Every finding on record at Fircrest Nursing Facility

Based on interview and record review, the facility failed to provide a written bed hold notice at the time of transfer to the hospital for 3 of 4 residents (Residents 1, 2 & 86), and failed to provide a written transfer notice and notify the Office of the State Long-Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) of the transfer, as required for 1 of 4 residents (Resident 2), reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital, protection of resident rights during transfers, and a diminished quality of life. Findings included. Review of the facility's policy titled, Nursing Facility Bed Hold Policy, dated 04/11/2023, showed, In case of an emergency transfer to hospital or hospital admission, the guardian will be provided prompt notification of this policy and that the Ombudsman will be notified utilizing the Notification of Transfer or Discharge Notice form for additional notification. The policy further showed, Notices will be sent for all hospitalizations that are in excess of 24 hours. RESIDENT 1Review of the nursing progress notes dated 07/18/2025, showed that Resident 1 was transferred to the hospital for a change in condition. Review of the discharge Minimum Data Set (MDS-an assessment tool) dated 07/18/2025, showed that Resident 1 had an unplanned discharge to a Short-term General Hospital. Review of Resident 1's Electronic Health Record (EHR) showed no documentation that a bed hold notice was provided to Resident 1 and/or their representatives. In an interview on 11/04/2025 at 9:40 AM, Staff D, Registered Nurse (RN) 2, stated that they would email and notify the residents' representatives of their bed hold policy. Joint record review of Resident 1's progress notes did not show documentation that a bed hold notice was provided to Resident 1's representative. Staff D stated that they did not see a progress note that it was provided. RESIDENT 2Review of the nursing progress notes dated 08/09/2025, showed that Resident 2 was transferred to the emergency room for a change in condition. Review of the discharge MDS dated [DATE], showed that Resident 2 had an unplanned discharge to a Short-term General Hospital. Review of Resident 2's EHR did not show documentation that a bed notice and a written notice of transfer/discharge were provided to Resident 2 and/or their representative. Further review of the EHR did not show documentation that the Ombudsman was notified of Resident 2's transfer. A joint record review and interview on 11/04/2025 at 9:48 AM with Staff D showed Resident 2's EHR had no documentation that a bed hold notice was given to Resident 2 and/or their representative. Staff D stated that they could not find a progress note that a bed hold notice was provided to Resident 2's representative. In an interview on 11/06/2025 at 9:41 AM, Staff B, RN 4, stated that when a resident was transferred to the hospital, they would complete a transfer/discharge notice form, provide one to the residents' representative and send a copy of the notice to the Ombudsman. Staff B stated that they would provide bed hold notices to the residents' representatives. Staff B stated that they could not find a copy of Resident 2's transfer/discharge notice form and that the Ombudsman was not notified of Resident 2's transfer to the hospital. Staff B further stated that they expected that bed bold notices would have been provided to Resident 1 and Resident 2's representatives. RESIDENT 86Review of the nursing home transfer or discharge notice dated 09/11/2025 showed Resident 86 was transferred to the hospital. Further review of Resident 86's EHR showed no documentation that Resident 86's guardian was notified of the facility's bed hold policy. In an interview and joint record review on 11/05/2025 at 2:00 PM, Staff H, RN 2, stated that the facility's bed hold policy would be provided to the resident's guardian upon hospital transfer/discharges and would be documented. Joint record review of Resident 86's clinical record (EHR and hard chart) showed no documentation that the facility notified Resident 86's representative of the facility's bed hold policy. During an interview on 11/06/2025 at 2:01 PM, Staff B stated that they expected the facility's bed hold policy would be provided to the resident's guardian and documented when a resident was transferred to the hospital. Reference WAC 388-97-0120 (2) (a-d) (4) .

Based on observation, interview, and record review, the facility failed to accurately assess 4 of 18 residents (Residents 4, 12, 9 & 5), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding pressure ulcer (injury to the skin caused by prolonged pressure), antipsychotic (medications used to treat symptoms of psychotic [mental health condition characterized by a loss of touch with reality]) medication review, restraint (devices or methods that limit a resident's freedom of movement), and diagnosis placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). Review of the facility's policy titled, Individual Plan of Care Process Requirement, dated 12/10/2024 showed, The RAI assessment must accurately reflect the resident's status. RESIDENT 4Review of the quarterly MDS dated [DATE], showed in Section M (skin conditions) that Resident 4 had a Stage 3 (a deep wound that extends through the skin and into the fat layer) pressure ulcer. It further showed that under Section M1200 (skin and ulcer/injury treatments) that pressure ulcer/injury care was not marked. Review of the wound clinic note dated 09/16/2025, showed that Resident 4 had a Stage 3 pressure ulcer on their coccyx (tailbone). Review of a nursing progress note on 09/24/2025, showed treatment order applied on coccyx for Resident 4. In an interview and joint record review on 11/06/2025 at 11:26 AM, Staff V, Registered Nurse (RN) 2, stated that they used the RAI manual for completing MDS assessments. Staff V stated that they would code for pressure ulcer/injury care if staff were doing dressing changes. Staff V stated that Resident 4 had a Stage 3 pressure ulcer and was unsure if pressure ulcer/injury care should be marked. Joint record review of the RAI manual showed pressure ulcer care includes any intervention for treating pressure ulcers. Joint record review of the quarterly MDS dated [DATE], showed Section M1200 was not marked for pressure ulcer/injury care. Staff V stated, no, it's not [marked for pressure ulcer/injury care]. In an interview and joint record review on 11/07/2025 at 9:08 AM, Staff Q, RN 3, stated that the process for coding for pressure ulcer/injury care would be if staff were using any ointment, treatment on a pressure ulcer. Joint review of the quarterly MDS dated [DATE], showed Section M1200 was not marked for pressure ulcer/injury care. Staff Q stated, yes, it should be coded. RESIDENT 12Review of Resident 12's quarterly MDS dated [DATE], showed in Section N0450 (Antipsychotic Medication Review), the date of the last attempted Gradual Dose Reduction (GDR-a process to determine if a lower dose of medication is sufficient) was 07/20/2022. It showed that it was marked No-GDR has not been documented by a physician as clinically contraindicated [treatment or procedure should not be used because it could be harmful]. It further showed that it was blank for the Date physician documented GDR as clinically contraindicated. Review of Resident 12's physician orders, showed an order for clozapine (an antipsychotic medication) started on 03/20/2024. Review of the Medication Regimen Review (MRR-monthly medication review) dated 10/08/2025, showed the last GDR for clozapine was done on 09/17/2025 and showed it was clinically contraindicated to make a dose reduction. Review of the physician progress note on 09/19/2025, showed that dose reduction [for clozapine] clinically contraindicated. In an interview and joint record review on 11/07/2025 at 8:49 AM, Staff Q stated that they would look at the MRR and physician notes to know how to code for Section N0450. Joint record review of Resident 12's MRR dated 10/08/2025, showed that the last GDR was on 09/17/2025. Joint record review of the physician note from 09/19/2025 showed it was clinically contraindicated to make a dose reduction for Resident 12's clozapine. Joint record review of Resident 12's quarterly MDS dated [DATE], showed that for Section N0450 that the date of the last attempted GDR was 07/20/2022. It showed it was marked No-GDR has not been documented by a physician as clinically contraindicated. It further showed that it was blank for the Date physician documented GDR as clinically contraindicated. Staff Q stated that that the date of the last attempted GDR was not accurate. Staff Q stated that they would expect the MDS to be marked as Yes-GDR has been documented by a physician as clinically contraindicated and to enter the date the physician documented it. Staff Q further stated that the quarterly MDS was not accurate. In an interview on 11/07/2025 at 9:14 AM, Staff B, RN 4, stated that they expected the MDS to be accurate. RESIDENT 9The RAI manual defines physical restraints as, Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. It further showed, Limb restraints include any manual method or physical or mechanical device, material or equipment that the resident cannot easily remove, that restricts movement of any part of an upper extremity (i.e., hand, arm, wrist) or lower extremity (i.e., foot, leg) that either restricts freedom of movement or access to their own body. Hand mitts/mittens are included in this category.Review of Resident 9's quarterly MDS dated [DATE] showed Resident 9 had severely impaired cognition. The assessment further showed physical restraint was not used for Resident 9 during the assessment period. Observations on 10/31/2025 at 9:30 AM, on 11/03/2025 at 8:37 AM and at 1:43 PM, on 11/04/2025 at 8:01 AM, on 11/05/2025 at 8:13 AM and at 1:14 PM, showed Resident 9 had a black hand mitten applied on both their hands. Further observation on 11/03/2025 at 1:43 PM, showed Resident 9 was trying to touch their face with their mittened right hand. Review of the skin integrity care plan revised on 08/02/2025 showed an intervention to apply mittens to Resident 9's hands at all times to prevent them from rubbing and scratching their face. In an interview and joint record review on 11/05/2025 at 1:40 PM, Staff J, RN 2, stated that hand mittens could be considered as restraints if the resident was unable to remove them. Joint record review of Resident 9's quarterly MDS dated [DATE] showed that Section P (Restraints and Alarms) was not marked. Staff J stated that Resident 9's hand mittens were not coded on the MDS, and that they would talk to their supervisor and would modify the MDS. During an interview on 11/06/2025 at 2:01 PM, Staff B stated that the facility follows the RAI manual for completion of MDS assessments. Staff B further stated if a resident was using hand mittens, and they were unable to remove them, it would be considered a restraint and should be coded on the MDS. RESIDENT 5Review of Resident 5's face sheet printed on 10/31/2025, showed Resident 5 had a diagnosis of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive declines). Review of the quarterly MDS dated [DATE], showed Resident 5 was not marked for Alzheimer's Disease in Section I (Active Diagnoses – under I4200). In an interview and joint record review on 11/06/2025 at 10:46 AM, Staff G, RN 2, stated that they would follow the RAI Manual for MDS accuracy. Joint record review of Resident 5's quarterly MDS dated [DATE] showed that Alzheimer's disease was not marked in Section I4200. Joint record review of Resident 5's face sheet, active diagnosis list, and Psychiatry consultation dated 08/27/2025 showed that Resident 5 had an active diagnosis of Alzheimer's disease. Staff G stated Resident 5's quarterly MDS was not accurate and that Alzheimer's Disease should have been marked in Section I4200. In an interview on 11/07/2025 at 10:15 AM, Staff B stated that they expected the quarterly MDS for Resident 5 to be completed accurately. Reference: (WAC) 388-97-1000(1)(b) .

Based on observation, interview, and record review, the facility failed to ensure foods were stored and handled in accordance with professional standards of food safety for 1 of 2 kitchen walk-in refrigerators (Kitchen Main Preparation Walk-In Refrigerator), and 2 of 10 staff (Staff M & N), reviewed for food services. The failure to cover and label food items in the kitchen walk-in refrigerator and perform hand hygiene when assisting residents with their meals placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included . Review of the facility's policy titled, Facility Food Storage and Meal Preparation Policy, revised in December 2024 showed that the facility is committed to upholding safe food handling, storage, and consumption protocols for the meals provided to our clients and residents. Food Storage: Retain food in its original packaging until needed.If transferred, use food-safe containers, and clearly mark them with contents and date. The policy further showed, Food Service: Staff responsible for handling food must ensure their hands are cleaned using soap and water for a minimum duration of 20 seconds prior to handling food and following any activity that may lead to contamination. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated in March 2023, showed that the purpose was to avoid the spread of infection through cross-contamination. It showed that hand hygiene was to be performed before feeding clients, eating, and touching clients. It further showed that hand hygiene was to be performed after feeding a client and after working with a client. KITCHEN MAIN PREPARATION WALK-IN REFRIDGERATORIn an interview and joint observation on 11/03/2025 at 8:52 AM with Staff F, Food Service Manager, showed one uncovered/labeled tuna casserole in metal pan, one uncovered/unlabeled pan of noodles with chopped onions, three uncovered/unlabeled trays with 40 individual pie pans filled with broccoli, cauliflower, and cheese on an uncovered metal cart in the kitchen main preparation walk-in refrigerator. Staff F stated that food items should have been covered and labeled with what the food item was and the date it was prepared. In an interview on 11/07/2025 at 9:05 AM, Staff A, Superintendent, stated that they expected the food items in the kitchen main preparation walk-in refrigerator to have been covered and labeled. HAND HYGIENESTAFF MObservation on 10/30/2025 at 12:26 PM, showed Staff M, Attendant Counselor 1 (AC1), assisted Resident 56 with their lunch in the dining room. Staff M wiped food off Resident 56's mouth with an orange washcloth. When Staff M was done assisting Resident 56 with their meal, Staff M placed the resident's plate and orange washcloth on the return counter by the kitchenette. Staff M then wheeled Resident 56 to the day room. Staff M went back to the dining room and took an orange wash cloth in a basket on the table that Resident 11 was sitting in. Staff M wiped Resident 11's mouth with the orange washcloth and placed it on the sink counter in the kitchenette. Staff M exited the kitchenette and wheeled Resident 11 to the day room. Staff M did not perform hand hygiene before and after they assisted Resident 56 and Resident 11 with their meals. In an interview on 10/30/2025 at 1:12 PM, Staff M stated that they would perform hand hygiene all the time, before and after they assisted the residents to eat, when they touched the residents and/or their wheelchairs. When Staff M was informed of the above observation, Staff M stated that they should have performed hand hygiene before and after they assisted Resident 56 and Resident 11. STAFF NObservation on 11/05/2025 at 8:42 AM, showed Staff N, AC1, assisted Resident 45 with their meal in the dining room. Staff N wiped Resident 45's mouth multiple times with an orange washcloth when food got around their mouth. When Staff N finished assisting Resident 45 with their meal, Staff N placed the dishware on the return counter by the kitchenette. Staff N took a clean orange washcloth, wiped Resident 45's hands, and wheeled Resident 45 to the day room. Staff N did not perform hand hygiene after they assisted Resident 45 with their meal and before they assisted the resident to the day room. In an interview on 11/05/2025 at 8:50 AM, Staff N stated that they would perform hand hygiene before/after resident care, meals, applying personal protective equipment (gloves, gowns) and between resident care. Staff N further stated that they should have performed hand hygiene before they assisted Resident 45 out of the dining room. In an interview on 11/05/2025 at 9:02 AM, Staff E, Attendant Counselor Manager, stated that Staff M should have performed hand hygiene between resident care and after they assisted residents with their meals. Staff E further stated that Staff N should have performed hand hygiene prior to taking Resident 45 to the day room and prior to touching their wheelchair handle. In an interview on 11/05/2025 at 9:09 AM, Staff D, Registered Nurse (RN) 2, stated that they expected ACs to perform hand hygiene before/after they assisted residents with their meals and between resident care. Staff D stated that Staff M should have performed hand hygiene before/after dining assistance and between resident care. Staff D further stated that Staff N should have performed hand hygiene after assisting Resident 45 with their meal and before they touched their wheelchair. In an interview on 11/05/2025 at 2:57 PM, Staff B, RN 4, stated that they expected staff to perform hand hygiene before/after assisting residents with their meals and between resident care. Staff B stated that Staff M should have performed hand hygiene before and after resident care. Staff B further stated that Staff N should have performed hand hygiene prior to assisting Resident 45 to the day room. Reference: (WAC) 388-97-1100 (3)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene and proper glove use were followed for 2 of 16 Staff (Staff N & K) and failed to ensure Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 2 of 13 Staff (Staff O & I), reviewed for infection control. These failures placed the residents, staff, and visitors at an increased risk for infection and related complications.Findings included. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated March 2023 showed, the purpose was to avoid the spread of infection through cross-contamination. The policy further showed, Hand Hygiene performed before .applying gloves . and Hands hygiene performed after.handing [handling] contaminated objects.removing gloves. HAND HYGIENE/GLOVE USESTAFF NObservation on 11/03/2025 at 1:34 PM, showed Staff N, Attendant Counselor 1 (AC 1), was outside the laundry room with a double compartment cart in front of the laundry room and was wearing gloves. Staff N removed the trash bag from the cart and threw the trash bag in a dumpster outside of the building. Staff N went back inside the building wearing their gloves. Staff N then removed the glove on their right hand and pushed the cart to the bathroom with their gloved left hand. Staff N placed the cart against the wall and removed the glove from their left hand. Staff N did not remove their gloves and perform hand hygiene after they threw the trash bag in the dumpster outside the building. Another observation on 11/06/2025 at 1:51 PM, showed Staff N, took a trash bag from a room by the foyer and walked down the hallway to the laundry room wearing gloves. Staff N took bags of linens/clothing out from a cart that was outside the laundry room. Staff N removed their gloves and applied new gloves without performing hand hygiene. Staff N went inside the laundry room and took clothes out of the washing machine and the dryer. When Staff N was done, they took a bag of soiled linens into the soiled utility room and placed it in a large bin. Staff N removed their gloves, applied new gloves and pushed the cart to the bathroom. Staff N did not perform hand hygiene between glove use. In an interview on 11/06/2025 at 1:58 PM, Staff N stated that they would perform hand hygiene before and after resident care, laundry task, between glove use, and when they get in contact with anything dirty. Staff N stated they were separating the bags of linens and had changed their gloves. When asked if they should have performed hand hygiene between glove use, Staff N stated, yes. Staff N further stated they should have thrown away their gloves and perform hand hygiene after they threw out the trash in the dumpster. In an interview on 11/06/2025 at 2:14 PM, Staff D, Registered Nurse (RN) 2, stated that they expected staff to perform hand hygiene when their hands were soiled, before/after resident care and glove use. Staff D further stated that they expected Staff N to perform hand hygiene between glove use and to remove their gloves after they threw the trash in the dumpster. STAFF KObservation and interview on 11/07/2025 at 7:25 AM showed Staff K, RN 2, was in Resident 6's room wearing a gown, gloves and face shield. Staff K took Resident 6's suction (a device used to clear body fluids) canister/tubing that was on their table and took the items to the bathroom. Staff K removed their gloves and applied new gloves without performing hand hygiene. Staff K took the suction canister/tubing and washed it in the bathroom sink wearing their gloves. Staff K then wiped the canister/tubing with a clean towel using the same gloves. When Staff K was done, they placed the dirty towel in a bin and removed their gloves. Staff K went to the bathing room, got a clean towel and went back to the bathroom. Staff K applied new gloves and placed the canister/tubing back to Resident 6's table. Staff K did not perform hand hygiene between glove use and did not change gloves between tasks. In an interview on 11/07/2025 at 7:45 AM, Staff K stated that they would perform hand hygiene between glove use and before/after any procedure. Staff K further stated that they should have performed hand hygiene before they applied new gloves and that after they cleaned the suction canister/tubing, they should have disposed of their gloves, performed hand hygiene and applied new gloves prior to drying it with a clean towel. In an interview on 11/07/2025 at 10:19 AM, Staff C, RN 2, stated that they expected staff to perform hand hygiene between residents, between glove use, between dirty/clean tasks, before serving food, and if their hands become soiled/dirty. Staff C stated that they expected Staff N and Staff K to have performed hand hygiene between glove use. Staff C further stated that Staff K should have removed their dirty gloves, performed hand hygiene and applied new gloves after cleaning the suction canister/tubing. In an interview on 11/07/2025 at 11:00 AM, Staff B, RN 4, stated that their expectation was for staff to perform hand hygiene and to do it properly and follow the guidelines. EBPReview of the facility's procedure titled, Enhanced Barrier Precautions, reviewed in October 2025 showed, Staff will don [put on] gowns and gloves.when engaging in high-contact resident care activities with residents known to be colonized or infected with a MDRO as well as those with wounds or indwelling devices [that is inserted into the body to drain fluids or introduce medication]. Indwelling medical device: Provides direct pathway for pathogens [a tiny organism that causes disease, often called a germ] in the environment to enter the body such as indwelling urinary catheters [a thin, flexible tube inserted into the bladder to drain urine when a person cannot urinate on their own], feeding tubes [a flexible tube used to deliver nutrition to the stomach], and tracheostomy tubes [a medical device inserted into a surgically created opening in the neck to provide a breathing pathway]. STAFF OObservation on 10/31/2025 at 10:22 AM, showed Staff O, AC 1 and Staff P, AC 1, were preparing to transfer Resident 9 with a mechanical lift. Resident 9 was receiving nutrition via feeding tube. Staff O and Staff P transferred Resident 9 from their wheelchair to their bed using the mechanical lift. Staff P was wearing a gown and gloves, but Staff O was not wearing a gown during the transfer. In an interview on 10/31/2025 at 10:27 AM, Staff O stated that wearing gown and gloves were required to transfer residents with tube feeding. When asked why they were not wearing a gown during Resident 9's transfer, Staff O stated that they should have worn a gown during the transfer. STAFF IObservation on 11/05/2025 at 8:25 AM, showed Staff I, Licensed Practical Nurse 2, was preparing to administer medication to Resident 33 via feeding tube. Staff I prepared and administered Resident 33's medication via feeding tube wearing gloves and was not wearing a gown. In an interview on 11/05/2025 at 10:38 AM, Staff I stated that they were required to wear gown and gloves to administer medications via feeding tube. Staff I further stated they should have worn a gown prior to Resident 33's medication administration. In an interview on 11/06/2025 at 1:35 PM, Staff C stated that staff were expected to apply a gown and gloves prior to transferring residents with a feeding tube and administering medications via feeding tube. In an interview on 11/06/2025 at 1:51 PM, Staff B stated that their expectation was for staff to wear gown and gloves prior to transferring residents with a feeding tube and administering medications via feeding tube. Reference: (WAC) 388-97-1320(1)(a)(c) .

Based on interview and record review, the facility failed to ensure an informed consent explaining the risks/benefits for psychotropic medication (alters mood, perception, and behavior) was completed prior to medication administration for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. This failure placed the residents and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications prior to administration.Findings included .Review of the facility's policy titled, Use of Psychoactive Medications [used to control or manage challenging behaviors], revised on September 2021, showed, As appropriate, the client, parent and/or client representative, shall be provided with information on the psychoactive medications used or proposed in their individual case, and assisted in understanding the information supplied. Informed consent is required when psychoactive medications are used.Resident 5 was admitted to the facility on [DATE] with diagnoses that included insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep).Review of physician orders printed on 11/03/2025 showed that Resident 5 was prescribed an antidepressant (medication to treat mood disorder that causes persistent feeling of sadness and loss of interest in activities) on 07/03/2025 for insomnia.Review of the October 2025 Medication Administration Record printed on 10/30/2025, showed that Resident 5 received Trazodone (antidepressant medication) daily.Review of Resident 5's clinical records (electronic health record and hard chart) showed no documentation that the resident and/or representative were informed of the risks/benefits of Trazodone use.In an interview and joint record review on 11/05/2025 at 1:55 PM, Staff G, Registered Nurse (RN) 2, stated that they expected an informed consent explaining the risks/benefits for psychotropic drug use would have been completed in the resident's clinical records. Joint record review of Resident 5's clinical record showed no documentation that the resident and/or representative were informed of the risks/benefits of Trazodone use. Staff G stated that they expected an informed consent explaining the risks/benefits should have been obtained prior to Resident 5 receiving the first dose of Trazodone.In an interview on 11/07/2025 at 10:10 AM, Staff B, RN 4, stated that they expected an informed consent explaining the risks/benefits for any psychotropic medication including Trazodone, to be completed with the resident/representative prior to the medication use.Reference: (WAC) 388-97-0260 (2) (a-d).

Based on observation, interview, and record review, the facility failed to implement a care plan for 2 of 18 residents (Residents 4 & 86), reviewed for comprehensive care plans. The failure to implement the care plans for tube feeding (a way to deliver liquid nutrition through a flexible tube into the body) and indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Individual Plan of Care Process Requirements, dated 12/10/2024, showed the process for Individual Plan of Care for residents included, Care Plan Development which establishes a course of action that moves a resident toward a specific goal utilizing individual resident strengths and interdisciplinary expertise; crafting the how of resident care. It further showed the process of Care Plan Implementation which included putting that course of action.into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the how and when of resident care. RESIDENT 4Review of the facility's policy titled, Gastrostomy [feeding tube inserted through a surgical opening directly into the stomach] Tube Replacement/Maintain the Patency of G/J or Jejunostomy Tube [feeding tube inserted through a surgical opening directly into the small intestine], and Stoma [surgically created opening into the abdomen] Care, reviewed in March 2024, showed that there were guidelines for holding and running the enteral [provides nutrients through a feeding tube] feeding. The guidelines included that the Attendant Counselor (AC) staff will place the feeding pump on hold during personal care, wait at least 15 minutes prior to laying the client [resident] down flat in bed. Then perform the task, when the task is completed elevate the head of the bed up 30 or 45 degrees [a unit of measurement] as per care plan. Review of Resident 4's nutrition/tube feeding care plan, reviewed on 10/04/2025, showed an intervention to always elevate head of bed 30 degrees.when client is in bed, except during personal care and transfers to prevent aspiration [when something other than air gets in the lungs]. Observation on 11/05/2025 at 8:44 AM, showed Resident 4 was lying in bed, was connected to their feeding pump, and the enteral formula was infusing. It further showed that the bed control panel displayed the head of bed at 11 degrees. Observation on 11/06/2025 at 11:08 AM, showed Resident 4 was lying in bed, was connected to their feeding pump, and the enteral formula was infusing. It further showed that the bed control panel displayed the head of bed was at 21 degrees. In an interview and joint observation on 11/06/2025 at 11:53 AM, Staff T, AC 1, stated that the residents can't [cannot] lay flat if getting feeds [enteral formula]. Joint observation showed Resident 4 was connected to their feeding pump with the enteral formula infusing and the bed control panel displayed the head of bed was at 21 degrees. Staff T stated that it's [it is] ok. In an interview and joint observation on 11/06/2025 at 12:00 PM, Staff U, Licensed Practical Nurse 2, stated that when a resident was getting tube feedings that they expected the head of bed to be at 30 degrees. Joint observation showed Resident 4 was connected to their feeding pump with the enteral formula infusing and the bed control panel displayed the head of bed was at 21 degrees. Staff U adjusted the head of bed to 30 degrees and stated that the head of bed should have been at 30 degrees. In an interview and joint record review on 11/06/2025 at 2:18 PM, Staff U stated that I'm [I am] familiar with care plans. Joint record review of Resident 4's nutrition/feeding tube care plan showed the intervention to always elevate head of bed 30 degrees.when client is in bed, except during personal care and transfers to prevent aspiration. Staff U stated, I'm responsible for making sure to keep [the head of bed] at 30 degrees. In an interview and joint record review on 11/06/2025 at 2:40 PM, Staff V, Registered Nurse (RN) 2, stated that they expected staff to follow care plans. Joint record review of Resident 4's nutrition/feeding tube care plan showed the intervention to always elevate head of bed 30 degrees.when client is in bed, except during personal care and transfers to prevent aspiration. Staff V stated yes, has to be 30 degrees with feeds on. In an interview on 11/07/2025 at 10:50 AM, Staff B, RN 4, stated that you have to follow the care plan. When asked if the care plan showed to elevate the head of bed 30 degrees during tube feedings, Staff B stated, I would expect that they [residents] would not be flat, would expect it [head of bed] to be elevated without a doubt. RESIDENT 86Review of the facility's policy titled, Individual Plan of Care Process Requirement, dated 12/10/2024 showed, Care Plan Implementation: Putting that course of action (specific interventions derived through interdisciplinary individualized care planning) into motion by staff knowledgeable about the resident's care goals and approaches; carrying out 'how' and 'when' of resident care. Review of the electronic health record showed Resident 86 admitted to the facility on [DATE] with diagnosis that included neurogenic bladder (a condition where the nerves that control the bladder function abnormally, leading to problems with urine storage and/or release). Review of the annual MDS dated [DATE] showed Resident 86 was severely impaired with cognition and dependent on staff with all aspects of Activities of Daily Living (ADL). The assessment further showed Resident 86 had indwelling urinary catheter. Review of the urinary care plan last reviewed on 09/07/2025 showed intervention instructions for AC to perform peri care (cleaning of the private areas) and catheter care for Resident 86 every two hours and as needed. Observations on 11/03/2025 at 9:12 AM, 11/04/2025 at 8:18 AM, and at 11/05/2025 at 8:24 AM, showed Resident 86 had an indwelling urinary catheter. Review of the clinical notes dated on 10/20/2025 showed Resident 86 was diagnosed with bladder infection and prescribed antibiotic (type of medication that fight bacterial infections by killing bacteria or stopping them from multiplying) medication. Review of the Treatment Administration Record (TAR) for the months of September 2025, October 2025, and November 2025 did not show implementation of catheter care plan. Review of the ADL verification sheet for the Month of November 2025 printed on 11/06/2025 did not show documentation that catheter care plan was implemented. In an interview on 11/05/2025 at 1:53 PM, Staff R, AC1 and Staff S, AC1, stated that they would provide catheter care with incontinent care but there was no area to document the catheter care being provided. In an interview and joint record review on 11/05/2025 at 2:15 PM, Staff H, RN 2, stated that catheter care would be provided by AC staff every shift and would be documented in the TAR. Joint record review of Resident 86's November 2025 TAR showed no documentation of catheter care. During an interview on 11/06/2025 at 2:04 PM, Staff B, RN 4, stated that catheter care would be care planned with step-by-step instructions on how to provide the care. Staff B stated that catheter care would be provided by checking every two hours and during incontinence care. Staff B further stated their expectation was catheter care plan would be implemented and the care documented. Reference: (WAC) 388-97-1020(1)(2)(a)(b) .

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 1 of 1 resident (Resident 83), reviewed for respiratory care. The failure to change the AIRVO 2 (a humidifier with an integrated flow generator that delivers warmed, humidified, high-flow air and/or oxygen) chamber placed the resident at risk for respiratory infections, and related complications.Findings included.Review of the facility's policy titled, Preparation and Administration of Medication and Treatment, dated July 2025, showed, To ensure the prompt and safe administration of medication and treatments ordered for clients.Review of a face sheet printed on 11/03/2025 showed that Resident 83 was admitted to the facility on [DATE] with diagnoses that included tracheostomy (a surgical hole in the windpipe that helps with breathing) status.Review of Resident 83's November 2025 Treatment Administration Record (TAR) showed an order to Change Airvo [AIRVO 2] Chamber Kit, Tubing, and Water Chamber Every 2 [two] months on NOC [night] Shift Sunday. Write Date and Initial on AIRVO chamber kit, tubing and water chamber with an order date of 05/07/2025.Observations on 10/30/2025 at 10:53 AM, on 10/31/2025 at 8:53 AM and at 2:59 PM, on 11/03/2025 at 9:28 AM and on 11/04/2025 at 9:56 AM, showed an AIRVO 2 machine on top of a table by Resident 83's bed. Further observation showed that the AIRVO 2 chamber was dated 07/21/2025.In an interview and joint observation on 11/04/2025 at 10:40 AM, Staff L, Licensed Practical Nurse 4, stated that Resident 83 used AIRVO 2 every night to humidify their tracheostomy. Staff L stated that the AIRVO 2 chamber was changed every two months on night shift. Joint observation of Resident 83's AIRVO 2 chamber, showed that it was dated 07/21/2025. Joint record review of Resident 83's November 2025 TAR showed an order to change the AIRVO 2 chamber kit every two months. Staff L stated that they were not sure why the AIRVO 2 chamber was dated 07/21/2025 and that they would change it.A joint record review and interview on 11/04/2025 at 10:52 AM with Staff D, Registered Nurse (RN) 2, showed Resident 83's September 2025 MAR had an order to change the AIRVO 2 chamber kit, tubing, and water chamber every two months and that it was scheduled to be changed on 09/21/2025. Further review showed that it was marked with an = [equal] sign on 09/21/2025 which indicated as previously scheduled. Staff D stated that they did not know what previously scheduled meant but that staff should have changed the AIRVO 2 chamber kit as ordered.In an interview and joint record review on 11/04/2025 at 3:05 PM, Staff B, RN 4, stated that they expected staff to follow physician orders. Joint record review of Resident 83's September 2025 MAR showed an order to change the AIRVO 2 chamber kit, tubing, and water chamber every two months and that it was scheduled to be changed on 09/21/2025. Further review showed that it was marked with an = [equal] sign on 09/21/2025 which indicated as previously scheduled. Staff B stated that they did not know what that meant but would ask Staff Q, RN 3. Staff Q stated that the equal sign meant that it was scheduled but was not signed that it was completed. Staff B stated that they expected staff to change the AIRVO 2 chamber as ordered.Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on interview and record review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for serious harm and injury, and a diminished quality of life.Findings included.Review of the facility policy titled, Detection and Prevention of Abuse, Neglect and Financial Exploitation, revised on January 2024, showed [name of facility]'s highest priority is to maintain the safety and well-being of all clients [residents].Resident 1 was admitted to the facility on [DATE] with diagnosis that included profound intellectual disabilities (severe learning disabilities requiring extensive support and care in all areas of daily life).Review of the annual Minimum Data Set (an assessment tool) dated 07/25/2025 showed Resident 1 had severe cognitive impairment and required total care with activities of daily living.Review of Resident 1's comprehensive care plan printed on 08/14/2025 showed an intervention to provide 1:1 [one on one] protective supervision, AM [morning] and PM [evening]. Further review of the care plan showed Resident 1 had self-injurious (deliberately harming one's body) behavior and pica (abnormal desire to eat substances not normally considered food).Review of the facility's investigation report dated 07/17/2025, showed Staff C, Certified Nurse Assistant (CNA) had been assigned to provide 1:1 protective supervision to Resident 1. Further review of the investigation report showed Staff B, Attendance Counselor Manager was notified of Resident 1's absence from lunch and went to check Resident 1 in their room and Staff B found Resident 1 asleep in their wheelchair and observed Staff C sitting on a chair asleep as well. Further review showed Staff B called out Staff C's name three times to wake them up.In an interview on 08/14/2025 at 11:22 AM, Staff B stated that they were notified by Staff D, CNA, that Resident 1 was not in the dining room for their lunch meal. Staff B stated that they went to look for Resident 1 and found the privacy curtain drawn closed all the way in Resident 1's room area. Staff B stated that they peeked through the curtain and saw Resident 1 asleep in their wheelchair and saw Staff C asleep on a chair. Staff B stated that they called out Staff C's named three times to wake them up. Staff B further stated that Staff C was expected to pay close attention to Resident 1 and to monitor their behavior.In an interview and joint record review on 08/14/2025 at 12:01 PM, Staff E, Registered Nurse 2 stated that staff assigned to resident requiring 1:1 was expected to monitor them all the time. Their [staff] eyes should always be on them. A joint record review of Resident 1's behavior care plan showed Resident 1 had self-injurious behavior and pica and needed 1:1 protective supervision. Staff E stated that Staff C did not pay close attention because [Staff C] was sleeping.In an interview on 08/20/2025 at 1:39 PM, Staff A, Director of Nursing, stated that they expected staff to follow according to the individual care plan and to be alert, awake, [and] not sleeping when assigned 1:1 with the resident. Staff A further stated that Staff C did not provide protective supervision to Resident 1.Reference: (WAC) 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to ensure baseline care plan (initial instructions on necessary care until a comprehensive care plan is established) was accurate for 1 of 3 residents (Resident 2), reviewed for resident records. This failure placed the resident at risk for unmet care needs and a diminished quality of care.Findings included.Review of a face sheet printed on 08/14/2025 showed Resident 2 was admitted to the facility on [DATE] for respite care (short-term care).Review of a baseline care plan printed on 08/14/2025 showed Resident 2's Recreation (Activity) care plan had another resident's name in it. Further review of the baseline care plan showed, [other person's name] requires colostomy [a surgical opening for the large intestine through the abdomen for stool elimination] care. had been included in Resident 2's self-care deficit care plan.Review of the physician's progress note dated 07/24/2025 did not show Resident 1 had a colostomy.In an interview and joint record review on 08/20/2025 at 1:17 PM, Staff F, Registered Nurse 2, stated they formulated Resident 2's baseline care plan. Staff F stated that the baseline care plan was part of Resident 2's medical records and must be accurate. A joint record review of Resident 2's recreation care plan showed a name different from Resident 2's name. Staff F stated the recreation care plan had another person's name in it and that it was an error. A joint record review of Resident 2's self-care deficit care plan showed another person's name that included colostomy care. Staff F stated that Resident 2 had no colostomy and that it was inaccurate information. Staff F stated that they expected Resident 2's baseline care plan to be accurate.In an interview and joint record review on 08/20/2025 at 1:32 PM, Staff A, Director of Nursing, stated that a resident's care plan must reflect their clinical status. Staff A stated that the care plan was part of a resident's medical records and must be accurate. A joint record review of Resident 2's recreation and self-care deficit baseline care plan showed other persons' names and the self- care deficit care plan had colostomy care. Staff A stated that Resident 2's care plan had inaccurate information and that they expected accuracy with their medical records.Reference: (WAC) 388-97-1720 (1)(a)(i)(ii).

Based on observation, interview, and record review, the facility failed to ensure timely reporting of an injury of unknown source to the State Agency for 1 of 3 residents (Resident 1), reviewed for abuse/neglect reporting. This failure placed the resident at risk for potential unidentified and ongoing abuse and lack of protection from abuse. Findings included . Review of the facility's policy subject titled, Detection and Prevention of Abuse and Neglect, dated 05/01/2019, showed, Guidance is provided by NF [Nursing Facility] Purple Book, DDA [Developmental Disabilities Administration] policy, state and federal regulation. Review of the facility's policy subject titled, Protection from Abuse: Mandatory Reporting, issued on 07/2024, showed All administration employees, contractors, volunteers, interns, and work-study students must report every incident of observed, reported, or suspected abuse, neglect, exploitation, and abandonment, as well as injuries of unknown origin. The policy further showed, Immediately meant there should be no delay between reporter awareness of the incident/allegation and making the report and that a mandated reporter's responsibilities applied at all times, including off-duty hours. Review of Resident 1's Clinical Note dated 04/17/2025 (at 2:35 AM), showed, Resident 1 had partially discoloration, yellowish, blue, to their left first toe. An additional Clinical Note dated 04/17/2025 (at 2:07 PM) showed, it was reported Resident 1 had a red, swollen toe, and that upon assessment they were noted to have, Dark, patchy ecchymosis [a discoloration of the skin resulting from bleeding underneath, typically caused by bruising]. Further review of the note showed there was left first toe trauma, with unknown cause, and an X-ray was pending. Review of Resident 1's Clinical Note dated 04/18/2025, showed that at 1:30 PM, the Medical Doctor called and noted that Resident 1 had a left foot 5th distal (away from center) metatarsal bone fracture (broken foot bone). Review of Resident 1's investigation report showed that on 04/17/2025, the Registered Nurse (RN) observed bruising and discoloration to resident's left great toe and notified the provider. The provider ordered an x-ray and on 04/18/2025 confirmed a fracture of the fifth metatarsal in the left foot. The investigation also showed there was no probable cause for the injury. Further review of the investigation showed that the incident was reported into the State Agency on 04/21/2025. On 05/19/2025 at 12:53 PM, Staff C, Licensed Practical Nurse 2, stated that if a resident had bruise that would be suspicious of abuse or neglect, they would need to call the hotline and report it to the State Agency. Staff C stated that Resident 1 was on alert charting for a left foot distal metatarsal bone fracture and that they did not know how they got it. Staff C further stated that Resident 1 was on a one on one followed by staff and was able to get around easily. Observation on 05/19/2025 at 1:00 PM, showed Resident 1 self-propelling in their wheelchair with staff following closely behind them. Resident 1 was wearing a protective orthopedic boot shoe to their left foot. On 05/19/2025 at 3:01 PM, Staff B, RN 4, stated that they would expect staff to report an injury of unknown source to the State Agency immediately or within 24 hours. Staff B stated that on 04/17/2025 they did not know the cause of Resident 1's bruising/discoloration to their foot and that they would have expected it to be reported to the State Agency by 04/18/2025 not on 04/21/2025 when it was reported. On 05/19/2025 at 4:37 PM, Staff A, Administrator, stated that Resident 1's injury was reported on 04/21/2025 when staff made a connection, between Resident 1's bruising/discoloration on their left foot and the results of the x-ray indicating a left foot fracture. Reference: (WAC) 388-97-0640 (5)(a)

Based on observation, interview, and record review the facility failed to follow the plan of care and provide adequate supervision for 1 of 1 resident (Resident 1), reviewed for accident hazards. This failure placed the residents at risk for further fall, injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, Fall Protocol, revised on 01/23/2023, showed Falls require prompt response to determine cause, injury, and adherence to Care Plan (CP) or Individualized Habilitation Plan (IHP) expectations. The policy showed that if a client [resident] is unable to get up from a fall they will remain where they are until a nurse comes to assess them. The policy further showed that the Attendant Counselors (AC/Certified Nursing Assistant [CNA]) were responsible for following the resident's individualized plan of care as developed by the Interdisciplinary Team. Review of Resident 1's Activities of Daily Living (ADL) care plan initiated on 01/12/2023, showed, Always stay [sic] [in front] of client when giving her a shower. Review of Resident 1's fall risk care plan initiated on 01/12/2023, showed, Always keep client at line of sight at all times for safety, and Do not leave client by herself at any time. Review of Resident 1's clinical note dated 03/28/2025, showed, Ac [AC/CNA] staff reported to this RN [Registered Nurse] about [Resident 1's] fall in the bathroom post shower. Ac staff stated that after she gave shower to [Resident 1], she turned to pick the lotion leaving the client in her w/c [wheelchair] and the client flipped off and fell on the floor. Further review of the clinical note showed that upon arrival at the scene, Resident 1 was found back in their wheelchair and looked stable upon initial RN assessment. Review of Resident 1's fall investigation that occurred on 03/28/2025, showed, [Staff E, CNA] stated that after giving [Resident 1] a shower, she briefly stepped away to place lotion on the counter. During the short interval, [Resident 1] flipped to her left side, and [Staff E] found her lying on the floor alongside her wheelchair. [Staff E] noted that [Resident 1] appeared agitated that morning and exhibited continuous rocking behavior. The investigation showed it was noted that the wheelchair was placed on a curved section of the floor designed for water drainage, which likely contributed to the incident as [Resident 1] rocked. Further review of the investigation showed that Staff E failed to follow Resident 1's care plan. Observation on 04/23/2025 at 1:50 PM, showed Resident 1 was mobile in their wheelchair, and an unknown staff member following them. In an interview on 05/02/2025 at 1:24 PM, Staff F, CNA, stated that Resident 1 was on a one on one because they had behaviors and could move easily in their wheelchair and to accompany them for safety. In a phone interview on 05/02/2025 at 3:03 PM, Resident 1's Collateral Contact 1 (CC1), stated that Resident 1 had a fall because their chair was not on a flat surface. CC1 stated that Resident 1 rocked and bounced in their chair and that if it was not positioned on a flat surface, they would be able to tip over pretty easily. In an interview and joint observation on 05/06/2025 at 10:48 AM, Staff E stated that if a resident was one on one, staff had to remain with the resident the entire time and not be left unattended. A joint observation showed a shower room on the Hickory Unit with a slight slope. Staff E stated that on 03/28/2025 they assisted Resident 1 with their shower. Staff E stated that they turned towards the counter to set a lotion container down, when Resident 1 was reaching for the shower hose and tipped over in the shower chair. Staff E stated that they were expected to follow the care plan. On 05/02/2025 at 11:33 AM, Staff D, Licensed Practical Nurse 4, stated that if a resident had a fall a RN was responsible for assessing the resident on the ground, and once they were safe to move, they would be assisted to do so. In an interview and joint record review on 05/06/2025 at 11:46 AM, Staff C, RN 2, stated that staff were expected to follow the care plan. A joint record of Resident 1's ADL care plan showed an intervention to Always stay in front of client when giving her a shower. Staff C stated that staff should not have turned their back to Resident1 when setting something on the counter. Staff C further stated that the RN was responsible for assessing the resident post fall. On 05/06/2025 at 12:32 PM, Staff B, RN 4, stated that it was their expectation that staff followed a resident's care plan. Staff B stated that on 03/28/2025 Resident 1 had a fall in the shower and that their chair had not been positioned on a flat surface when the resident fell forward. Staff B stated that it was the RN's responsibility to assess a resident post fall prior to moving them. Staff B further stated that the fall on 03/28/2025 could have been avoidable and that they expected staff to be attentive to the residents' environment, equipment, and know the care plan of each resident they provided care for. On 05/06/2025 at 1:45 PM, Staff A, Administrator, stated that there was a slope in the shower room that could have contributed to Resident 1's fall on 03/28/2025. Staff A stated that they would expect staff not to place the shower chair on the slope surface. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to inform the residents' representatives (RR) about the residents' positive Respiratory Syncytial Virus (RSV-a germ that could easily spread and cause lung infections) test and treatments for 2 of 3 residents (Resident 1 & 2), reviewed for change in condition. This failure placed the residents and/or their representatives at risk of not being provided adequate information to make informed decisions about their medical condition. Findings included . Review of the facility's undated policy titled, DSHS [Department of Social and Health Services]/DDA (Developmental Disabilities Administration) Policy 9.06 Health Services, Department of Health Surveillance and Reporting Guidelines for Disease Outbreaks ., showed that when the Primary Nurse is aware of any clients [residents] .with flu-like symptoms (or other contagious disease), the LN [licensed nurse] will report to the Resource Nurses or HCC [Health Care Coordinator] . The policy further stated that HCC or Resource Nurse will notify parents/guardians. RESIDENT 1 Resident 1 admitted to the facility on [DATE] with diagnosis that included profound intellectual disability (a condition that involves significant limitation in intelligence, learning and everyday abilities necessary to live independently). Review of the nursing clinical notes dated 01/27/2025, showed Resident 1 had dry cough, wheezing, and mild runny nose and that their nasal swab (a test that checks for viruses and bacteria that could cause lung infections) test came back positive for RSV. Further review of the nursing clinical notes showed Resident 1 was given Guaifenesin (a cough medicine) and a dose of DuoNeb (a liquid medication used with a nebulizer [a device used to administer medication in the form of a mist inhaled into the lungs] to increase air flow to the lungs. In an interview on 02/11/2025 at 2:42 PM, Resident 1's Representative (RR1) stated that they were not informed about Resident 1's change in condition, their positive RSV test, and the treatment that was provided to Resident 1. RR1 stated, I did not get any email or call from them [facility] about [Resident 1]'s condition. In an interview on 02/11/2025 at 3:12 PM, Staff C, Registered Nurse (RN) 2/HCC, stated that they had informed RR1 regarding Resident 1's condition. When asked, Staff C was unable to provide documentation to show RR1 was notified about Resident 1's positive RSV test, their change in condition, and the treatments provided to the resident. RESIDENT 2 Resident 2 admitted to the facility on [DATE] with diagnosis that included profound intellectual disability. Review of the nursing clinical notes dated 01/22/2025 showed Resident 2 had occasional dry cough, appeared tired, and was lethargic (having little energy). Further review of the nursing clinical notes showed Resident 2 had a nasal swab and the result came back positive for RSV. Further review of Resident 2's nursing clinical notes dated 01/26/2025 showed Resident 2 was given Guaifenesin that day. In an interview on 02/11/2025 at 3:29 PM, Resident 2's Representative (RR2) stated that they became aware of Resident 2's change in condition and their positive RSV test when they came to visit the facility on 01/27/2025. RR2 stated, I was not allowed to get into the building to visit [Resident 2]. I was not informed about [their] condition or [Resident 2]'s treatment prior to that. In an interview on 02/12/2025 at 9:51 AM, Staff C stated, I think I also notified the guardian of [Resident 2]. When asked, Staff C was not able to provide documentation to show notification was made to RR2 about Resident 2's positive RSV, their change in condition, and the treatment provided to the resident. In an interview on 02/12/2025 at 10:45 AM, Staff D, RN 3/Infection Control Nurse, stated that HCC or the primary nurse [RN 2] would be the one to inform the family and/or their representative for any change in condition and for a specific client [resident] who tested positive for RSV. In a follow-up interview at 12:33 PM, Staff D stated that they did not see any documentation or notification of representatives regarding the change in condition and treatments provided for Resident 1 and Resident 2. On 02/12/2025 at 1:01 PM, Staff B, RN 4 stated that no notifications were made to RR1 and RR2 and that they expected staff to have had notified them regarding positive RSV tests, changes in condition, and treatments provided for Resident 1 and Resident 2. Reference: (WAC) 388-97-0300(3)(a) .

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information postings were posted on daily basis at the beginning of each shift. In addition, the facility failed to ensure the nurse staffing information postings were in prominent locations readily accessible to residents and visitors for 5 of 5 units ([NAME], Hickory, Elm, Cherry, and Birch), reviewed for Nurse Staffing Information. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information. Findings included . [NAME] UNIT Observations on 10/30/2024 at 10:46 AM, on 10/31/2024 at 8:33 AM, on 11/01/2024 at 8:52 AM, on 11/04/2024 at 9:05 AM, and on 11/05/2024 at 11:52 AM, showed the [NAME] Unit's nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Further observation showed the nurse staffing information form was placed on a clipboard and the clipboard was placed in the wall file holder with other files. Observation on 10/31/2024 at 8:33 AM, showed the [NAME] Unit's nurse staffing information for 10/30/2024 evening shift was not posted on the form, and it was blank. In an interview and joint observation on 11/05/2024 at 12:03 PM, Staff W, Attendant Counselor (AC) 3, stated they were responsible for completing the unit's nurse staffing information form. Joint observation showed the nurse staffing form was placed on a clipboard, and the clipboard was placed in the wall file holder. Staff W stated, They [the facility] used to post it [nurse staffing information] on the wall. HICKORY UNIT Observations on 10/30/2024 at 12:49 PM, on 10/31/2024 at 10:28 AM, on 11/01/2024 at 10:12 AM, on 11/04/2024 at 10:09 AM, and on 11/05/2024 at 9:23 AM, showed the Hickory Unit's nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Further observation showed the nurse staffing information form was placed on a clipboard labeled as Daily staffing hours and census, and the clipboard was placed in the wall file holder with other files. On 11/05/2024 at 9:32 AM, Staff S, AC Manager, stated that the unit's nurse staffing information form was always placed in the wall file holder. ELM UNIT Observations on 10/30/2024 at 1:05 PM, on 10/31/2024 at 10:38 AM, on 11/01/2024 at 10:21 AM, on 11/04/2024 at 10:01 AM, and on 11/05/2024 at 10:02 AM, showed the Elm Unit's nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Further observation showed the nurse staffing information form was placed in a blue file folder labeled as Daily staffing hours and census, and the file folder was placed in the wall file holder with other files. Observation on 11/05/2024 at 10:02 AM, showed the Elm Unit's nurse staffing information for 11/04/2024 night shift was not posted, and it was blank. In an interview, joint observation/record review on 11/05/2024 at 10:05 AM, Staff U, AC 3, stated that they were responsible for completing the nurse staffing information form. Staff U stated after they completed the form, they would place it in the blue file folder and the file folder would be placed in the wall file holder. Joint observation showed the blue file folder was placed in the wall file holder. Staff U stated they did not know if the nurse staffing post was for visitors/residents or for the facility staff. Joint record review of the nurse staffing form showed that the nurse staffing information for 11/04/2024 night shift was not completed, and it was blank. Staff U stated the night shift might not receive the nurse staffing information, or they probably forgot to fill out the form. CHERRY UNIT Observations on 10/30/2024 at 1:30 PM, on 11/01/2024 at 2:03 PM, on 11/04/2024 at 10:19 AM, and on 11/05/2024 at 9:49 AM, showed the facility's Cherry Unit's nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Further observation showed the nurse staffing information form was placed in a green file folder labeled as Census, and the folder was placed in the wall file holder with other files. In an interview and joint observation on 11/05/2024 at 9:51 AM, Staff T, AC 2, stated they were responsible for completing the nurse staffing information form. Staff T stated that after they fill out the form, they would place it in green file folder and the file folder would be placed in the wall file holder. Joint observation showed the green file folder labeled as Census. Staff T stated that the folder was labeled as Census not the nurse staffing information. BIRCH UNIT Observations on 10/31/2024 at 1:34 PM, on 11/01/2024 at 2:12 PM, on 11/04/2024 at 10:32 AM, and on 11/05/2024 at 10:23 AM, showed the Birch Unit's nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Further observation showed the nurse staffing information form was placed on a clipboard labeled as Census, and the clipboard was placed in the wall file holder with other files. In an interview and joint observation on 11/05/2024 at 10:29 AM, Staff V, AC 3, stated they were responsible for completing the Birch Unit's nurse staffing form. Staff V stated after they completed the form, they would place it on a clipboard labeled as Census and the clipboard would be placed in the wall file holder. Joint observation showed the nurse staffing form was placed on a clipboard labeled as Census, and the clipboard was placed in the wall file holder with other files. Staff V stated the nurse staffing information form was for the facility staff and was not posted for visitors or residents. In an interview on 11/06/2024 at 1:26 PM, Staff A, Nursing Facility Program Area Team Director, stated that they expected the nurse staffing information to be posted daily, in prominent area, and readily accessible to residents and visitors. No associated WAC

Based on interview and record review, the facility failed to develop and/or implement comprehensive care plans for 5 of 22 residents (Residents 44, 88, 45, 24, & 77), reviewed for care planning. The failure to develop/implement care plans for antidepressant medication use, pressure ulcer (bed sore) care, antibiotic (medication to treat infection) use, refusal of care and use of antipsychotic medication (to treat symptoms of certain mental health disorders) placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled Roles and Responsibilities of Nursing Facility Interdisciplinary Team Members, dated 01/23/2023, indicated that a care plan is an individualized plan based on comprehensive assessment and professional recommendations. Further review of the policy showed that the care plan aims to promote the individual's highest level of functioning, with a focus on improvement where possible, maintenance of skills and abilities, and the prevention of avoidable decline. RESIDENT 44 Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 09/23/2024, showed Resident 44 had unhealed pressure ulcers. Review of Resident 44's record titled, Consult/Evaluation Request, dated 10/02/2024, showed Resident 44 had nonhealing stage three pressure ulcer/injury (that extends through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) of the coccyx (tailbone). Review of Resident 44's comprehensive care plan printed on 11/05/2024, showed no care plan was initiated for pressure ulcer. In an interview and joint record review on 11/06/2024 at 12:57 PM, Staff Z, Registered Nurse (RN) 2, stated that Resident 44 did not have a care plan for pressure ulcer care. Joint record review of the comprehensive care plan showed Resident 44 had no care plan for pressure ulcer care. Staff Z stated that Resident 44 had an alert care plan for their pressure ulcer and was not needed to include it in their comprehensive care plan. On 11/07/2024 at 10:19 AM, Staff B, RN 4, stated that they were aware that Resident 44 had a pressure ulcer and expected a care plan for it. RESIDENT 88 Review of the physician's order dated 10/16/2024, showed Resident 88 had an order for antidepressant (medication to treat symptoms of depression). Review of the October 2024 and November 2024 Medication Administration Records (MAR) showed Resident 88 was on an antidepressant medication. Review of Resident 88's comprehensive care plan printed on 10/30/2024, showed no care plan was initiated for antidepressant medication use. In an interview and joint record review on 11/05/2024 at 9:51 AM, Staff Z stated that Resident 88 had an antipsychotic care plan. Joint record review of Resident 88 comprehensive care plan did not show a care plan for antidepressant medication use. Staff Z stated that they did not believe a separate care plan for antidepressants was necessary. On 11/07/2024 at 9:17 AM, Staff AA, Psychologist, stated that residents on antidepressant medication should have a care plan for it. Staff AA further stated that Resident 88 should have had a care plan for their antidepressant medication use. On 11/07/2024 at 10:19 AM, Staff B stated that residents on antipsychotic and antidepressant medications required separate care plans. Staff B further stated that Resident 88 should have had a care plan for their antidepressant medication use. 45146 RESIDENT 45 Review of the quarterly MDS dated on 07/23/2024, showed Resident 45 received an antibiotic. Review of the August 2024, September 2024 and October 2024 (MAR) showed Resident 45 received three antibiotic medications. Review of Resident 45's comprehensive care plan printed on 11/01/2024 showed no comprehensive care plan for the use of multiple antibiotics. In an interview and joint record review on 11/05/2024 at 12:13 PM, Staff H, RN 2, stated that long-term use of antibiotics would be addressed under comprehensive care plan. Joint record review of Resident 45's August 2024 through October 2024 MAR showed that the resident was receiving antibiotics. Joint record review of Resident's 45 comprehensive care plan printed on 11/01/2024, showed no care plan for antibiotics use. Staff H stated that they could not find a care plan for multiple antibiotic use. In an interview on 11/06/2024 at 2:25 PM, Staff B stated that there should be a comprehensive care plan for long-term antibiotic use. 47680 RESIDENT 24 Observations on 10/31/2024 at 12:42 PM, on 11/01/2024 at 9:31 AM and on 11/04/2024 at 1:43 PM, showed Resident 24 had facial hair (beard and mustache). Review of Resident 24's comprehensive care plan printed on 10/31/2024, did not show a care plan for behaviors/refusal of care. In an interview and joint observation on 11/04/2024 at 1:50 PM, Staff RR, Attendant Counselor 1, stated that they shave residents every morning and that some residents were hard to shave like Resident 24. Staff RR stated that it takes two staff to shave them. Staff RR stated that Resident 24 was shaved at least twice a week and that they let the nurse know if they refused. Joint observation showed Resident 24 had facial hair (beard and mustache). Staff RR stated, it's long, especially his mustache and that they will try to shave them. At 1:57 PM, Staff RR stated that Resident 24 refused and was moving their hands over their face as they were trying to shave them. When asked where they documented if a resident declined care, Staff RR stated that Touchscreen [charting software] that they used to chart did not have a place for them to document refusals. Joint observation of the Touchscreen software did not show a place to document refusals. Staff RR stated there was no place to document refusal on Touchscreen and to check with the nurse. In an interview on 11/04/2024 at 2:05 PM, Staff E, RN 2, stated behaviors were documented in the behavioral logbook and Touchscreen. Staff NN, Attendant Counselor 3, stated that Resident 24 had been refusing care and was known to refuse care all the time. Staff NN stated that it should be documented. Staff NN looked at the behavioral logbook and was not able to find any documentation that Resident 24 refused care. Staff E and Staff RR stated that Resident 24 was difficult to provide care, required two person assistance and becomes aggressive. In an interview on 11/04/2024 at 2:28 PM, Staff E stated that Resident 24 did not have a care plan for behaviors/rejection of care and should have one. Staff E stated that staff had told them that Resident 24 was difficult to shave. Staff E further stated that staff should be documented when Resident 24 had refused care. In an interview on 11/06/2024 at 1:32 PM, Staff B stated that they expected residents who had behaviors/refuses care to be documented and should have an individualized care plan. 46912 RESIDENT 77 Review of the facility's undated policy titled, Quarterly Nursing Physical Exam and Monitoring of Side Effects system [[NAME]], showed that the [NAME] form is used for all residents receiving neuroleptics [also known as an antipsychotic medication] and that it was used to monitor residents for side effects of certain medications. Review of the November 2024 MAR showed Resident 77 had an order for Risperidone (an anti-psychotic medication) daily. Review of the Risk for Adverse side effects of Antipsychotic drug care plan printed on 10/31/2024, showed Resident 77 had an intervention for [NAME] every 6 month [s]. Review of the Resident 77's clinical record (electronic health record and paper chart) showed Resident 77 had a [NAME] assessment completed on 08/10/2024. It further showed that the previous [NAME] assessment had been completed on 10/30/2023. In an interview and joint record review on 11/05/2024 at 10:35 AM, Staff G, RN 2, stated that if a resident was on an antipsychotic medication they had a [NAME] assessment completed every six months. A joint record review of Resident 77's Risk for Adverse side effects of Antipsychotic drug care plan showed that Resident 77 should have had a [NAME] assessment completed every six months. A joint record review of Resident 77's clinical record showed that Resident 77 had a [NAME] assessment completed on 08/10/2024 and the previous one was completed on 10/30/2023. Staff G stated it had been more than six months between the assessments and it should have been done in April 2024. Staff G further stated the care plan intervention for Resident 77 to have a [NAME] assessment completed every six months was not followed and it should have been. In an interview on 11/07/2024 on 10:45 AM, Staff B stated that they expected staff to follow and implement care plans. Staff B stated that the care plan should have been followed for Resident 77 to have their [NAME] assessment completed every six months. Reference: (WAC) 388-97-1020 (1)(2)(a)(b) .

Based on interview and record review, the facility failed to accurately assess 6 of 22 residents (Residents 348, 82, 45, 35, 97, & 12), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding capturing occurrences during the look-back period for anticoagulant (medication that helps to prevent blood clots from forming) use, tracheostomy (an opening into the trachea (windpipe) from outside the neck) care, timing of MDS sections completion, completion of a discharge assessment, placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). Most MDS items themselves require an observation period, such as seven or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. When completing the MDS, only those occurrences during the look-back period will be captured. In other words, if it did not occur during the look-back period, it is not coded on the MDS. The RAI's tracheostomy care coding instruction directed to code suctioning (removing secretions or fluids) and cleansing of the tracheostomy and/or cannula (a small plastic tubing that is inserted in the tracheostomy) in this item if during the 14-day look-back period the resident had received tracheostomy care and suctioning. RESIDENT 348 Review of Resident 348's Electronic Health Records (EHR) showed MDS assessments were completed and submitted in the order of a discharge MDS dated [DATE], an annual MDS dated [DATE] and an entry tracker MDS dated [DATE]. In a joint record review and interview on 11/04/2024 at 9:23 AM with Staff L, Registered Nurse (RN) 2, showed Resident 348's EHR had a leave of absence from the facility starting on 10/02/2024 and returned to the facility on [DATE]. Staff L stated that Resident 348 was not at the facility during the assessment period of their annual MDS dated [DATE]. A joint record review and interview on 11/04/2024 at 9:25 AM with Staff L, showed sections of Resident 348's annual MDS dated [DATE], had an observation period of seven days from 10/05/2024 through 10/11/2024. These completed sections included Sections B (Hearing, Speech, and Vision), C (Cognitive Patterns), D (Mood - Staff Assessment for Resident Mood), E (Behavior), F (Preferences for Customary Routine Activities), GG (Functional Abilities), H (Bladder and Bowel), I (Active Diagnoses), J (Health Conditions), K (Swallowing/Nutritional Status), L (Oral/Dental Status), M (Skin Conditions), N (Medications), O (Special Treatments, Procedures, and Programs), P (Restraints and Alarms), and Q (Participation in Assessment and Goal Setting). Staff L stated that Resident 348 was not observed during the observation period of their annual MDS dated [DATE] because Resident 348 was not at the facility during the seven-day observation period. Staff L further stated that the annual MDS dated [DATE] was inaccurate and should not have been completed and submitted. In an interview on 11/06/2024 at 1:03 PM, Staff B, RN 4, stated the facility followed the RAI Manual, for the completion of accurate MDS assessments. Staff B further stated they expected Resident 348's annual MDS to be accurate and completed following the observation period. RESIDENT 82 Review of the RAI Manual's Coding Tips and Special populations, listed on page N-9, showed aspirin should not be coded as an anticoagulant. The RAI manual further specified that the antiplatelet medication like aspirin should not be coded in Section N. A joint record review and interview on 11/06/2024 at 2:45 PM with Staff L, showed Resident 82 was marked to have taken an anticoagulant in Section N (Medications) in their quarterly MDS dated [DATE], 05/29/2024 and 09/29/2024. Further record review of Resident 82's physician orders, printed on 11/07/2024, did not show that Resident 82 was prescribed an anticoagulant from February 2024 through September 2024. Staff L stated, I don't think [they have] taken [anticoagulants] before. Staff L stated that Resident 82 was prescribed aspirin (blood thinner). Staff L stated aspirin should not have been marked as an anticoagulant in Resident 82's quarterly MDS dated [DATE], 05/29/2024 and 09/29/2024. In an interview on 11/06/2024 at 1:03 PM, Staff B stated the facility followed the RAI Manual for the completion of accurate MDS assessments. Staff B further stated they expected aspirin not to be coded as an anticoagulant based on the RAI Manual. 45146 RESIDENT 45 Resident 45 admitted to the facility on [DATE] with diagnoses that included tracheostomy status. Review of the quarterly MDS dated [DATE], showed Resident 45's tracheostomy care and suctioning were not coded on the MDS assessment. Review of the July 2024 Treatment Administration Record (TAR) showed that Resident 45 had received tracheostomy care and suctioning. In an interview and joint record review on 11/05/2024 at 12:29 PM, Staff H, RN 2, stated that the MDS would be completed based on review of the resident's medication administration record, TAR, and progress note. A joint record review of Resident 45's July TAR showed the resident had received tracheostomy care and suctioning. Joint record review of the quarterly MDS dated [DATE], showed tracheostomy care and suctioning was not coded on Resident 45's MDS. Staff H stated the tracheostomy care and suctioning should have been coded on the MDS. RESIDENT 35 Review of Resident 35's annual MDS dated [DATE], showed that the assessment was signed completed on 08/26/2024. Further review of the assessment showed that Section GG was completed and signed on 08/13/2024 (5 days before the assessment's lookback period's start date), and Section K was completed and signed on 08/01/2024 (17 days before the lookback period's start date). In an interview and joint record review on 11/05/2024 at 10:51 AM, Staff E, RN 2, stated that MDS would be completed based on the ARD and lookback period. A joint record review of Resident 35's annual MDS dated [DATE] showed Section GG and K were completed before the assessment period. Staff E stated, Staff should have not completed [MDS sections] before the look back period. On 11/06/2024 at 2:35 PM, Staff B stated that staff should have followed the RAI Manual and that they should have not completed the sections of the MDS prior to the look back period. 46912 RESIDENT 97 Review of the discharge MDS dated [DATE] showed Resident 97's MDS was marked as discharged to acute hospital. Review of a nursing progress note dated 09/10/2024, showed Resident 97 discharged to their home on 09/10/2024. A joint record review and interview on 11/05/2024 at 2:33 PM with Staff Z, RN 2, showed Resident 97's EHR revealed they discharged to home. Staff Z stated that Resident 97's discharge MDS should have been coded as discharge to the community. In an interview on 11/07/2024 at 10:45 AM, Staff B stated that they expected the MDS to be accurate. 47680 RESIDENT 12 Review of Resident 12's annual MDS with an ARD of 04/27/2024, showed it was completed on 04/27/2024. Further review showed Sections A (Identification Information), B, C, D, E, F, GG, H, I, J, L, M, N, O and P were completed on 04/19/2024, prior to the observation period. In an interview and joint record review on 11/07/2024 at 11:41 AM, Staff G, RN 2, stated they followed the RAI Manual for MDS completion. Staff G stated that they started the MDS after the observation period. When asked if they would complete the MDS prior to the observation period, Staff G stated, no. Joint record review of Resident 12's annual MDS Section Z (Assessment Administration) showed that it was completed on 04/27/2024. Staff G stated that staff must wait after the observation period to complete the MDS. Further joint record review showed Sections A, B, C, D, E, F, GG, H, I, J, L, M, N, O, and P were completed on 04/19/2024. Staff G stated that the seven day observation period was from 04/21/2024 through 04/27/2024 and that staff must wait to complete the MDS until after the observation period. Staff G further stated that Resident 12's annual MDS was completed inaccurately. In an interview and joint record review on 11/07/2024 at 12:05 PM, Staff B stated that they expected the MDS to be completed and coded accurately. Joint record review of Resident 12's annual MDS with an ARD of 04/27/2024, showed that the MDS was completed before the observation period and was signed as completed on the ARD date. Staff B stated that they expected Resident 12's MDS to be completed after the ARD. Reference: (WAC) 388-97-1000 (1)(b)

Based on observation, interview, and record review, the facility failed to ensure staff were fit tested (a test protocol conducted to verify that a respirator provides the wearer with the expected protection) timely for N95 (a device/mask designed to protect the wearer against particles and help prevent the spread of germs) masks and used correctly for 2 of 6 staff (Staff EE & Staff FF), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care for 5 of 14 staff (Staff Z, L, JJ, Q & R), failed to disinfect medical equipment for 2 of 2 staff (Staff II & U), and failed to ensure that infection control practices were implemented with storage of sharp containers for 3 of 3 medication rooms (Cherry, Birch & Hickory). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . N95 MASK USE Review of the facility's document titled, Respiratory Protection Program, revised in May 2024, showed that filtering facepiece respirators (FFR) (e.g., N95 or N100) are disposable, negative-pressure, air purifying respirators where an integral part of the facepiece or the entire facepiece is made of filtering material and that respirators rely on a tight facial seal. It showed, staff required to wear FFR, supervise the use of FFR, or issue FFR must undergo training prior to the work assignment and at least every 12 months thereafter. Re-training may be required if an individual has not retained training knowledge, or there are changes in the workplace or equipment, or to update prior training. It further showed that fit tests will be provided at the time of initial assignment and at least every 12 months thereafter. Observation and interview on 10/31/2024 at 1:20 PM, showed Staff EE, Attendant Counselor (AC) 3, was wearing an N95 mask (model 3M 1870+) with a surgical mask underneath while working in the Birch unit (on quarantine precautions [a strict isolation imposed to prevent the spread of disease] that require N95 mask). Staff EE stated that an N95 mask should have a good seal. When asked why they wore a surgical mask under their N95 mask, Staff EE stated, the one I used to use was smaller, but we don't have it right now, I use the surgical mask under, so it fits better. In an interview on 11/01/2024 at 10:00 AM, Staff FF, AC 1, stated they were hired in July 2023 and had been fit tested for their N95 mask. Staff FF stated they did not have a fit testing done in July 2024, and I think it's supposed to be done yearly. Review of the annual fit testing records showed that Staff EE had last been fit tested on [DATE] and had failed the fit testing for the 3M 1870+ model of N95 mask. Further review showed that Staff FF had been fit tested on [DATE] and did not show that they had been tested in the year 2024. In an interview and joint record review on 11/05/2024 at 3:32 PM, Staff GG, Safety Officer 3, stated they were responsible for N95 mask fit testing for staff and that fit testing should be done annually. Joint record review of the annual fit testing records [as of 10/15/2024], showed that Staff EE failed their test for the 3M 1870+ model. When asked if Staff EE should be using the 3M 1870+ mask, Staff GG stated, no, not at all. Further joint record review showed that Staff FF had fit testing done on 07/26/2023. Staff GG stated that they sent a list of staff needed fit testing to managers and maybe [Staff FF] didn't come for testing. In an interview on 11/06/2024 at 2:40 PM, Staff C, Registered Nurse (RN) 3, stated that staff should wear N95 masks when a unit was on quarantine precautions. Staff C stated that if staff failed their fit testing, they should not be working on a quarantine unit and may be reassigned to another unit. Staff C further stated that Staff EE, should not have been wearing a surgical mask under their N95 mask and should not have been working on a quarantine unit. In an interview on 11/07/2024 at 10:53 AM, Staff B, RN 4, stated they expected staff to have fit testing to ensure proper fitting of N95 masks. Staff B stated they did not expect staff to work on a quarantine unit if they had a failed fit test or would wear a surgical mask under their N95 mask. HAND HYGIENE/GLOVE USE Review of the facility's policy titled, Use of Disposable Gloves, reviewed in November 2018, showed that Gloves are removed after contact with body fluids, mucous membranes, or non-intact skin and properly discarded . When gloves are worn, staff shall wash their hands with soap/water, or use sanitizing gel, immediately before putting on gloves and after removal of the gloves . remove the gloves between contact with residents. Review of the facility's policy titled Handwashing/Hand Hygiene reviewed in March 2023, showed hand hygiene should be performed before applying gloves; hand hygiene should be performed after administering medications and treatments of each resident and [after] removing any personal protective equipment. STAFF Z Observation and interview on 11/06/2024 at 1:22 PM showed Staff Z, RN 2, performed a dressing change for Resident 44's pressure ulcer (bed sore). Staff Z donned gown and gloves and took off the old dressing. Staff Z took off their used gloves and put on new gloves to clean the pressure ulcer. Staff Z did not perform hand hygiene between glove change. After cleaning the wound, Staff Z applied skin prep around the wound, took off their gloves and put on new gloves without performing hand hygiene. Staff Z finished the dressing change and then removed their gloves and performed hand hygiene. Staff Z stated that their process was to perform hand hygiene between changing gloves. In an interview on 11/06/2024 at 2:45 PM, Staff C, stated they expected staff to perform hand hygiene before and after glove use. Staff C further stated that Staff Z should have performed hand hygiene between glove use. In an interview on 11/07/2024 at 10:53 AM, Staff B stated that they expected staff to perform hand hygiene before and after glove use. 47680 STAFF L Observation on 11/06/2024 at 8:34 AM, showed Staff L, RN 2, applied gloves, removed Resident 95's sock and the dressing on their left heel, which had yellow colored drainage on it. Staff L removed their gloves, poured normal saline into a cup and applied gloves without performing hand hygiene. Staff L soaked a gauze (small squares of soft, absorbent fabric) into the cup, cleansed Resident 95's wound on their left heel with the gauze and applied skin prep (film-forming dressing that forms a protective film) to the surrounding area. Staff L removed their gloves, cut the Mepilex (absorbent foam dressing), applied gloves without performing hand hygiene, and continued to cut the Mepilex as instructed. Staff L then applied the dressing to Resident 95's left heel and covered it with a transparent dressing. Staff L removed their gloves and performed hand hygiene. In an interview on 11/06/2024 at 8:51 AM, Staff L stated that when they removed their gloves, they would perform hand hygiene before they would put on a new one. Staff L stated that they should have performed hand hygiene after they removed their gloves and that they forgot that part. In an interview on 11/06/2024 at 10:38 AM, Staff C stated that they expected staff to perform hand hygiene before and after glove use. Staff C further stated that Staff L should have performed hand hygiene between glove use. In an interview on 11/06/2024 at 1:19 PM, Staff B stated that Staff L should have performed hand hygiene between glove use. STAFF JJ Observation on 10/30/2024 at 12:10 PM, showed Staff JJ, Attendant Counselor (AC) 2, was assisting Resident 34 with their lunch meal. When Resident 34 was finished with their meal, Staff JJ wiped Resident 34's mouth and right hand with an orange cloth. Staff JJ then took a blue cloth, wiped the table with it and then placed it in a bin. Staff JJ then pushed Resident 34 out of the dining room into the right wing. Staff JJ did not perform hand hygiene after assisting Resident 34 with their meal and after wiping their mouth and right hand. In an interview on 10/30/2024 at 12:21 PM, Staff JJ stated that they were taught to perform hand hygiene before and after they provide care and between residents. Staff JJ stated that they took Resident 34 to the right wing and did not perform hand hygiene. In an interview on 11/05/2024 at 2:15 PM, Staff S, AC Manager, stated that they expected staff to perform hand hygiene between resident care, after removing gloves and between residents. Staff S stated that they expected Staff JJ to have performed hand hygiene after wiping Resident 34's mouth and hands. In an interview on 11/06/2024 at 1:19 PM, Staff B stated that they expected staff to perform hand hygiene after providing care. Staff B further stated that Staff JJ should have performed hand hygiene after they assisted Resident 34. STAFF Q Observation and interview on 11/04/2024 at 12:20 PM showed Staff Q, Licensed Practical Nurse 2, had gloves on when they soaked gauze pads with water and cleansed the outside of Resident 2's eyes, before placing the used gauze pads in the trash can. Further observation showed Staff Q administered Resident 2's artificial tears [eye drops that help moisten dry eyes] and that they used the same gloves from handling used gauze pads. Staff Q stated they should have taken off their gloves after handing the used gauze pads and performed hand hygiene with alcohol-based hand sanitizer and donned new gloves before administering Resident 2 their eye drops. In an Interview on 11/04/2024 at 1:13 PM, Staff H, RN 2, stated they expected staff to perform hand hygiene whenever staff donned gloves. Staff H further stated that gloves should have been changed between tasks such as cleansing eyes and when eye drops are administered. STAFF R Observation and interview on 11/06/2024 at 8:04 AM showed Staff R, LPN 4, with gloved hands, wiped off mucus [gel-like substance produced by the body to line and protect the respiratory system] from Resident 41's face with a cloth towel. Staff R then removed the used gloves and donned gloves without performing hand hygiene. Staff R then placed Resident 41's medications in the pill crusher and measured out water from a pitcher into a disposable cup. Staff R documented and handled pages in the medication administration record binder. Without changing their gloves and performing hand hygiene, Staff R then took Resident 41's syringe [large syringe used to deliver liquids or medications directly into a person's stomach through a feeding tube (medical device used to provide nutrition to persons who cannot eat by mouth)] and administered Resident 41's medication through their Jejunostomy tube [a type of feeding tube]. Staff R then removed their used gloves and donned gloves without performing hand hygiene. Staff R administered a moisturizer ointment to Resident 41's right nostril using a Q-tip [small stick with a piece of soft cotton at the tip]. When asked about the facility's policy and procedure for hand hygiene and glove use during medication administration, Staff R stated they should have performed hand hygiene whenever they changed gloves. In an interview on 11/06/2024 at 8:22 AM, Staff X, RN 2, stated that before staff donned gloves, they have to sanitize [their hands]. In an interview on 11/06/2024 at 12:20 PM at 11:05 AM, Staff C stated gloves should be changed once contaminated such as moving from one task to another and that staff need to remove [used gloves] and [perform] hand hygiene, even if it is the same [resident]. Staff C further stated, no exception, whenever [staff] change gloves, they need to sanitize [their hands]. In an interview on 11/06/2024 at 1:03 PM, Staff B stated, Between tasks and when changing gloves, I expect [staff] to perform hand hygiene. DISINFECTING VITAL SIGN/MEDICAL EQUIPMENT Review of the facility's policy titled, Cleaning and Disinfecting, revised in February 2022, showed, Client equipment if shared such as vital sign equipment, oximeter [a device that measures blood oxygen levels and heart rate] is sanitized in between clients and allowed to dry per manufacture instructions. Staff II Observation on 10/31/2024 at 8:40 AM, showed Resident 27 place their thumb and second finger in their mouth. Staff II, AC 1, placed the oximeter on Resident 27's second finger. When Staff II was done with the oximeter, they placed it in a plastic container labeled with Resident 26's name and left it uncovered on top of a cabinet that was in the common area of the left wing. At 9:05 AM, Staff II applied gloves, covered the plastic container labeled with Resident 26's name and placed it inside the cabinet. Staff II did not disinfect the oximeter prior to placing it inside the cabinet. In an interview on 10/31/2024 at 9:20 AM, Staff II stated that each resident had their own vital sign equipment and that every morning they disinfected it with alcohol wipes. Staff II stated that they were concerned with Resident 27's condition that they took the wrong resident's vital signs equipment container. Staff II stated that they took the oximeter and placed it back without disinfecting it. In an interview on 11/05/2024 at 2:15 PM, Staff S stated that the residents had vital signs equipment kits that have their names on them. Staff S further stated that staff should not be using another resident's vital signs equipment and that if they had to use another resident's vital signs equipment, they would be sanitized. In an interview on 11/06/2024 at 10:50 AM, Staff C stated that they had a set of vital signs equipment for each resident to avoid contamination. When asked if they were to use another resident's vital signs equipment, Staff C stated that it needed to be disinfected. Staff C further stated that to avoid contamination, staff should grab the correct vital signs equipment and that if they took another resident's vital signs equipment, they need to disinfect it before they put it back. In an interview on 11/06/2024 at 1:25 PM, Staff B stated that if vital signs equipment were shared, it had to be cleaned between use. Staff B further stated that they expected staff to disinfect the vital sign equipment after use. 48899 Review of the facility's policy titled, Cleaning and Disinfecting, reviewed in May 2023, showed, Equipment which may become contaminated with blood or other potentially infectious material shall be checked routinely and disinfected immediately after use, both inside and outside, prior to servicing or shipping. The policy further showed all equipment, environmental, and working surfaces shall be properly cleaned and disinfected after contact with blood or other potentially infectious materials. Observation on 10/30/2024 at 10:13 AM, showed that Staff U, AC 3, and Staff Y, AC 1, transferred Resident 29 from their wheelchair to their bed using a Hoyer lift (mechanical lift that helps transfer residents with limited mobility). Staff U and Staff Y then went to Resident 21's room with the same Hoyer lift they used for Resident 29. Staff U and Staff Y transferred Resident 21 to their wheelchair using the same Hoyer lift. Staff U and Staff Y did not disinfect the Hoyer lift between use. In an interview on 10/30/2024 at 10:28 AM, Staff Y stated that they did not disinfect the Hoyer lift between resident use. Staff Y further stated that they did not disinfect the Hoyer lift because it was already cleaned by the night shift staff. In an interview on 10/30/2024 at 10:31 AM, Staff U stated that they did not disinfect the Hoyer lift between resident use. Staff Y further stated that they disinfected the Hoyer lift at the end of the shift. In an interview and record review on 11/04/2024 at 2:00 PM, Staff P, AC Manager, stated that if staff wore gloves and performed hand hygiene, the Hoyer lift did not need to be disinfected between resident use. Joint record review of the equipment NOC [night] Cleaning Checklist, showed that the Hoyer lift cleaning was scheduled weekly. Staff P stated that the Hoyer lift was being disinfected by the night shift. On 11/05/2024 at 9:26 AM, Staff Z stated, in my opinion, if the staff put on gloves and sanitize their hands, they don't need to clean the Hoyer lift as frequently. However, it should be cleaned at least at the end of each shift. On 11/06/2024 at 10:21 AM, Staff C stated that the facility had not instructed the staff to disinfect the Hoyer lift between resident use. Staff C acknowledged that when the Hoyer lift was shared among multiple residents, there was a possibility of contamination. Staff C stated that they needed to start cleaning it. On 11/07/2024 at 10:19 AM, Staff B stated that they considered the Hoyer lift as shared equipment and that it should have been disinfected between resident use. Staff B stated that there was always a risk of contamination, and staff should have disinfected the Hoyer lift between resident use. 51090 STORAGE OF SHARP CONTAINERS IN MEDICATION ROOMS Review of the facility's Infection Control Manual's policy titled, Biohazard Waste, revised in November 2018, showed sharps (device used to break the skin) once used was considered the highest risk item for Hepatitis B Virus (virus [infectious agent] that affects the liver) and Human Immunodeficiency Virus (virus that attacks the body's immune system [the body's defense against infection]) transmission. Further review showed that sharp containers once filled would be capped and transported to the designated area for disposal in accordance with county regulations. CHERRY BUILDING MEDICATION ROOM Joint observation and interview on 11/04/2024 at 11:12 AM with Staff L showed an open box of tongue depressors (popsicle sticks used for mixing medications), an open box of plastic pill cups (shallow cups used to hold medications in a pill crusher device), and a used biohazard sharps container (puncture-resistant container used to safely dispose of used needles and other sharp medical instruments), stored under the hand washing sink. Staff L stated that the tongue depressors and plastic pill cups should not have been stored under the sink with the biohazard sharps container. Staff L further stated that supplies used for medication administration (tongue depressors and plastic pill cups) should have been stored in the nurse supply room instead. BIRCH BUILDING MEDICATION ROOM Joint observation and interview on 11/05/2024 at 10:48 AM with Staff F, LPN 2, showed an open box of plastic spoons, an opened box of plastic pill cups, a box of tongue depressors, and two used phlebotomy (needles and other sharp instruments used in the process of drawing blood) containers, stored under the hand washing sink. Staff F stated that the plastic spoons, pills cups and tongue depressors were supplies used by staff to administer crushed and mixed medications to residents. Staff F stated they would not expect supplies used for medication administration to be stored with used phlebotomy sharp containers under the sink. Staff F further stated, We have a big storage there [separate area from the medication room] for nursing supplies, but sometimes they [staff] put it there [under the sink] to make it easier to get. In an interview on 11/05/2024 at 10:57 AM with Staff G, RN 2, stated they would not expect medication administration supplies to be stored with used biohazard phlebotomy sharp containers. Staff G further stated that they expected staff to obtain their supplies from the medical supply storage and to have stored supplies in the medication cart to be used for the day. HICKORY BUILDING MEDICATION ROOM Joint observation and interview on 11/05/2024 at 10:14 AM with Staff D, LPN 2, showed an open box of plastic spoons, a box of plastic pill cups and a used biohazard sharp container stored together under the hand washing sink. Staff D stated that the biohazard sharp container contained used needles and that supplies used to administer medications (plastic spoons and plastic pill cups) should be in the medical supply room because they can't be together [with biohazard sharps containers]. In an interview on 11/05/2024 at 10:32 AM, Staff E, RN 2, stated they did not expect medication administration supplies to be stored with biohazard sharp containers. Staff E further stated, there should be nothing under the sink. In an interview on 11/06/2024 at 11:05 AM, with Staff C stated they expected biohazard sharps containers to be attached to the medication carts while in use and once filled, they should be removed and taken to the biohazard disposal area, located outside of the nursing facility buildings. Staff C stated they would not expect medication administration supplies would be stored with biohazard containers. Staff C further stated that there was the potential to expose residents to biohazardous material when supplies used to administer medications and biohazardous materials were stored together. Staff B stated they would not expect supplies used for medication administration to be stored with biohazard sharps containers. Staff B further stated that there was the potential to expose residents to biohazard material when supplies for medication administration were stored with biohazardous containers and that they wouldn't want them together. Reference: (WAC) 388-97-1320 (1)(a)(c)(5)(c)

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 2 of 3 refrigerators (Walk-in Produce/Milk Refrigerator and Walk-in Preparation Salad Refrigerator), 1 of 1 dry storage room (Commissary Dry Storage Room), and for 3 of 8 staff (Staff NN, OO & PP), reviewed for food services. The failure to date and discard food items past the use by/discard date, perform hand hygiene and handle kitchen equipment appropriately placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Facility Food Storage and Meal Preparation Policy, dated [DATE], showed, Remove all expired food items and Any food that appears spoiled, contaminated, or past its use-by date must be discarded immediately. The policy showed, Note that the use of disposable gloves is not a substitute for proper hand washing. Hands must be washed before putting on gloves and after removing gloves. The policy further showed, Ensure cleanliness and sanitation of cutting boards, utensils, equipment, and countertops, especially when transitioning between raw and cooked foods. WALK-IN PRODUCE/MILK REFRIGERATOR Observation on [DATE] at 8:40 AM, showed one plastic container of Chef Salad with a discard date of [DATE]. In an interview and joint observation on [DATE] at 8:59 AM, Staff KK, Office Assistant, stated that food items that were past the use by date/discard date would be thrown away. Joint observation showed that the chef salad had a discard date of [DATE]. Staff KK stated that it should have been thrown away because it was past the discard date. In a joint observation on [DATE] at 10:30 AM with Staff LL, Food Service Manager, showed two opened bags of green shredded cabbage with use by date of [DATE]. Staff LL stated it was cabbage and should have been discarded. WALK-IN PREPARATION SALAD REFRIGERATOR In a joint observation on [DATE] at 8:54 AM with Staff KK, showed one unlabeled unknown food item inside a Ziplock (brand of resealable plastic bag) in a metal container. Staff KK stated that they would find the cook to ask what it was. Staff MM, [NAME] 1, stated it was roast beef from yesterday and that it should have been labeled. A joint observation on [DATE] at 10:34 AM with Staff LL, showed one unlabeled Ziplock containing slices of bread. Staff LL stated it was raisin bread and that it should have been labeled. In a follow up interview on [DATE] at 11:17 AM, Staff LL stated that their policy was to put a preparation date and discard date on food items. Staff LL stated that food items past the use by date should have been discarded and that the bag of roast beef should have been labeled. COMMISSARY DRY STORAGE ROOM A joint observation on [DATE] at 10:36 AM with Staff LL, showed four cans of cream of mushroom dated [DATE]. Staff LL stated that they would have to check with their distributor as the container did not say if it was the use by date or expiration date. On [DATE] at 10:04 AM, Staff LL provided an email document dated [DATE] that showed that the date on the product indicated the expected shelf life. It further showed, We recommend using the product before this date to ensure the best flavor, texture, and overall quality. Staff LL stated that the four cans of cream of mushroom should have been discarded. HAND HYGIENE STAFF NN Observation on [DATE] at 12:12 PM, showed Staff NN, Attendant Counselor (AC) 3, was at the Hickory Kitchenette dishwashing station rinsing dirty dishes with gloves on. At 12:15 PM, with the same gloves that they used to rinse the dirty dishes, Staff NN took two crackers from the cabinet and gave it to Staff QQ, Speech Pathologist. Staff NN then touched a bottle of Hersey's (brand-chocolate syrup) that was in a metal container of ice and closed the cabinet door. Staff NN opened the meal cart, pulled a metal tray out of the meal cart, placed it back in, closed the meal cart and went back to the dish washing station with the same gloves they used to rinse the dirty dishes. Staff NN did not remove their gloves and performed hand hygiene after rinsing the dirty dishes. In an interview on [DATE] at 12:51 PM, Staff NN stated that they were taught to perform hand hygiene between glove use. Staff NN stated that they should have removed their gloves and performed hand hygiene. In an interview on [DATE] at 2:15 PM, Staff S, AC Manager, stated that they expected staff to perform hand hygiene before and after glove use. Staff S stated that they expected that Staff NN to remove their gloves after rinsing dirty dishes and perform hand hygiene. In an interview on [DATE] at 1:19 PM, Staff B, Registered Nurse 4, stated that Staff NN should have removed their gloves before touching anything. STAFF OO Observation on [DATE] at 9:02 AM, showed Staff OO, [NAME] 2, checked the temperature of the pureed vegetables with a thermometer and disinfected it after use. Staff OO removed their gloves and wrote the temperature in a log. Staff OO applied new gloves without performing hand hygiene. Staff OO placed eight labels onto eight foil and removed their gloves. Staff OO applied new gloves without performing hand hygiene and poured the pureed vegetables into the containers and covered it with foil. Staff OO did this eight times. When Staff OO was done, they poured the remaining pureed vegetables into a different metal container and covered it with foil. Staff OO rolled the cart to the warmer and placed all eight items into the warmer. Staff OO returned to their working station and took a plastic bag of vegetables from the bottom of the cart, labeled it and placed it in the Main Big Cooler. When Staff OO returned to their working station, they removed their gloves and applied new gloves without performing hand hygiene. Staff OO took a metal container of cooked vegetables from the steamer and placed the vegetables inside the puree machine. When they were done pureeing the vegetables, Staff OO placed the pureed vegetables in a metal container, took the temperature with a thermometer, disinfected it, covered it with foil and labeled it. Staff OO logged the temperature in their log, carried the metal container to the warmer and placed it inside. Staff OO removed their gloves, placed the used metal containers in the dishwashing room. Staff OO went back to their working station and applied gloves without performing hand hygiene. In an interview on [DATE] at 9:37 AM, Staff OO stated that they were taught to perform hand hygiene all the time after they touched meat/raw food and when they changed gloves. Staff OO stated that they were working in the same station, doing the same thing, and that they did not perform hand hygiene when they removed their gloves. In an interview on [DATE] at 11:48 AM, Staff LL stated that staff were to perform hand hygiene in between task and between glove use. Staff LL further stated that Staff OO should have performed hand hygiene especially in between task. KITCHEN EQUIPMENT STAFF PP Observation on [DATE] at 10:38 AM, showed Staff PP, Food Service Worker, were on their knees on the kitchen floor with one green plastic meal tray on the floor as they were placing food items in the meal cart. When Staff PP was done, they got up, picked up the green plastic meal tray from the floor, walked over to the tray line and placed the remaining food items on a tray in the tray line. Staff PP then placed the empty green plastic meal tray that they placed on the floor back onto a stack of clean plastic meal trays. In an interview on [DATE] at 11:42 AM, Staff PP stated that if something were to touch the floor, they would pick it up and place it in the big cart where they place dirty dishes. Staff PP stated that the food items that were on the green plastic meal tray were desserts. When asked if they should place the green plastic meal tray that they placed on the floor with the other clean trays, Staff PP stated, probably not. Staff PP further stated that they should have placed it in the cart. In an interview on [DATE] at 11:48 AM, Staff LL stated that if a meal tray were to touch the floor, staff were to put it in the dish room. Staff LL stated that they placed dirty dishes in the cart and took it to the dish room. Staff LL stated, If it was something dirty, that's where they put it to get washed. Staff LL further stated that they expected Staff PP to place the plastic meal tray in the cart where they put dirty dishes. In an interview on [DATE] at 1:42 PM, Staff A, Nursing Facility Program Area Team Director, stated that they expected staff to follow their policy and procedures. Staff A stated that food items that are past the use by date/discard date should be discarded. Staff A stated that they expected food items to be labeled. Staff A stated that staff should follow policy, wash hands between glove use. Staff A further stated that if a kitchen equipment was dirty, staff were to not use them and to wash them. Reference: (WAC) [DATE] (3)

Based on observation, interview, and record review, the facility failed to ensure expired medication was disposed of timely and a controlled substance (a drug or chemical that is regulated by the government because it can be addictive or harmful if misused) medication was handled and accounted appropriately for 1 of 3 medication carts ([NAME] Building), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications and for potential diversion or misappropriation of controlled substance medication. Findings included . Review of the facility's policy titled, Preparation and Administration of Medications and Treatments, revised in 05/2024, showed that for medication in the original manufacturer's container (bottle), staff should check expiration dates of medication on manufacture's label .dispose of expired medications. Review of the facility's policy titled, Controlled Substance Medication Handling and Accountability, revised in 05/2023, showed that the facility's controlled substances perpetual inventory is a complete and accurate continuous record of controlled substance medications. Further review showed that the perpetual inventory of controlled substances schedule II through schedule V [controlled substances are classified into five schedules based on their potential for abuse, medical use, and risk of dependence] medications were maintained in nursing controlled substances [inventory] ledgers. EXPIRED MEDICATION IN MEDICATON CART Joint observation and interview on 11/04/2024 at 1:28 PM with Staff F, Licensed Practical Nurse (LPN) 2, showed a used bottle of over the counter (medication that can be bought directly from a store or pharmacy without needing a prescription from a doctor) liquid antacid (medication to relieve symptoms caused by stomach acid) had a manufacturer's label and expiration date of September 2024. Staff F stated that the medication was expired and that they have to take it out [of the medication cart]. In an interview on 11/06/2024 at 1:03 PM, Staff B, Registered Nurse (RN) 4, stated they expected expired medications stored in medication carts to be disposed of timely. CONTROLLED SUBSTANCE MEDICATION IN MEDICATION CART Joint observation and interview on 11/04/2024 at 1:30 PM with Staff F and Staff N, LPN 2, showed the total count of lacosamide 200 milligram (mg- a unit of measurement) tablets (a controlled substance medication used to help control seizures) in a blister pack (packaging system for medications, used to seal each dose in its own individual bubble or compartment) for Resident 15, did not equal the total count of lacosamide 200 mg tablets recorded in the controlled substance inventory ledger. Staff F and Staff N stated that the 11/04/2024, 8:00 AM dose of lacosamide 200 mg for Resident 15 was not recorded in the controlled substance inventory ledger. Staff F and Staff N further stated that they expected medications withdrawn from the controlled substance inventory to be recorded once the medication was given and that Resident 15's 8:00 AM dose should have been recorded when the medication was given. In an Interview on 11/04/2024 at 2:02 PM, Staff H, RN 2, stated they expected the controlled substance inventory ledger to be accurate with the resident's name to Make sure that medication was given to that person. Staff H further stated that they expected nurses to record medications whenever they were withdrawn and administered to Resident 15. In an interview on 11/06/2024 at 1:03 PM, Staff B stated they expected nurses to record medication withdrawn in the controlled substance inventory ledger at the point of use and that nurses are expected to record it right away after they prepared the medication. Reference: (WAC) 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to inform residents and/or their representatives of risks and benefits before application of a restraint for 2 of 5 residents (Residents 41 & 12), reviewed for physical restraint. This failure placed the residents and/or their representatives at risk for not being fully informed before making decisions regarding their health care, alternative treatment options, and the right to refuse care. Findings included . Review of the facility's policy titled, Informed Consent, revised on 10/15/2024, showed that informed consent means agreement to proceed with a particular treatment or service based upon certain components including the name, relationship to the client, and signature of the person giving informed consent signifying that they do or do not grant consent. The Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) shall obtain appropriate informed consent from individuals with capacity to give informed consent before starting a program or service, medication, or medical treatment that presents a risk to residents' safety, where such risk is not considered to be insignificant. Informed consent is obtained when there is recommendation to infringe on the resident's right. When an individual cannot give informed consent, the IDT shall seek consent from the appointed guardian of the resident or the resident's legal representative. The policy further showed that restraints used as part of a positive behavior support program as well as support devices that restraint voluntary or involuntary movements (such as wheelchair seatbelts, wheelchair trays, chest support for maintaining upright positioning) are treatment and services that would require informed consent. RESIDENT 41 Review of the annual Minimum Data Set (an assessment tool) dated 10/03/2024 showed Resident 41 had severely impaired cognition and was on trunk restraint during this assessment period. Observations on 10/31/2024 at 9:03 AM, on 11/01/2024 at 9:49 AM and at 1:40 PM, on 11/04/2024 at 9:11 AM, and on 11/05/2024 at 11:54 AM, showed Resident 41 was sitting in their wheelchair with their wheelchair seatbelt applied around their waist. Review of Resident 41's informed consent for the use of wheelchair with seatbelt showed that the consent was signed by Resident 41's representative on 01/31/2023. Further review of the informed consent showed, This consent is valid for one year from the date of the written consent unless otherwise stated. During an interview and joint record review on 11/06/2024 at 10:39 AM, Staff M, Registered Nurse (RN) 2, stated that informed consent would be obtained before an implementation of a restraint. Joint record review of Resident 41's informed consent for the use of wheelchair with a seatbelt dated 01/31/2023 showed the consent was valid for one year from the date of the written consent unless otherwise stated. Staff M stated that the consent was valid for one year from the date it was obtained. On 11/06/2024 at 2:47 PM, Staff B, RN 4, stated that Resident 41's informed consent should have been updated annually. 46912 RESIDENT 12 Review of the face sheet printed on 11/01/2024, showed Resident 12 admitted to the facility on [DATE] with diagnoses that included athetoid cerebral palsy (a brain disorder that affects movement and includes involuntary muscle movements). Review of the physical supports to maintain client in an upright position care plan, printed on 11/01/2024, showed Resident 12 used a tilt in space manual wheelchair [a wheelchair that can reposition a person by tilting the chair in a way that lowers the seated person's head and raises their feet at the same time] .to provide back, trunk and upper leg support. Further review of the care plan showed Resident 12 used a padded seatbelt to stabilize the pelvis in the wheelchair and a padded shoulder harness to provide additional trunk support. Review of Resident 12's clinical record (electronic health record and paper chart) showed no documentation that Resident 12 or their representative were informed of the use of tilt in space wheelchair, shoulder harness or seatbelt. Observations on 11/01/2024 at 11:29 AM, on 11/05/2024 at 9:26 AM, and on 11/06/2024 at 9:29 AM, showed Resident 12 was sitting in their tilt in space wheelchair and wearing a seatbelt and shoulder harness. In an interview on 11/04/2024 at 1:08 PM, Staff G, RN 2, stated that there needed to be a physician's order, an assessment by occupational therapy, and a consent before a resident used a shoulder harness and a seatbelt. Staff G stated they were unsure if a consent was needed for a tilt in space wheelchair. In an interview and joint record review on 11/05/2024 at 11:27 AM, Staff DD, Occupational Therapist 3, stated that they do an evaluation prior to residents using a tilt in space wheelchair, shoulder harness, or a seatbelt. Staff DD stated they did not provide anything to the guardian that that they need to sign. Staff DD stated that risks and benefits were verbally discussed, but nothing officially signed. A joint record review of the Informed Consent policy showed that treatment and services requiring informed consent include .restraints used as .support devices that restrain voluntary or involuntary movement (such as wheelchair seatbelts, wheelchair trays, chest supports for maintaining upright positioning, etc.). In a follow up email at 2:48 PM, Staff DD, stated that based on how this policy is written and the specific examples included, then consent should have been obtained using the standardized form. A joint record review of the Informed Consent policy and interview on 11/07/2024 at 11:09 AM with Staff B, showed that treatment and services requiring informed consent include .restraints used as .support devices that restrain voluntary or involuntary movement (such as wheelchair seatbelts, wheelchair trays, chest supports for maintaining upright positioning, etc.). Staff B stated, I agree, there should be consent for those things [tilt in space wheelchair, seatbelt and shoulder harness]. Reference: (WAC) 388-97-0260(2) (a-d) (3)(c)

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with a meal for 1 of 18 residents (Resident 29), reviewed for dining observation. This failure placed the resident at risk for a diminished self-worth and over all wellbeing. Findings included . Review of Resident 29's quarterly minimum data set (an assessment tool) dated 10/03/2024, showed that the resident had moderately impaired cognition. Review of Resident 29's Activities of Daily Living (ADL) care plan, printed on 11/04/2024, directed staff to sit down at Resident 29's eye level when assisting with meals. Observation on 10/31/2024 at 12:04 PM, showed Resident 29 was seated upright in their wheelchair in the dining room with their lunch tray. Resident 29 was observed eating their lunch and dropped food. Further observation showed, Staff O, Attendant Counselor 1 assisted Resident 29 while standing over them. On 10/31/2024 at 12:33 PM, Staff O stated that Resident 29 was halfway through their lunch meal, and they started helping after observing them drop food. Staff O stated that they were not sitting next to Resident 29 while assisting them. Staff O stated that they were not supposed to assist while standing over the resident. Staff O further stated that the facility trained them to assist residents with meals while seated next to them. During an interview and joint record review of Resident 29's ADL care plan on 11/04/2024 at 2:00 PM, Staff P, Attendant Counselor Manager, stated that except for Resident 29, staff must sit when assisting residents with their meals. Staff P stated that Resident 29 used a high wheelchair, making it difficult for staff to sit at their eye level. Staff P stated that Resident 29's care plan specified that staff should not sit whey they assisted Resident 29 with meals. A joint record review of the ADL care plan showed that staff should sit down at Resident 29's eye level when they assist with their meals. Staff P stated the care plan should be updated. In another interview on 11/05/2024 at 1:12 PM, Staff P stated that staff were supposed to use highchairs when assisting Resident 29 with their meal. Staff P further stated that since the highchairs were broken and unavailable, staff could assist residents while standing. On 11/07/2024 at 10:19 AM, Staff B, Registered Nurse 4, stated that staff should be seated when assisting residents with their meals. Staff B stated that if a resident had a care plan for dining/eating, staff must follow it. Staff B stated that if there was a shortage of chairs, it should have been communicated. Staff B further stated, If necessary, an appropriate chair should be ordered and assisting Resident 29 while standing is not the correct approach. On 11/07/2024 at 11:45 AM, Staff A, Nursing Facility Program Area Team Director, stated that they expected the staff to be seated at eye level with Resident 29 when assisting their meal. Staff A further stated that Resident 29's care plan should have been followed. Reference: (WAC) 388-97-0180(2)

Based on observation, interview and record review, the facility failed to prevent an accident with substantial injury for one of four residents sampled (Resident #1) when the resident fell to the floor after a transfer in the bathing room. This failure led to substantial injuries: facial injuries and a head scalp laceration that required an emergency room treatment with staples. Findings included . Review of facility medical records showed Resident #1 resided at the facility for long term care since (YEAR) and had a [DIAGNOSES REDACTED]. According to the facility Minimum Data Set assessment, dated 08/18/19, (before the fall), Resident #1 sometimes understands, had impairment to range of motion of both upper extremities, unsteady balance, and was dependent on staff for all activities of daily living, including total dependence on two staff for bathing. Review of the facility care plan, dated 08/19/19, (before the recent fall) showed Resident #1 had a history of [REDACTED]. In addition, the staff used a two person transfer for Resident #1 with an electric lift and sling, as well as a bed alarm with frequent checks for safety. Review of the facility occupational therapy evaluation, dated 02/27/19, showed Resident #1 had the ability to sit up, roll and get out of bed with assistance, with many reported falls with [MEDICAL CONDITION] prior to admission to the facility. Resident #1 self propeled her wheelchair with her legs, needed supervision for safety, and also has had rocking behavior in the chair that placed her at risk for tilting the chair over. FALL WITH SUBSTANTIAL INJURIES Review of the facility investigation, dated 11/11/19, showed Resident #1 had a fall in the bathing room with two staff present. The investigation showed Resident #1 had fallen out of a device called the bath boat onto the floor, and looked scared. Resident #1 had a [MEDICAL CONDITION] with bleeding and forehead swelling over her left and right eye. The facility sent Resident #1 to the emergency room via 911 where she received staples to the [MEDICAL CONDITION]. The facility physician ordered Tylenol for pain when she returned to the facility from the emergency room . Review of the hospital emergency room discharge instructions, dated 11/11/19, showed Resident #1 had a head scalp laceration and staples applied to be removed in 7 to 10 days. Review of the facility progress note by a licensed nurse, dated 11/11/19, showed Resident #1 had a [MEDICAL CONDITION] with staples, bruise on the right side of the eye with abrasion on right eyebrow, and medication (Tylenol) was given for discomfort. The following day 11/12/19, the progress note by a licensed nurse showed Resident #1 had multiple bruises on her face and dark bruises to both eye sockets (orbitals) with swelling on the right side of the eye, as well as staples on the right top of the head on the scalp laceration, and medication was given for discomfort. Additional bruises were noted on the right upper arm and both thighs. The facility investigation witness report written by Staff A and Staff B on 11/11/19 showed Staff A and Staff B, nurse aides, transferred Resident #1 to the bath boat from the electric lift with sling, and closed the bath boat gate. Staff A turned away to remove the electric lift, Staff B moved toward the other side of the bath boat to prepare the bath water, and Staff A turned back and saw Resident #1 fall out of the bath boat with the bath boat gate observed to be open. The facility investigation concluded the fall could have been avoided if the staff had communication after the transfer to the bath boat and one person staying within an arm's reach to Resident #1, as Resident #1 was at risk for falls due to her cognitive deficit and ability to sit up in the bath boat. The facility incident report showed the bath boat side gate was unlatched at the time of the fall. During an interview with the facility Director of Nursing (DNS) on 12/10/19 at 11:40 a.m., the DNS stated that when Resident #1 was in the bath boat, apparently the bath boat gate was not secure, and it opened when the resident turned and she fell out while no one had eyes or hands on her. During an interview on 12/10/19 at 2:30 p.m., Staff A, a nurse aide present at the fall, stated that she thought the side gate to the bath boat was latched after they transferred Resident #1 into the boat device. Then she turned around to remove the electronic lift and when she looked back at Resident #1 she saw the resident fall to the floor and the boat bath gate was open. Staff A stated that she saw Staff B walking around the bath boat at the time of the fall to prepare the bath water. Staff A stated she thought Resident #1 must have sat up in the boat or turned in the boat because she is usually very active and moving and likes to look out over the side of the bath boat when she was in it. Staff A stated that Resident #1 needed constant reminders because of her movements. Staff A stated that the bath boat was an older piece of equipment and had since been replaced. During an interview on 12/10/19 at 2:40 p.m. Staff B, a nurse aide present at the fall, stated that Resident #1 sometimes moves and wants to sit up in the bath boat. Staff B stated that she thought they had latched the gate and as she moved to turn on the bath water, Resident #1 fell out of the bath boat very quickly and she could not grab her. Review of the facility progress notes, dated 11/25/19, showed 2 weeks after the fall, Resident #1 still had bruising around both eyes. Further review of the progress notes also showed Resident #1 still had bruising around the eyes three weeks after the fall (per note dated 12/02/19). Observation on 12/10/19 at 2:10 p.m., 29 days after the fall, showed Resident #1 had faded bruising under the left eye green and yellow in color over 2 inches in size, and a healing laceration on the right top of the head scalp area one-plus inches long and slightly pink in color. Resident #1 was nonverbal and not able to be interviewed. Review of the facility incident report, dated 11/11/19, also showed a plan for equipment check. Observation on 12/10/19 at 2:30 p.m. of the bath boat, in the left bathing room of the unit where the fall occurred, showed a new bath boat device (per Staff A) that consisted of a metal wheeled frame with side rails on each side called gates that have two latches on each gate. The device is over four feet high, and contained a plastic type inset (called the boat) where the resident lays down to be bathed. During an interview on 12/10/19 at 3:00 p.m., the facility Administrator stated that she checked the bath boat used during the fall for Resident #1 after the fall, and it latched properly. The Administrator was not sure how often the equipment was checked by maintenance. She confirmed the bath boat used during the fall had been replaced. Review of an email from the facility Administrator, dated 12/11/19, showed the the facility had no written records of documentation for equipment checks, but it was included in annual inspections for equipment. During an interview on 12/10/19 at 2:50 p.m., Staff C, the unit manager, stated that he checked the (original) bath boat gate latches after the fall for Resident #1, and it did not latch properly 2 out of 10 times, so the boat was replaced as the parts can become loose over time. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide adequate supervision and safety for 1 of 4 residents sampled for injuries (Resident #1), when the resident had an unwitnessed fall with substantial injury. This failure led to a forehead injury for Resident #1. Findings include: Review of facility medical records revealed, Resident #1 resided in the facility for long term care and need assistance from 2 staff for transfers, as well as staff assistance for all activities of daily living, and had a history of [REDACTED].#1 was not interviewable due to a developmental intellectual disability. Review of the facility physical therapy evaluation dated 10/23/18 revealed, Resident #1 had a history of [REDACTED]. The evaluation also noted Resident #1 needed staff to assist with transfers using a gait belt. There was no therapy note regarding the safe use of a recliner for Resident #1. Review of an occupational therapy evaluation dated 10/24/18 revealed, Resident #1 was at high risk for falls and needs assistance to stand from a chair, and needs a seatbelt when moving in the wheelchair. The evaluation noted Resident #1 prefers to sit in a recliner with an extra pillow, but had no intervention noted for this for safety. The care plan for Resident #1 had no intervention for safety for Resident #1 to sit in a recliner chair. Observation on 12/04/18 at 1:30 p.m., revealed, Resident #1 was seated in a large brown leather recliner in the day room with Staff E, a caregiver, close to her. Resident #1 was trying to stand up on her own and kept scooting to the edge of the recliner where Staff E had to stop her and redirect her to stay in the chair. During the above observation, Staff E stated, ever since Resident #1 admitted to the facility in (MONTH) of this year, she has tried to stand up from the recliner in the day room but she is not safe to do that, so the staff must watch her all the time or she will fall. Review of the facility fall investigation dated 11/15/18 revealed, Resident #1 was found on the floor in the day room after last seen sitting in a recliner chair. Review of the written staff statement by Staff A, the nurse aide assigned to Resident #1 on the evening of the fall, revealed Staff A noted that when Resident #1 was in the recliner chair, the staff watch her for sliding out of the chair, and Resident #1 tried to stand up and transfer by herself. Staff A noted he was not present when Resident #1 fell out of the recliner chair because Staff A was giving a shower to another resident. Review of the written Staff B statement revealed Staff B, a nurse aide, was also not present at the time of the fall, although Staff B also noted Resident #1 was normally visually monitored as she might try to walk by herself. In an interview on 12/04/18 at 2:45 p.m., Staff C, a licensed nurse, stated on the day of the fall, Resident #1 was in the recliner with feet up in the day room on 11/15/18 the evening shift. Staff C stated Resident #1 is usually in the wheelchair, I never saw her in that recliner before. Staff C also stated usually staff are always watching Resident #1. Staff C stated she was in the day room with Resident #1 before she fell , but Staff C left the area to do other things, and when she returned she found Resident #1 on the floor. Observation on 12/04/18 at 12:45 p.m. revealed, Resident #1 had 4 marks on her forehead: red/purple marks center forehead between eyes. Resident #1 was in a regular chair in the day room, and very restless, trying to stand up, and had a caregiver with her. During the above observation, Staff C stated the 4 purple marks on Resident #1's forehead were from the fall, and were not present before the fall. In an interview on 12/04/18 at 12:30 p.m., Staff D, a nurse supervisor, stated she saw Resident #1 the day after the fall and saw a 3 inch area of bruising on her forehead and a red left eye, that got worse over the following few days. Staff D also stated the fall was unwitnessed. The facility failed to provide adequate supervision to Resident #1 when she was seated in a recliner with no staff present, and with a known history of falls and attempts of unsafe self transfers. The facility also had no safety assessment or plan for Resident #1 to be seated in a leather recliner chair. This failure led to a substantial head injury on the forehead. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide services according to professional standards for 1 of 6 sampled residents (Resident #1) when the facility staff did not administer medications according to the physician's orders [REDACTED]. This failure led to 18 significant medication errors and placed the resident at risk for less than optimal health. Findings include: --see F225, F333, F425-- According to Fundamentals of Nursing, 7th Edition, 2011, (Taylor, Lillis, Lemone, & Lynn), page 125, nurses are legally responsible for carrying out the orders of the physician in charge a patient . According to Lippincott Nursing Procedures, 7th Edition, 2013 (Wolters Khrwer), nurses must prepare and administer medication, adhering to the five rights of drug administration, (Right Patient, medication, Dose, Time, Route). Review of facility physician's orders [REDACTED].#1 was to receive an anti-[MEDICAL CONDITION] medication (Levetiracetam) in the morning and in the evening. According to the facility incident investigation dated 08/01/17, the facility staff did not administer this anti-[MEDICAL CONDITION] medication as ordered, and instead administered the wrong medication ([MEDICATION NAME]) which was not ordered by the Physician for Resident #1: The bottle of [MEDICATION NAME] was incorrectly labeled as Levetiracetam and was delivered on 07/07/17 to Staff G, a licensed nurse. The facility licensed nurses (Staff A, B, C, D, E and F) omitted the correct medication (Levetiracetam) ordered for [MEDICAL CONDITION], for 9 doses, and administered the wrong medication ([MEDICATION NAME]-an anti manic) for 9 doses on 07/13/17 through the morning of 07/17/17, 7 facility nurses did not note the incorrect labeling of the liquid [MEDICATION NAME] medication for Resident #1; the facility nursing staff missed 10 opportunities to see the incorrect label: once on delivery of the medication on 07/07/17 and during 9 administrations of the medications 07/13/17-07/17/17. In an interview on 10/30/17 at 2:15 p.m. the facility Director of Nursing stated the facility trained the nurses to check labels on delivery and before medication administration, including the manufacturer label and the pharmacy labeling. Reference (WAC) 388-97-1620(2)(b)(ii)

Based on interview and record review, the facility failed to ensure 1 of 6 residents sampled (Resident #1) remained free of significant medication errors, when the facility failed to administer nine doses of a prescribed medication for [MEDICAL CONDITION], and administered nine doses an incorrect anti-manic medication; and failed to detect the errors until after Resident #1 discharged from the facility deceased . This failure placed the resident at risk for less than optimal health, drug interactions, and less than optimal assessment at the hospital due to lack of knowledge of the errors at the time of hospitalization . Findings include: --also see F225; F281; F425- Review of facility medical records revealed, Resident #1 resided at the facility for long term care for profound mental disability as well as major motor [MEDICAL CONDITIONS] had a feeding tube and a history of [MEDICAL CONDITION]. Review of a facility physician note dated [DATE] revealed, Resdient #1's Major Motor [MEDICAL CONDITION] were maintained on the [MEDICAL CONDITION] medication Levetiracetam twice a day, 1250 mg am and 1000 mg pm. as well as another [MEDICAL CONDITION] medication. Review of the facility incident investigation dated [DATE] revealed, significant medication errors: Resident #1 received incorrect medication ([MEDICATION NAME]) and did not receive his anti-[MEDICAL CONDITION] medication (Levetiracetam) in [DATE] for four days [DATE] to [DATE], total of nine doses of anti-[MEDICAL CONDITION] medication were omitted, and nine doses of the wrong medication administered by the facility. The significant medication errors were not discovered by the facility until after Resident #1 discharged to the hospital and was deceased . When his medications were returned to the In House Pharmacy on [DATE]. At that time, the pharmacy noted a bottle of liquid [MEDICATION NAME], opened [DATE] per markings, was labeled by the manufacture as [MEDICATION NAME], and had an incorrect pharmacy label for Levetiracetam for Resident #1. The facility investigation noted the 18 significant medication errors for Resident #1 were due to an incorrect label from the pharmacy, and the lack of facility staff to detect the incorrect label upon delivery of the medication from the pharmacy to the facility nursing staff, and during multiple medication administrations in the facility as noted above. According to the facility investigation, the [MEDICATION NAME] bottle (labeled Levetiracetam) was opened by facility staff on [DATE] in the morning (marked on the bottle). Review of the physician's orders [REDACTED]. According to the facility investigation, Resident #1 did not receive the above ordered doses of Levetiracetam for [MEDICAL CONDITION] for four days [DATE] to [DATE], but instead received 750 mg of [MEDICATION NAME] in the morning, and 600 mg of [MEDICATION NAME] at night. According to the Nurses Drug Handbook 2017, Levetiracetam is an anticonvulsive medication to prevent [MEDICAL CONDITION] and should not be stopped abruptly due to potential for rebound [MEDICAL CONDITION]; stopping any [MEDICAL CONDITION] medication at once can cause serious problems. [MEDICATION NAME] is an antimanic medication used to treat [MEDICAL CONDITION] disorder and manic-depression, a [DIAGNOSES REDACTED]. This medication can interact with another medication called [MEDICATION NAME], and the physician should be notified if the resident is on that medication. Resident #1 was on Enal[DATE] mg per day. According to the facility progress notes, Resident #1 had a change of condition on [DATE] (fourth day of undetected medication errors) , and was transferred to the hospital for respiratory congestion, increased temperature and low oxygen saturation; Resident #1 had been clammy and hypoxic (oxygen saturation 77% on 1 liter of oxygen), as well as sleepy all shift, and had a [MEDICAL CONDITION] at 7:05 p.m. before transferring to the hospital at 7:43 p.m. According to the medical record, Resident #1's last [MEDICAL CONDITION] was 22 days prior on [DATE] when he had a 13 minute [MEDICAL CONDITION] that was treated with emergency medication. Review of the hospital records dated [DATE] revealed, Resident #1 was in [MEDICAL CONDITION] upon arrival to the hospital and was intubated, deceased [DATE] and was diagnosed with [REDACTED]. The hospital had no knowledge of the medication errors, since the facility did not recognize the errors until after Resident #1 was deceased . The lack of knowledge of the omission of the anti-[MEDICAL CONDITION] medication, and administration of a wrong medication placed the resident at risk for less than accurate assessment/treatment by the hospital for Resident #1. In an interview on [DATE] at 2:10 p.m. the Director of Nursing stated the hospital did not know Resident #1 did not have [MEDICAL CONDITION] medication for four days, or that he had an incorrect medication administered, because the error was not found until after Resident #1 died and the medications were returned to the pharmacy where the mislabeling was identified and a facility investigation began. Reference (WAC) [DATE](3)(k)(iii)

Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assured the accurate dispensing of a drug for 1 of 6 residents sampled (Resident #1) when the pharmacy incorrectly labeled a liquid medication. This failure led to significant medication errors including nine omitted doses of an anti-seizure medication, and the administration of nine doses of a medication not ordered for Resident #1; placing the resident at risk for less than optimal health. Findings include: --also see F225; F281; F333-- In an interview on 10/30/17 at 2:30 p.m., Staff H, Director of the In House Pharmacy stated, the white bottles of the two medications that were involved in the incorrect labeling of a liquid medication for Resident #1, were stored on a shelf side by side, in identical looking bottles, both medications were labeled with the manufacturer labels and both medications started with the letter L. The Pharmacist stated this contributed to the significant medication error of labeling a bottle of Lithium with a label for the prescribed Levetiracetam for Resident #1 in the Pharmacy. In addition, the incorrect labeling was not identified by the two pharmacy employees (Staff I and J) who handled the dispensing of the prescribed liquid medication for Resident #1 on 07/07/17. Record review of the facility event investigation dated 08/01/17 revealed, a photo of the Lithium bottle with a manufacturer label for Lithium, and a Pharmacy label for Levetiracetam for Resident #1. The Pharmacy Director stated Resident #1 received a hefty total dose of Lithium (incorrect medication) with the significant medication errors in July 2017. Observation on 10/30/17 at 2:35 p.m. confirmed the above information by the Pharmacy Director and revealed the Pharmacy has moved the two bottles of medication apart for storage to assist in preventing future errors. Reference (WAC) 388-97-1300 (1)(a)

Based on observation, interview and record review, the facility failed to prevent accidents and substantial injury for 1 of 5 residents reviewed, (Resident #2) when the resident fell and sustained a deep laceration that required sutures. This failure resulted in pain, hospital care, and other injuries such as bruises to the knees. Findings include: Review of facility medical records reveled, Resident #2 resided at the facility for long term care. The facility Minimum (MDS) data set [DATE] noted, Resident #2 needed full assist from 2 staff for toileting. The facility Care Plan dated 09/04/16 revealed, Resident #2 required 2 staff for toileting transfer for safety from falls. Review of the facility incident investigation dated 11/07/16 revealed, Staff D transferred Resident #2 without a second staff member on 11/07/16 and Resident #2 fell and sustained a deep laceration to the forehead 2 inches by 1 inch that required sutures at the hospital. The facility investigation concluded Staff D did not follow the care Plan for Resident #2's safety during transfer and the resident fell . The facility investigation also noted Resident #2 sustained bruised knees in the fall on 11/07/16. Additionally, the physician ordered Tylenol for pain. According to the hospital Emergency Record dated 11/07/16, Resident #2 had a head injury and a laceration that required sutures from the fall at the facility. In an interview on 11/22/16 at 11;10 a.m., the Director of Nursing stated Staff D did not follow the safety plan of care for Resident #2 which resulted in the fall with deep laceration. In an interview on 11/22/16 at 2:10 p.m., Staff E, a staff manager assigned to the unit where Resident #2 lived, stated the deep laceration on the day of the fall for Resident #2 bled heavily and soaked 3 full gauze layers, that required a pressure head bandage. Staff E also stated the care plan had not been followed to prevent falls for Resident #2 when Staff D transferred the resident without a second staff member as required. In addition, Staff E stated Resident #2 (who could not verbalize pain) appeared to be in pain for several days after the fall as she winced, isolated herself more, and was more quiet that usual after the fall. Review of the medication administration record for Resident #2 dated 11/07/16 revealed, Tylenol as given to Resident #2 for discomfort. During observation on 11/22/16 at 2:05 p.m., Resident #2 had a red healing jagged laceration on her forehead about 2 inches long.

Based on observation, interview and record review the facility failed to accurately assess and implement measures to prevent pressure ulcer development for 1 of 2 sample residents (2). Failure to thoroughly inspect Resident 2's skin following a change in medical condition resulted in harm and the development of avoidable pressure ulcers. Findings include: Wound Staging: A) Stage 1 pressure sore-intact skin with non-blanchable redness of a localized area usually over a bony prominence, B) Stage 3 pressure sore-full thickness tissue loss. slough (dead tissue) may be present but does not obscure the depth of tissue loss. C) Unstageable-full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar in the wound bed. Eschar/Slough Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy (at times). Resident 2: Resident 2 had [DIAGNOSES REDACTED]. The MDS revealed she was at high risk for pressure ulcer development due to her decreased mobility and incontinence. Resident 2 received 100% of her nutritional intake by a feeding tube ([DEVICE]). The Plan of Care for 3/16/15 directed staff to apply a moisturizing cream to her feet every night. The Health Care (HC) note, dated 3/24/15, documented Resident 2's left ankle was swollen, had bruising with redness and "slight uncomfortable." The physician was notified, a X-ray was obtained and an order to "apply ace wrap to left ankle or foot splint". The HC notes documented the Licensed Nurses (LNs) continued to assess the circulatory status (CMS) of her left foot due to the "secured" ace wrap around her ankle. There was no documented evidence the skin under the ace wrap had been inspected until 3/28/15 (5 days later). The ace wrap was removed and a "dry dark scabbed red area on her L (left) heel was observed. The left ankle was re-wrapped with the ace wrap and supported with a bootie and her foot was elevated on a pillow. A "Pressure Ulcer Record" indicated the pressure ulcer on the left heel was first observed on 3/29/15. The diameter of the wound was 3 centimeters (cm) by 5 cm in size and was described as a "dry dark red scabbed area". On 3/31/15, the left heel wound was described to have eschar (dead tissue). Another "Pressure Ulcer Record" dated 3/29/15, indicated a Stage 2 pressure ulcer was on her left lateral malleolus (outer ankle). The pressure ulcer measured 2 cm by 1.5 cm in size. On 4/14/15 during an interview with the Licensed Nurse (LN A), she stated the left pressure wound on the left heel had hard eschar formation when she had initially assessed it on 3/29/15. On 4/14/15, at 9:00 a.m., Resident 2 was observed asleep in her bed. A dressing (gauze) wrap was noted around the left ankle and a small pillow rested against the toes. A blue cloth foam donut device was securely wrapped around her left calf. On 4/14/15 at 10:35 a.m., LN A stated Resident 2 initially had booties (plaid) that were used to protect her feet due to the ankle swelling, the left foot elevation on a pillow. When LN A was asked about whether the licensed nurses (LNs) had removed the ace wrap to inspect the skin, she stated the ace wrap was not removed daily to inspect the skin. On 4/14/15 at 11:05 a.m., the skin of the resident's lower extremities (legs) were observed with LN A. When the LN removed the donut from her left calf, a non-blancheable redness and indentation of the skin was observed. The pressure ulcer on the left heel was unstagable and the wound bed contained 100% black necrotic tissue and measured 3.5 cm by 5 cm in size with periwound redness. The pressure ulcers on the anterior ankle and lateral malleolous area was 7 cm by 7.5 cm in size. The wound base of the pressure wound on the outer ankle was dark purple in color and the wound base of the anterior portion of the foot was red with 10% slough and was macerated. Both wounds had periwound [DIAGNOSES REDACTED] (redness). During review of the Pressure Ulcer Record with LN A on 4/14/15, she verified that the wound base of the left heel contained 100 % black eschar when she discovered the pressure ulcer on 3/29/15. A physician's note, dated 3/30/15, indicated a decubiti on the left foot: "malleolus now with early ulcer formation at bony joint. 1 by 2 cm and heel with large 5 cm by 3 cm dk (dark) eschar (dead tissue) with inflammation around border." On 4/1/15, the resident was seen at the wound clinic. The wound clinic instructed the staff to keep all of the pressure off the resident left heel and outer ankle, "off-loading". The next visit to the wound clinic instructed LNs to keep the left ankle and heel pressure wounds dry and documented the wound healing would be a "long process". Review of the facility's policy dated 2006 and titled "Decubitis Care'", and the "Pressure Ulcer Record" form did not include all Staging for Pressure Ulcers to provide LNs an assessment tool and procedure to track pressure ulcer development/care. On 4/14/15, the Director of Nursing (DNS) verified their current policy and tracking form for pressure ulcers documentation were not current in accordance to the regulatory guidelines for pressure ulcer assessment, prevention, monitoring and evaluation.

Based on interview and record review, the facility failed to implement abuse prohibition policies and procedures to protect 1 of 2 sample residents (1). Failure to recognize an allegation and immediately protect the resident resulted in Resident 1 experiencing psychological harm. Findings include: The facility's policy read: sexual abuse: any form of non-consensual sexual contact; also includes any sexual contact between staff and a client whether or not it is consensual. The policy indicated that employees that suspect abuse must immediately take the following actions: 1) Protect the victim: this includes removing the offender, provide emotional support, and 2) initiate an event report and 3) report to the DSHS suspected abuse of a vulnerable adult. RESIDENT 1: Resident 1 was admitted on July of 2014 with a spinal cord injury. Review of the progress note, dated 3/31/15, revealed the resident reported that a staff had kissed him. The note indicated he was "upset". The investigative report, dated 4/1/15, indicated that the staff member who kissed Resident 1 remained in the facility caring for other residents. The report revealed that not until 4/2/15 (2 days later) was the staff member removed from direct resident care. Documentation on the post event assessment indicated, that the day after the allegation of kissing was reported, Resident 1 was seen by the psychology staff. The note indicated Resident 1 was still "very upset". This report indicated Resident 1 was "anxious during the interview" and "his eyes appeared watery and his speech was rapid and pressured". The report concluded the resident was experiencing trauma from this event. On 4/7/15 at 3:10 p.m., during an interview with the Licensed Nurse B (LN B). When asked about the policy for an allegation of abuse, she stated the resident is protected, the state hot line (DSHS) is called, and the employee is removed from providing any resident care. LN B stated the change of command (COC) is called to complete the report. On 4/7/15 at 5 p.m., during an interview with the Nursing Assistant C (NAC C) who worked with Resident 1 when the resident made the allegation of a NAC kissing him, stated that the NAC remained working with other residents throughout the remainder of her shift. Review of the State Reporting Log with the administrator on 4/7/15 at 2 p.m., stated the entry for Resident 1 dated 3/31/15 was a possible allegation of abuse. She stated a protection plan was initiated for Resident 1 and the employee was to have "no contact" with Resident 1. The administrator stated that the employee continued to work on the other side of the building with other residents with supervision. She verified that when she found out how Resident 1 felt about it (the kissing), she took it seriously. Failure to follow their abuse prohibition procedure placed Resident 1 and other residents at risks for further incidents of possible unwanted behaviors.

Based on observation, interview and record review, the facility failed to ensure that interventions were utilized to reduce hazards and risks associated with the use of mechanical lift devices (Hoyer Lift). Failure to properly use and follow safety precautions for the use of the Hoyer lift resulted in injury to one (Resident #1)of 5 sampled residents who require the use of a lift device for transfer. Failure to follow proper safety precautions when using lift devices places Residents at risk for injury and decreased quality of life. Findings Include: Resident #1 was admitted to the facility with profound mental retardation. She was unable to ambulate and was non-verbal. She required use of the Hoyer lift for all transfers. On 01/15/2013 at 3:00 PM, Staff J attempted to transfer Resident #1 using the Hoyer lift. The facility investigation revealed that Staff J was attempting to transfer the Resident alone without assistance. During this attempted transfer, the Resident fell to the floor. The fall resulted in multiple injuries to the Resident including bruises to her face and shoulder, concussion, and a femur fracture. A review of the incident investigation revealed that Staff J reported that the Resident had hit her head on the Hoyer lift and the left rear wheel on the Hoyer lift was loose which caused the lift to tilt. Staff J did not report that she fell to the floor, which caused a delay in treatment . (See F 282). A review of her care plan dated 10/18/2012 revealed that she was to be a two person assist for lifts with the Hoyer and " follow OT guidelines for lifting, transfers and positioning. " The care plan also states " Impaired Mobility, non- ambulatory: Transfers by 2-person Hoyer lift. " In an interview with Staff A, B and D on 01/30/2013, all stated that it was the facility policy that transfers using the Hoyer lift be done by two people for the safety of the resident. Staff A and B stated that when the event was discovered, the lift in question was removed from service, checked by the therapies supervisor and found to be in good working order. On 01/30/2013 at 12:45 PM an inspection of all Hoyer lifts in the Birch building was made with Staff F. All lifts and slings were clean, intact, and in good working order. The facility failed to consistently maintain a safe environment which caused Resident #1 to sustain injuries from a fall from a mechanical lift. .

Based on interview and record review, the facility failed to have a system in place to ensure that its policies and procedures regarding reporting of possible abuse and neglect were implemented for 1 of 6 residents sampled (Resident #1). Two facility staff (Staff I, J) had direct observation and knowledge of a fall with injury for Resident #1, and failed to report the fall with injury to the appropriate personnel for prompt medical care. Failure to implement abuse and neglect policies and procedures placed Resident #1, as well as other vulnerable residents at risk for unreported and further injury, abuse and/or neglect . Findings Include: POLICIES AND PROCEDURES According to record review on 01/30/13, the facility's policy and procedure for abuse and neglect prohibition included clear description of who staff should report possible abuse/neglect/injury incidents to. However, the facility "Detection and Prevention of Abuse and Neglect" Standard Operating Procedure dated 12/01/11, did not evidence what management was doing to ensure that facility staff were correctly implementing the information on which they were trained. There was no evidence that the facility's prevention program focused on management responsibility to prevent abuse/neglect/failure to report injuries such as the inclusion of factors: ensurance of supervision of staff providing care on shifts in the afternoon and evening in each building. STAFF KNOWLEDGE OF FALL WITH INJURY According to observation, interview and record review, Resident #1 was diagnosed with [REDACTED]. Resident #1 was unable to ambulate and was confined to bed and wheelchair. Record review of the facility investigation dated 01/16/13 revealed,that on 01/15/2013 staff J and I, CNA's (Certified Nursing Assistants) providing care to Resident #1, reported that while transferring Resident #1 from bed to wheelchair, Resident #1 was hit in the head on the mechanical lift (a sling device used for transferring or moving residents). According to the documentation, Resident #1 developed a bump on the right side of the head. Further record review of a facility report dated 01/16/13 revealed, Staff I came forward a day later after the initial injury, to report Resident #1 had not simply hit the head on the mechanical lift, but had actually fallen to the floor as Staff J (a CNA who trains other facility CNA's according to interview of Staff D), was attempting to transfer Resident #1 alone. Additional injuries found on 01/16/2013 revealed the Resident had two bruises on the right eye lid, one bruise on her shoulder and a swollen left knee which was later determined to be a fractured femur (the long bone in the top of the leg). The event was not initially investigated on the day of the incident 01/15/13 by the facility staff to rule out abuse/neglect, and was not reported to facility personnel in a timely manner. The facility failed to take action to prevent Resident #1 from further harm related to injury from incorrect staff handling due tofailure by facility staff to report the incident until a day later. According to the documentation, Staff I and J failed to report an actual incident had occurred during care and improper transfer by Staff J when using the mechanical lift alone resulting in a fall to the floor. This failure prevented a timely and accurate assessment and medical care for head and fracture injuries discovered later on Resident #1. Failure of 2 facility staff to report the accurate facts related to the fall with injuries of Resident #1, and the facility failure to ensure proper reporting of resident injuries placed the resident and other vulnerable residents at risk for further abuse/neglect/injuries and harm that could also be unreported. (Refer to F 282 and 323).

Based on interview and record review, the facility failed to ensure that staff demonstrated the actions of qualified care givers by failing to follow the plan of care, and failing to follow established procedures for the use of the mechanical lift device (Hoyer Lift) for one (Resident #1) of 5 sampled residents who require the use of the lift for transfers. Failure to follow the established plan of care and proper procedures for use of the lift resulted in injury, pain, discomfort, and delay in injury treatment for [REDACTED]. Findings include: Resident #1 was admitted to the facility for profound mental [MEDICAL CONDITION]. She was unable to ambulate or communicate. She was confined to her wheelchair or bed and required extensive assistance for ADL care. The Resident had no history of pain. The Resident ' s care plan dated 10/18/2012 stated the she was totally dependent and was a two person assist for transfers using the Hoyer lift. This care plan was posted for staff review and Staff I and J had signed that they had reviewed it. The facility investigation showed that on 01/15/2013 at approximately 03:30 PM, Staff J, CNA (Certified Nursing Assistant) attempted a transfer of Resident #1 from her bed to her wheelchair using a Hoyer lift. He was attempting to perform the transfer alone, without assistance. During the transfer, the Resident fell to the floor. Staff J called for help and Staff I, CNA responded. Staff J and Staff I placed the Resident back into her bed. It was reported by staff to the LN (Licensed Nurse) that the Resident had bumped her head on the lift as she was being transferred. The LN documented the Resident had a bump on the right side of her forehead. Staff I or J did not report to the LN on duty that the Resident had fallen onto the floor. (See F 226). On 01/15/2013 at 04:00 PM a review of the nursing notes revealed the resident was " currently lying in bed, screaming off and on " and had a " bump " on her forehead. " The nurse ' s notes revealed the Resident was experiencing ongoing pain. On 01/15/2013 at 9:45 PM the LN documented the Resident had a bruise on her right eye. On 01/16/2013 at 12 AM, the resident was found to have a bruise on her right shoulder. At 05:15 AM the LN notes state " staff making rounds noticed client has a swollen L. knee .... and it hot, red, swollen tender, shiny skin. " The Resident was also noted to be " uncomfortable " and had developed a fever of 101.5 F. At 06:30 AM a knee x-ray was obtained showing a femur fracture. 01/16/2012 at 11:35 the Resident was sent to the hospital and was found to have multiple bruises, a concussion, and a femur fracture. On 01/30/2013 in interviews with Staff A, Director of Nursing, Staff B, Administrator, and Staff D, CNA supervisor, all stated that the facility requires a two person assist for using the Hoyer lift devices and any falls should be reported immediately. Failure of the staff to follow the plan of care for this Resident resulted in multiple injuries and placed other residents at risk of injury and harm. Staff J failed to demonstrate the action of a qualified CNA when he created a hazardous environment for Resident #1. .

Based on observation, interview and record review, the facility failed to provide adequate prevention of an avoidable accidental fracture injury for 1 of 4 residents reviewed (Resident #1). Findings include: Record review of facility medical records on 12/31/12 revealed, Resident #1 had [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 was totally dependent on facility staff for transfer by 2 people, totally dependent on 1 person for locomotion in the wheelchair, hygiene, dressing, eating and incontinence. Record review on 12/31/12 revealed, Resident #1 sustained a fracture of the great toe on the left foot in the facility that was identified by the facility staff on 12/18/12. According to the facility "5 Day Investigation" report, Resident #1 had bruising on the left great toe and foot that extended across the base of 4 toes totaling 3.25 inches. According to the "Final X-ray Report" dated 12/19/12, Resident #1 had a displaced avulsion fracture from the corner of the left great toe extending to the joint surface. The facility "Health Care Notes" dated 12/18/12 noted, "bruise left foot from apparent trauma" and "left toes 1st to 4th toe bruises with purple color with slight edema" . The "physician progress notes [REDACTED]. The facility staff failed to ensure Resident #1, who was totally dependent on facility staff for all care and activities of daily living, was safe from injury during care and activities of daily living which resulted in a fractured toe. Observation on 12/31/12 at 10:45 a.m., revealed a slight light purple area on top of the left great toe still apparent 13 days later. Interview of Staff A on 12/31/12 at 10:15 a.m., confirmed the facility did not know how the substantial injury of the fractured toe occurred, and the facility surmised it may have occurred during a Hoyer lift transfer. In an interview of Staff B on 12/31/12 at 10:45 a.m., Staff C also confirmed Resident #1 was totally dependent for transfer with a Hoyer lift and 2 people, and totally dependent on staff for all mobility including when in the wheelchair. Interview of Staff C on 12/31/12 at 10:50 a.m., revealed Staff B saw the injury on Resident #1's left great foot on 12/19/12, and it was dark purple on the toe as well as around the foot and on other toes with some swelling. Staff B confirmed Resident #1 is transferred by Hoyer lift with 2 staff members and is totaling dependent for all mobility including when in the bath gurney and when in the wheelchair. Staff C also confirmed Resident #1 does not wear shoes and wears slippers over socks when out of bed. Observation on 12/31/12 at 10:45 a.m. revealed the area around Resident #1's bed contained a 5 drawer wood dresser and hard edges on the resident's bed when the gate was in the low position for transfers by the Hoyer. A demonstration of the 2 person Hoyer lift by Staff B and Staff C with Resident #1 revealed the resident swings in the sling and 1 person must hold the legs to keep Resident #1 from bumping body/feet on objects in the area. Observation on 12/31/12 at 11:05 a.m., revealed Resident #1 seated in a padded wheelchair in the common area wearing soft boot slippers on both feet rested in the padded footrests of the chair. Resident #1's feet were rested on the footrests with great toes extended out about 2 inches beyond the footrest leaving the toes vulnerable to possibly being bumped on any surface when wheeled by staff throughout the facility for daily activities and meals. Record review of the facility "Care Plan" dated 11/27/12 for Resident #1, noted a problem for potential for injury related to osteoporosis, goal to have no fractures, and interventions including: staff will use gentle care in transfers, repositioning; total dependence for bed mobility, Hoyer transfer, and locomotion in wheelchair. Further record review revealed an "Occupational Therapy Assessment" dated 07/03/12 that stated, "Resident #1 has had the ability to roll from a supine to prone, and assume sitting on his knees and feet, but has not displayed these skills this past year...the resident is unable to stand or propel wheelchair with feet." Further record review of the facility investigation on 12/31/12, revealed staff statements: "when 2 people use the Hoyer lift, one person holds the legs and the other person moves the Hoyer. If this is not done properly, (Resident #1's) legs will get dropped ...something must have happened.. the Hoyer might have hit the side of the wheelchair or the resident's feet were not held properly ...maybe hit on side of bed or on armrest of wheelchair, if staff not used to the Hoyer it can move unexpectedly....all evening staff agree something happened ...maybe during a transfer". The facility staff failed to provide adequate accident prevention for Resident #1, which resulted in a fracture of the left great toe, a substantial injury with harm to the resident while Resident #1 resided in the facility totally dependent on staff for all care and activities.