs that needed to be monitored. Staff J was unable to provide documentation Resident 38 had a detailed care plan in place at the time of this interview. <RESIDENT 152> Resident 152 admitted to the facility on [DATE], with diagnoses including but not limited to end stage kidney disease dependent on dialysis. Review of the comprehensive care plan on 03/29/2024, showed a focus area Resident 152 required hemodialysis related to renal failure. The interventions in place on the care plan did not include fluid and/or diet restrictions (if applicable), when (times) and where the resident received dialysis, contact information for the dialysis center or transportation information, specific care information for nursing assistants such as which arm, they should not obtain blood pressures on. <RESIDENT 248> Resident 248 admitted to the facility on [DATE], with diagnoses including but not limited to end stage kidney disease dependent on dialysis. Review of the comprehensive care plan on 03/29/2024, showed a focus area Resident 248 required hemodialysis related to renal failure. The interventions in place on the care plan did not include fluid and/or diet restrictions (if applicable), when (times) and where the resident received dialysis, contact information for the dialysis center or transportation information, specific care information for nursing assistants such as which arm, they should not obtain blood pressures on. In an interview on 04/01/2024 at 09:20 AM, Staff G, Registered Nurse (RN), stated all the dialysis information/monitoring they need for Resident 248 was located on the treatment administration record and they were unsure what a care plan was. In an interview on 04/01/2024 at 9:45 AM, Staff A, Administrator, stated care plans should be resident specific and include dialysis specific information for all resident's dependent on dialysis. Staff A was unable to provide any additional information. Refer to WAC 388-97-1020 (1),(2)(a)(b),(3)

Based on observation, interview and record review, the facility failed to ensure staff followed use of a respirator (N-95 mask that provides more protection) and Personal Protective Equipment (PPE, equipment to protect staff from contact with potentially harmful germs such as gown and gloves) for 1 of 2 rooms (room [ROOM NUMBER]) reviewed for Transmission Based Precautions (TBP, list of precautions staff were to use based on the type of disease or condition). Failure to follow TBP put staff and residents at risk for the transmission of communicable diseases. Findings included . Review of a facility's undated policy titled, Aerosol Generating Policy (AGP) and Procedure, showed the use of a bipap machine (uses air pressure to push air into the lungs) was considered an aerosol generating procedure (procedure that can cause germs to enter the air from the respiratory tract). Staff entering the room during an AGP and for three hours after discontinuation of the procedure required the use of a respirator. During an observation on 03/27/2024 at 10:20 AM, a sign was noted hanging outside of the door to room [ROOM NUMBER]. The sign showed an Aerosol Generating Procedure was in progress, and to restrict visitation. The sign showed the AGP started at 10:00 PM, was completed at 8:00 AM, and the precautions ended at 11:00 AM. The sign showed prior to entering the room, persons needed to use a respirator and wear eye protection. During an observation and interview on 03/27/2024 at 10:20 AM, Staff D, Nursing Assistant Certified, was observed to open the door to room [ROOM NUMBER] and start to enter, wearing only a procedure mask, and no other PPE. Staff D stated they worked for an agency and was not familiar with what the sign posted at the doorway meant. During an observation and interview on 03/27/2024 at 10:29 AM, Staff E, Registered Nurse (RN), was observed to knock on door to room [ROOM NUMBER], open the door and proceed to enter. Staff E stated they did not know what PPE was required to enter room [ROOM NUMBER] before 11:00 AM because they worked for a contracted agency and was not actually a facility employee. During an interview on 03/27/2024 at 10:39 AM, Staff B, RN/Director of Nursing Services, stated they expected staff, including agency staff, to put on a respirator, eye protection, gown, and gloves prior to entering a room if AGP precautions were still in place. Refer to WAC 388-97-1320 1(a), 2(a)(b) .

Based on interview and record review, the facility failed to provide documentation that staff were provided education regarding the benefits and potential risks associated with the COVID 19 (an infectious disease of a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) Vaccine for 2 of 2 staff (Staff F and G) reviewed for immunizations. This failure put staff at risk of not having adequate information to decide if the COVID 19 vaccination was appropriate for them. Findings included . During an interaction on 03/28/2024 at 11:47 AM, Staff C, Infection Control Specialist, was requested to provide documentation that Staff F, hospitality aide and Staff G, Registered Nurse, had been provided education regarding the risks and benefits of the COVID 19 vaccine. Staff C reported they would have to check their records. During an interview on 03/29/2024 at 10:52 AM, Staff B, Director of Nursing Services, stated the facility had not been providing education to staff on the COVID 19 vaccine. Staff B stated they did not have any documentation that Staff F and Staff G had been provided COVID 19 vaccine education. No Associated WAC

Based on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 3 residents (Residents 5 and 22) sampled for hospitalization . This failed practice placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital. Findings included . <RESIDENT 5> Resident 5 admitted to the facility on [DATE]. Review of Resident 5's medical record showed a progress note that resident was sent to the hospital on 03/07/2024. Review of Resident 5's medical record showed no record that resident or responsible party was offered a bed hold. In an interview on 03/29/2024 at 3:11 PM, Staff A, Administrator stated they were unable to find documentation that Resident 5 was offered a bed hold or that a copy of the bed hold policy was sent to the hospital with the resident. <RESIDENT 22> Resident 22 admitted to the facility on [DATE]. Review of an interact transfer form (communication form sent with the resident that contains information about their condition) showed the Resident 22 was sent to the hospital on 03/20/2024. Review of the medical record showed no record that Resident 22 or their responsible party was offered a bed hold. During an interview on 03/28/2024 at 9:38 AM, Staff C, Licensed Practical Nurse, stated the nurse sending the resident to the hospital was to send the bed hold form with them and then social services was to follow up to see if the resident wanted to do a bed hold. During an interview on 03/28/2024 at 11:24 AM, Staff H, Medical Records, reported there was no record of a bed hold in Resident 22's medical record. Staff H reported there was no documentation in the progress notes that social services followed up with the resident or their responsible party. Refer to WAC 388-97-0120(4)

Based on interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown and implement timely interventions necessary to prevent the development of facility acquired pressure ulcers for 1 of 2 residents (Residents 1) reviewed for pressure ulcers (PU). These failed practices caused harm to Resident 1, who developed an unstageable PU and placed other residents at risk for potential skin breakdown. Findings included . Review of the facility's undated policy titled, Skin Assessment, showed a full body, head to toe skin assessment would be conducted by a nurse upon admission to the facility and weekly thereafter. Review of the facility's undated policy titled, Pressure Injury Prevention and Management, showed the definition of Avoidable, meant that the resident developed a pressure injury, and that the facility did not do one or more of the following: evaluated the resident's clinical condition . define and implement interventions that were consistent with the resident needs . and professional standards of practice. Evidence based interventions included redistribute pressure and provide appropriate, pressure-redistributing, support surfaces. Rental of a low air loss mattress may be needed and would be provided by the facility. The Centers for Medicare & Medicare Services' Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, defined the stage of a PU to include: - An unstageable PU was a full thickness skin and tissue loss was obscured by slough (non-viable yellow, tan, gray, green or brown tissue found in the base of the wound or present in clumps through the wound bed) or eschar (dead or devitalized tissue); and - A Deep Tissue Injury (DTI) was described as purple or maroon area of discolored intact skin due to damage of underlying soft tissue. Resident 1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (disease of the brain that affects memory), malnutrition, muscle weakness, and reduced mobility. Review of the Admission Nursing Assessment, dated 05/26/2023, showed Resident 1 admitted to the facility without PUs. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 06/02/2023, showed Resident 1 required extensive two-person assistance with bed mobility, transfers, and toileting. Resident 1 had severe cognitive impairment and admitted to the facility without PUs or pressure injuries (PI - also known as a pressure ulcer) but was noted to be at risk for developing a PU and/or a PI. Review of the Care Area Assessment (CAA - a process designed to assist the assessor to systematically interpret the information recorded on the MDS), showed Resident 1 had a potential for a PU/PI due to their need for extensive assistance with bed mobility, frequent incontinence of bowel and was at risk of developing PIs. The care plan consideration was the risk the resident to develop a PU/PI would not be addressed in the resident's comprehensive care plan. Review of Resident 1's care plan on 07/07/2023, showed a focus area for potential impairment to skin integrity related to fragile skin initiated on 05/26/2023. The care plan created on admission did not have pressure reducing/pressure prevention interventions in place. The care plan was revised on 06/19/2023 to indicate that the resident had an unstageable PU to the left heel and at that time pressure reducing/relieving interventions were implemented, after the development of the PU. Review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (a scale used to assess a resident's risk for developing a PU) assessment, showed on 05/26/2023, 06/02/2023 and 06/17/2023 the resident was at moderate risk for developing PUs, and on 06/09/2023 the resident was assessed to be a high risk for developing PUs. Review of the June 1 through June 17, 2023, Treatment Administration Record (TAR), showed Resident 1 had an order for a skin check to be done weekly. Review of the documentation on the TAR showed that Resident 1 had a skin check on 06/07/2023 and then on 06/18/2023. Review of the Skin Check - Pressure Injury Weekly assessment, dated 06/17/2023, showed Resident 1 had an unstageable PU to the left heel which measured 4.0 centimeters (cm) by 4.0 cm, area appeared dark brown/black in color. Review of the medical record showed there was no other assessments completed for Resident 1, between the initial findings of the PU on 06/17/2023 until discharge on [DATE]. Review of the discharge summary form dated 06/28/2023, showed that Resident 1 discharged to another skilled nursing facility with an unstageable PU on the left foot that measured 6.2 x 4.1 cm in size. During an interview on 07/26/2023 at 12:03 PM, Staff D, Registered Nurse (RN)/MDS Nurse, stated they completed the admission MDS assessment dated [DATE]. Staff D stated Resident 1 required extensive assistance of two people for bed mobility but did not initiate a risk for PU care plan as the resident did not admit with any PUs, stating, everyone is at risk for skin impairments, but if they do not have an actual pressure ulcer then I do not proceed with that specific care plan or interventions. In an interview on 07/26/2023 at 12:25 PM, Staff B, Director of Nursing (DNS), stated they were aware that Resident 1 did not have a skin check for 10 days, stating the resident had moved floors (the facility was located on two different floors) and the day/time of their skin check changed when that happened, and it slipped by and wasn't completed when it was supposed to be. Staff B stated their expectation was that skin checks should be completed by nurses weekly and documented on the TAR as well, the nurse should complete a weekly skin check assessment on pressure or non-pressure areas. Staff B stated that the facility identified multiple system failures that happened and resulted in an in house acquired PU. Reference WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to ensure nursing assistant competencies were assessed and completed yearly, for four of four staff (F, R, S, and U) employee files reviewed. This failed practice had the potential to negatively affect the competency of the nursing assistants and impact the quality of care provided to residents. Findings included . Staff F, Nursing Assistant Certified (NAC), had a hire date of 10/12/2014. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff R, NAC, had a hire date of 02/15/2021. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff S, NAC, had a hire date of 06/12/2020. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff U, NAC, had a hire date of 08/17/2015. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. In an interview on 02/06/23 at 10:55 AM, Staff V, Staff Development Coordinator, acknowledged staff competency evaluations were not done. Reference: (WAC) 388-97-1680 (2)(b)

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 2 residents (4), reviewed for resident-to-resident altercations. The facility failed to ensure residents were free from repeated verbal abuse and unwanted touching, resulting in psychosocial harm to Resident 4 who verbally stated they were scared of Resident 1, and placed all other residents at risk for further abuse. This constituted an Immediate Jeopardy. An Immediate Jeopardy (IJ) related to abuse was called on 06/30/2022 at 5:28 PM. The facility assessed all current residents, completed thorough investigations of incidents, and reported to the proper state offices. They provided abuse and neglect training to all staff as well as specific training pertaining to Resident 1, which include monitoring and interventions related to specific behaviors. This led to the removal of the IJ on 07/08/2022, which was verified by an onsite investigation. Findings included . Review of facility policy titled, Abuse, Neglect and Exploitation, undated, showed that it was the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan included: - Screening; - Training; - Prevention, Identification and Investigation of Abuse, Neglect and Exploitation; - Protection of Resident; and - Reporting/Response. VERBAL ABUSE RESIDENT 1 Resident 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/09/2022, showed the resident had a Brief Interview of Mental Status (BIMS) of 7 out of 15, which indicated severe cognitive impairment. A review of the nursing progress notes for Resident 1, showed on 02/01/2022 at 9:46 PM, Resident 1 was in their room yelling and cursing at another resident that was walking past their room in the hallway. The nurse documented Resident 1 felt that the other resident was looking for an opportunity to do bad things to them. A review of the nursing progress notes for Resident 1, showed on 05/21/2022 at 10:51 PM the nurse found the resident screaming and yelling at another resident in the TV room. The nurse documented that Resident 1 stated they were mad at the other resident as they had made sexual gestures towards them. The nurse documented that they did not witness any sexual gestures, and that the other resident was observed to be afraid of Resident 1. The nurse documented that Resident 1 continued to yell at the other resident, and the nurse escorted the resident to their room away from Resident 1. Review of the facilities state reporting log showed that the above resident to resident incidents had not been reported or investigated to rule out abuse and/or neglect. On 05/21/2022, Resident 1 had been verbally abusive to another resident and on 05/27/2022 Resident 1 was witnessed touching different male residents without permission. A review of Resident 1's current care plan showed a focus concern dated 07/05/2022, that the resident had potential for behaviors that may affect other residents and staff; 45 days after the initial incident. On 06/30/2022 at 5:38 PM, an Immediate Jeopardy was called in the facility for F600. This was related to the facility failing to identify, report and investigate episodes of verbal abuse and unwanted touching by Resident 1. During the facilities investigation process related to the IJ, it was found that Resident 1 had been observed by staff screaming and yelling at Resident 4 on 05/21/2022 at 10:51PM. RESIDENT 4 Resident 4 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Annual MDS assessment, dated 04/15/2022, showed resident had a BIMS of six out of 15, indicating severe cognitive impairment. Review of Resident 4's clinical record, showed that the verbal abuse incident that involved Resident 1 was not documented in Resident 4's clinical record. There was no documentation to show that the incident had been reported or investigated to rule out abuse. During an observation and interview on 06/30/2022 at 2:15 PM, the resident was observed in their room. When asked about the resident-to-resident incident, Resident 4 was unable to recall what had happened exactly. During the facilities investigation process it was determined that Resident 4 was the resident that had been verbally abused by Resident 4 on 05/21/2022, which resulted in Resident 4 being scared. UNWANTED TOUCHING A review of progress notes for Resident 1 stated on 05/21/2022 at 10:51 PM, the nurse documented that the resident had tried to go into three different male residents' rooms without permission. The nurse documented that the resident was not re-directable, began playing loud music in the hallway and was disturbing other residents. A review of progress notes for Resident 1 on 05/27/2022 at 11:28 PM, showed the nurse documented that The resident had been playing loud music in their room and had touched different male residents without their consent. Review of the State reporting log for May 2022, showed that no resident-to-resident incidents related to unwanted touching were reported or investigated, making it difficult to determine which residents were involved in those incidents. During the facilities investigation process related to the IJ, it was found that two current residents complained of unwanted touching that occurred in the facility by other residents. The facility-initiated investigations at that time. During an interview on 06/30/2022 at 2:30 PM, the Director of Nursing Services (DNS) confirmed that no concerns had been reported to them regarding any resident-to-resident incidents or abusive behaviors of Resident 1. Staff had reported that Resident 1 does have a history of getting aggressive physically and verbally towards staff, but they were not aware of those things happening with other residents. The DNS stated that Resident 1 had known behaviors of stalking men out in the facility. The DNS also stated that they had recently completed Abuse and Neglect training again with staff because it was felt that staff were not comprehending the training the first time, they completed it and stated as an example the staff were confused as to who the facility abuse coordinator even was. In summary, review of nursing progress notes showed that Resident 1 had multiple episodes involving verbal abuse and unwanted touching of other residents that went unreported and were not investigated to rule out abuse and neglect. Most of these incidents occurred late in the evening, nighttime so they were not observed occurring during onsite. The facility allowed Resident 1 to move about the facility unsupervised which allowed for these incidents to continue to happen, putting all residents at increased risk. Reference WAC 388-97-0640 (1)(2)(b)(5)(a)(6)(a-c)