Every finding on record at Park Manor Rehabilitation CTR

Based on observation, interview and record review, the facility failed to ensure the food was palatable and served at a safe and appetizing temperature and in a timely manner for 6 of 9 residents (Residents 51, 19, 4, 55, 45 and 19) reviewed for food. This failure placed residents at risk for food-borne illness, dissatisfaction with meals, and inadequate nutritional intake. Findings included.Review of the Washington State Food Code, dated 03/01/2022, showed long-term care facilities must comply with the food code for temperature control, while meeting specific resident care requirements. Facilities must provide nourishing, palatable meals that were attractively served and adjusted to residents' preferences and needs. Further review showed food must be held at 135 degrees Fahrenheit (F-unit of measure) or above for hot holding or below 41 degrees F for cold holding, minimizing time in the dangerous zone (the temperature range where harmful bacteria multiply fastest on perishable foods) of 41 degrees F to 135 degrees F. Resident 51 Review of the medical record showed Resident 51 was admitted to the facility with diagnoses including a right below the knee amputation and diabetes (excess sugar in the blood). The 02/17/2026 comprehensive assessment showed Resident 51 required the assistance of one to two staff for activities of daily living (ADLs-activities related to personal care) and had an intact cognition. Resident 19 Review of the medical record showed Resident 19 was admitted to the facility with diagnoses including heart and kidney disease. The 03/11/2026 comprehensive assessment showed Resident 19 required the assistance of one to two staff for ADLs and had intact cognition. Resident 4 Review of the medical record showed Resident 4 was admitted to the facility with diagnoses to include diabetes and eating difficulties. Review of the comprehensive assessment dated [DATE], showed the resident was dependent on a staff member to assist with meals and their cognition was intact. Resident 55 Review of the medical record showed Resident 55 was admitted to the facility with diagnoses including Parkinson's disease (a progressive movement disorder that causes tremors, stiffness and impaired balance) and anemia (a deficiency in red blood cells). Review of the 04/20/2026 comprehensive assessment showed Resident 55 was independent for eating and had intact cognition. Resident 45 Review of the medical record showed Resident 45 was admitted to the facility with diagnoses including heart failure, kidney disease and chronic pain. Review of the 02/11/2026 comprehensive assessment showed Resident 45 required set-up assistance of one staff member for eating and had an intact cognition. Resident 71 Review of the medical record showed Resident 71 was admitted to the facility with diagnoses including myocardial infarction (a lack of oxygen to the heart that causes damage or death to the heart) and diabetes. Review of the 10/21/2025 comprehensive assessment showed Resident 71 required the assistance of one to two staff members for ADLs and had an intact cognition. During a resident council meeting (a formally organized, independent group of residents who meet regularly to advocate for their rights, voice concerns, and plan activities) on 05/12/2026 at 1:33 PM, Resident 51 stated their food was consistently cold when served to them in their room, located on the west hall of the facility. They stated their meals were always cold because the west hall was the last to be served from the kitchen. Resident 51 stated there were scheduled mealtimes, but the times they actually received their meals varied greatly. At 1:40 PM, Resident 19 stated the meals were always cold by the time the west hall received their trays. Resident 19 stated it didn't seem fair that the south hall and south dining room of the facility always got their meals served fresh and hot from the kitchen while the west hall was always served last. They stated their food was consistently served cold. During an interview on 05/11/2026 at 11:32 AM, Resident 55 stated their food was lukewarm at best. Resident 55 stated they were last to be served, as their room was at the end of the west hall. Resident 55 stated the meal serve out times were varied and not consistent. During an interview on 05/11/2026 at 12:06 PM, Resident 45 stated their meals were served late, the food was cold, and the facility was aware of the problem. During an observation on 05/11/2026 at 12:24 PM, showed the meal cart was delivered to the west hall. At 12:46 PM, the last meal tray was delivered to the residents, 22 minutes after the meal cart was delivered to the west hall. The meal cart was a non-insulated steel cart with doors accessible on both sides of the cart and were not shut completely after each meal tray was obtained. During an interview on 05/11/2026 at 3:15 PM, Resident 4 stated the steak served was so tough, they could not chew it, the food was served cold and was just not fit to eat. During a concurrent observation and interview on 05/13/2026 at 11:17 AM, Staff E, Cook, observed the kitchen staff serve out the lunch meal. They stated they took food temperatures when they were plating the food and documented them on a form used in the kitchen but did not check the temperatures again after the residents were served. During an observation on 05/13/2026 at 12:32 PM, showed the first meal cart was delivered to the west hall and delivery was completed at 12:43 PM. The second meal cart was delivered to the west hall at 12:48 PM. The meal cart doors were not shut completely after each meal tray was obtained. Observation of test trays requested on 05/13/2026 at 12:32 PM, showed Staff E used an oven safe dial thermometer when they obtained the temperatures of the test trays prior to leaving the kitchen. The temperatures were as follows: chicken patty temperature of 140 degrees F, rice pilaf of 125 degrees F, steamed mixed vegetables at 136 degrees F, and the alternative meal, the haystack (loose lettuce with chili and corn chips) at 125 degrees F. At 12:46 PM, Staff D, Dietary Supervisor, obtained the temperatures of the test trays once all resident trays were served. Staff D used an oven safe dial thermometer and obtained the following temperatures: chicken patty temperature of 110 degrees F, rice pilaf of 105 degrees F, steamed mixed vegetables of 110 degrees F, and the haystack of 99 degrees F. Staff D stated they did not understand how the food temperatures could have dropped so much, as the food was steaming when plated. They stated the temperatures must be off. During an interview on 05/13/2026 at 12:39 PM, Resident 51 stated they ate their lunch in the North dining room because they get their lunch an hour earlier than when they had lunch in their room and they did not want to wait to eat later or have cold food. During a taste testing of the test tray by the surveyors on 05/13/2026 at 12:56 PM, the chicken patty was cold in the center and had a bland, rubbery and freezer-burned aftertaste to it. The rice pilaf was cold, plain and stale (lacked freshness), the vegetables were cold and bland, and the alternative meal, the haystack, had canned chili beans on it that were cold to eat. During on observation on 05/13/2026 at 5:11 PM, showed the south hall meal cart had been delivered and the last meal tray was being served. At 6:01 PM, the west hall meal cart had been delivered, 50 minutes after the south hall residents were served. During an interview on 05/14/2026 at 1:49 PM, Resident 71 stated the food was cold, unappealing, and tasted like cardboard. Resident 71 stated meals were served at inconsistent times, despite the scheduled times for meals. During an interview on 05/15/2026 at 8:32 AM, Staff A, Administrator stated they were aware of the inconsistent food temperatures and would be discussing it with the team to find a better process. Staff A stated they do have some things to fix. Reference: WAC 388-97-1100(1)(2)

Based on interview and record review the facility failed to implement their abuse prohibition policy/procedures to identify, investigate, and report allegations of abuse/neglect for 5 of 8 residents (Residents 82, 71, 4, 33, and 77) reviewed for grievances. This failure placed the residents at risk of continued abuse/neglect, emotional distress, feeling unsafe, loss of dignity and unmet care needs. Findings included. Review of the facility policy titled, Abuse Prevention and Reporting, revised 10/2025, showed residents had the right to be free from abuse, including the failure to provide basic care/services, physical, verbal, and mental abuse. The policy showed all suspected allegations would be thoroughly and completely investigated and reported to the State Agency (SA). Resident 82 Review of the medical record showed Resident 82 was admitted to the facility with diagnoses including chronic kidney disease (a long-term condition where the kidneys are damaged and lose their ability to filter waste and excess fluid from the blood). Review of the 04/07/2026 comprehensive assessment showed Resident 82 was cognitively intact and required the assistance of one staff member with activities of daily living (ADLs). Review of a facility grievance form dated 01/06/2026, showed Resident 82 stated a Nursing Assistant, (NA), was rough during a brief change. The grievance showed Resident 82 stated they told the NA they did not need to be so rough during their care and did not want them to provide further care for them. Further review showed despite the allegation of abuse, the facility did not escalate the grievance and report to the SA. During an interview on 05/15/2026 at 9:15 AM, Resident 82 stated an NA, came in to change their brief during the night shift and was rough. The resident stated they reported the incident and it felt like they were trying to clean a toilet or something, it really hurt. Resident 71 Review of the medical record showed Resident 71 was admitted to the facility with diagnoses including myocardial infarction (a lack of oxygen to the heart that causes damage or death to the heart), diabetes (excess sugar in the blood) and obstructive sleep apnea (OSA-a sleep disorder with breathing interruptions that causes airway blockage). Review of the 10/21/2025 comprehensive assessment showed Resident 71 required the assistance of one to two staff members for ADLs and had an intact cognition. Review of a facility grievance form dated 11/04/2025, showed Resident 71 felt the NA was rude, hurried and did not provide care in a personal manner. The grievance showed Resident 71 stated the NA nearly took their lips off, when the NA placed their OSA mask on, and they requested the NA not provide any additional care for them. There was no record of a facility investigation or report made to the SA, regarding the allegation of abuse. During an interview on 05/14/2026 at 1:49 PM, Resident 71 stated the incident with the NA was rushed and felt they did not want to provide any cares for them. Resident 71 stated they did not know a grievance form was completed and did not state the NA needed customer service training. Resident 71 stated they received no response from the facility. Resident 4 Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including heart failure, diabetes, and a stroke (a medical emergency that occurs when blood flow the brain is disrupted and deprives the brain of oxygen, leading to brain damage, disability or death). Review of the 11/24/2025 comprehensive assessment showed Resident 4 was dependent on one to two staff members for ADLs, including eating, and had an intact cognition. Review of a facility grievance form dated 12/05/2025 showed Resident 4 was being assisted during a meal when the NA shoveled food into their mouth and they felt they were choking. Resident 4 did not want the NA to provide cares for them. Further review of the grievance showed Resident 4 did not like the NA and the NA would complete a training module on customer service. There was no record of a facility investigation or report to SA regarding the allegation of abuse. Resident 33 Review of the medical record showed Resident 33 was admitted to the facility with diagnoses including pneumonia (a respiratory virus infecting the lungs making it hard to breathe), heart failure and malnutrition. Review of the 01/27/2026 comprehensive assessment showed Resident 33 required the assistance of one to two staff members for ADLs and had a moderately impaired cognition. Review of the facility grievance form dated 01/28/2026 showed Resident 33 needed to use the restroom and was told by an NA you literally went 15 minutes ago; can you hold it? The grievance showed Resident 33 said they could not and the NA reluctantly assisted them. Resident 33 felt they should not have been questioned when they needed to use the restroom. Further reviews showed there was no facility investigation or report made to the SA after the allegation of abuse. Resident 77 Review of the medical record showed Resident 77 was admitted to the facility with diagnoses including a displaced fracture of the left hip and aftercare for a left hip replacement surgery. Review of the 04/17/2026 comprehensive assessment showed they were cognitively intact and required assistance from one to two staff members to transfer from one seated or lying position to another. Review of Resident 77's admission physician orders dated 04/15/2026 showed not to bend the hip past 90 degrees, cross the leg, turn on the left foot, or point the toes inward to prevent dislocation. Review of a facility grievance form dated 04/17/2026, showed Resident 77 had requested assistance to use the bathroom around dinnertime on 04/15/2026. The NA that assisted Resident 77 rushed them to the bathroom, grabbed the left surgical hip area and caused Resident 77 to yell out and was too rough. Resident 77 stated the NA would not listen when they told the NA they were hurting them. Further review of the grievance form showed no facility investigation or report made to the SA after the allegation of abuse. During an interview on 05/13/2026 at 4:59 PM, Resident 77 stated the NA seemed rushed and wasn't moving them correctly causing them so much pain that they yelled out for the NA to stop. Resident 77 stated the NA would not listen to them and continued to manhandle them to the toilet. Resident 77 stated they were frightened the NA was going to dislocate their newly fixed hip. Resident 77 stated they reported to the facility because the NA had hurt them and believed if the NA did that to them, they must be doing it to others and wanted to ensure the staff were aware and watchful of the NA. Further review of the grievance form showed the facility did not escalate the grievance regarding an allegation of abuse and perform a thorough investigation and report to the SA. During an interview on 05/14/2026 at 3:02 PM, Staff C, Social Services Director, stated the grievance process was when a resident had a complaint the resident would be provided a grievance form to fill out, or the facility would complete one for the resident. Staff C stated depending on the reported concern/complaint, they would proceed with additional questions to the residents and when needed escalate to the department head for the complaint. Staff C stated when the grievance was more than rude staff member, they would ensure the Assistant Director of Nursing or Director of Nursing was made aware. Staff C stated when the facility did not believe the grievance to be an allegation of abuse, they would still need to report to the SA and complete an investigation. During an interview on 05/14/2026 at 3:30 PM, Staff B, Director of Nursing, stated when grievances were about abuse/neglect they would be made aware. Staff B stated grievances regarding resident concerns with rough care or rude statements made by staff to the residents could be abuse or neglect. Staff B stated they would discuss the concern with Staff A, Administrator and Staff C, ensure the residents were safe, suspend the staff member, complete a facility investigation and report to SA. Staff B stated this process was not followed for the allegations of abuse and neglect. During an interview on 05/14/2026 at 3:58 PM, Staff A stated the grievances could be allegations of abuse/neglect and the facility should have escalated the incidents, fully investigated them, and reported to the SA. Staff A stated the facility abuse prohibition policy was not followed. Reference WAC: 388-97-0640(1)(2)(b)(3)(a)(c)(5)(6)(a)

Based on observation, interview, and record review, the facility failed to 1) assess for a change in condition related to increased shortness of breath and weakness for 1 of 3 residents (Resident 56), and 2) consistently follow physician orders to prevent constipation (unable to pass stool regularly, that eventually becomes hardened) for 1 of 3 residents (Resident 71) both reviewed for quality of care. Resident 56 experienced harm when their bowels became impacted (when you're unable to regularly pass stool or feces and it backs up inside your colon), pain, and required a hospital intervention for relief. This failure placed all residents at risk for delay of treatment, unmet care needs, and negative health outcomes. Findings included . Review of a policy titled, Best Practice in Change of Condition and Endorsement, dated 05/2016 showed when a change in condition was recognized for the ability to eat or drink, changes in weight/intake, or had a change in their medical condition they would be placed on a 24 hour report with no less than 3 days of documentation and an attempt to identify the cause of decline. The physician, resident, and resident responsible party would be notified, and the Director of Nursing Services (DNS) would review the changes for any needed follow-up. Review of the policy titled Bowel Protocol, dated 03/25/2025, showed when a resident did not have a BM in three days (nine shifts) the Licensed Nurse (LN) would implement the bowel protocol: Shift one, administer Milk of Magnesia (MOM, a brand of medication that stimulates the bowels), may administer two additional shifts if no results; If no results after the MOM, the next shift administer a Bisacodly suppository rectally (a brand of medication that stimulates the bowels); if no results in two to three hours; Administer a saline enema rectally (Fleets, a brand of medication that stimulates the bowels, if no results in two to three hours notify the provider for additional instructions. Review of a policy titled Bilevel positive airway pressure and Continuous positive airway pressure [Bipap/CPAP, machines that use pressure to push air into the lungs], dated 05/2007, showed when a resident admitted with a bipap machine there would be a physician's order, the machine settings were to be verified, and if any changes, notify the provider. The policy additionally showed the resident would be reassessed as needed for changes in their condition. <Resident 56> Review of the resident's medical record showed they admitted on [DATE] with diagnoses to include a stroke (when blood and oxygen to the arteries in the brain become blocked by a blood clot), diabetes (lack of sugar in the blood), and kidney disease. The comprehensive assessment dated [DATE] showed Resident 56 had moderately impaired cognition, required substantial to maximum assistance for toileting and transfers, and was continent of their bowels. During an interview on 03/24/2025 at 12:00 PM, Resident 56 stated they had recently visited the hospital due to a bowel blockage [constipation]. Resident 56 stated their constipation caused them pain while trying to push out the hardened stool, so they needed to be sent to the hospital (03/14/2025) due to the pain. Review of Resident 56's Medication Administration Records (MAR) from January 2025 through March 2025 showed: Orders on 01/23/2025 for the bowel protocol, and Miralax (a brand of medication for constipation) daily as needed for constipation (as needed [PRN] Miralax had not been administered in January, February, or March 2025). Order on 03/12/2025 for Miralax daily for constipation and then changed on 03/14/2025 to three times daily for constipation. Review of Resident 56's bowel tasks (a record that showed how often the resident had a BM and what the size of the BM's were) showed: 01/23/2025 evening shift through 01/28/2025 day shift, five days and one shift with no BM (the PRN MOM and Miralax were not administered per orders). 01/30/2025 evening shift through 02/07/2025 evening shift, eight days and two shifts no BM (two shifts showed no documentation) (the PRN MOM, Bisacodyl, Enema, and Miralax were administered per orders). 02/10/2025 night shift through 02/17/2025 day shift, six days and two shifts no BM (the PRN MOM, Bisacodyl, Enema, and Miralax were not administered per orders). 02/27/2025 day shift through 03/03/2025, four days and one shift no BM (the PRN MOM and Miralax were not administered per orders). 03/03/2025 night shift through 03/11/2025 night shift, seven days and two shifts no BM (the PRN MOM, Bisacodyl, Enema, and Miralax were not administered per orders). During an interview on 03/27/2025 at 12:04 PM, Staff K, Registered Nurse, stated when a resident was having constipation issues, they would notify the doctor for further orders. Staff K stated there was a clinical alert (a warning that appeared in the Resident's Electronic Health Record [EHR] that alerted LNs there needed to be an intervention) in the resident's EHR that would automatically alert the LNs when a resident had not had a BM in three days, and at that time they would start the bowel protocol. During an interview on 03/27/2025 at 5:56 PM, Staff B, DNS, stated they expected LNs to discuss recurring constipation with residents. Staff B stated the residents should be asked what their normal patterns were, what they have used in the past that helped, and then discuss those findings with the provider for better bowel management. Staff B stated after three days without a BM the LNs should have implemented the facility bowel protocol and would follow each step each shift, not each day, when there were no results. Staff B stated they expected the LNs to start assessing bowel tones, abdomen distention, and pain after the nine shifts without a BM. Review of Resident 56's clinical alerts from 01/23/2025 to 03/27/2025 showed there were 29 shift alerts that showed Resident 56 had not had a BM in three or more days. Review of nursing progress notes dated 03/14/2025 showed: 7:17 AM a PRN MOM was administered related to no BM in three days, 8:45 AM a PRN Bisacodyl was given due to difficulty having BM, 9:37 AM Resident 56 had been yelling out in discomfort because they were constipated. The note showed the Medical Director (MD) had been at the facility and gave orders to administer the Fleets enema and if no results administer a half a bottle of Magnesium Citrate (a brand of liquid medication that stimulates the bowels) and notify the provider if no results. 3:16 PM Resident 56 had a couple small hard BMs and reported pressure pain in their rectum. The Contracted Advanced Registered Nurse Practitioner (ARNP) assessed Resident 56 to be impacted. The ARNP ordered a second Fleets enema to be given, not to administer the Magnesium Citrate ordered earlier, and if no results, send to the hospital. 5:47 PM showed Resident 56 was sent to the hospital for evaluation due to their pain from trying to pass the hard stool. Review of the 01/23/2025 Care Plan (CP) showed Resident 56 experienced constipation related to decreased mobility. The CP showed no documented history, normal bowel patterns, or what the resident normally used to assist them with their constipation. Review of the 03/14/2025 hospital notes showed Resident 56 had a bowel impaction and required digital disimpaction (a medical procedure used to manually remove stool from the rectum, with a gloved finger, to break up and remove trapped stool. Typically performed when other methods of relieving constipation or fecal impaction have failed). Review of additional documentation provided by the facility, dated 12/12/2024 (prior to admission), showed Resident 56's Primary Care Provider documented the resident managed their constipation effectively by using dark chocolate (which was not documented or care planned). Review of the ARNP note dated 03/12/2025 (two days before being sent to the hospital), showed Resident 56 communicated they had chronic constipation and had several days without having a BM since being admitted to the facility. The ARNP gave new orders for Miralax to be given daily. Review of the ARNP note on 03/14/2025 (the day the resident was sent to the hospital), showed the LNs reported the resident experienced rectal pain and discomfort and Resident 56 had received PRN Bisacodyl and MOM that were ineffective. Per additional orders, the LN's administered the PRN Fleets enema and Resident 56 experienced pain and difficulty passing the stool, so the LN digitally removed some very hard stool. The note showed that later in the day Resident 56 yelled out for help and was having pain and was ordered to be sent to the hospital for evaluation. During an interview on 03/28/2025 at 2:44 PM, the MD stated they were notified of Resident 56's constipation issues in passing (while they were in the facility to see another resident) on 03/14/2025 and ordered a second Fleets enema to be given. The MD stated they had not been notified of Resident 56's constipation issues prior to 03/14/2025. <Resident 71> Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses of respiratory failure with hypoxia (when you don't have enough oxygen in your blood from a lung or heart disease), pneumonia (a bacterial infection in the lungs), malignant cancer (when some of the body's cells grow uncontrollably and spread to other parts of the body) of the liver, right eye, and their bile duct, and sleep apnea (a condition that makes you stop breathing while you're sleeping). The 03/15/2025 comprehensive assessment showed Resident 56's cognition was intact and required substantial to maximum assistance with bed mobility and transfers. During a concurrent observation and interview on 03/24/2025 at 2:26 PM, Resident 71 was lying in bed., While the resident was speaking, they appeared short of breath, taking deep breaths in and out, while blowing out of their mouth in between words. Resident 71 stated they were tired and weak and had been on chemotherapy (a medicated treatment for cancer [a disease in which cells grow uncontrollably and spread to other parts of the body]). Resident 71 stated they had not felt tired and weak before but that had resolved with the pneumonia. Resident 71 stated the LN had been in to check their oxygen levels and they were okay. Additionally, there was a blue square medical equipment bag sitting on the nightstand to the right side of the resident (later referenced as a bipap machine). During an observation and concurrent interview on 03/25/2025 at 9:47 AM, showed Resident 71 lying in bed and continued to present with shortness of breath when talking, experienced nausea (a feeling of sickness in the stomach that could lead to vomiting) and had no appetite. Observed on the nightstand beside the bed was the blue medical equipment bag seen on 03/24/2025. Resident 71 stated the bag contained their bipap machine, but they were not using it because they were having issues. Resident 71 stated they had problems with the mask leaking so they were given a new mask and then the resident stated they did not have the energy to apply the mask at night themselves and did not receive offers to assist them with it so had the staff pack the machine back up. During an observation and concurrent interview on 03/26/2025 at 9:23 AM, Resident 71 was sitting upright in bed and stated they did not have therapy the day before because they were too weak and tired. Resident 71 also stated they had nausea, and did not eat breakfast because they felt sick. Resident 71 stated they did not have pain in their mouth but that it was really dry and were observed to be short of breath and mouth breathing in between words. The bipap machine was observed unpacked from the blue bag and the mask straps were hanging up on a hook on the wall. Resident 71 stated they did not use the mask because the straps needed to be washed and were not dried. Resident 71 stated they had a very dry mouth and would require a drink of water every fifteen to twenty minutes and was asking the staff to constantly come in to replace the mask and this made them feel bad, so stopped asking for assistance or using the machine. Staff K entered the room and stated Resident 71's pneumonia had resolved, but they were recently being treated for thrush (a yeast infection that can grow in your mouth, throat and other parts of your body). During an interview on 03/27/2025 at 12:11 PM, Staff K stated the LNs received orders from the hospital for equipment residents would bring from home. Staff K stated the bipap machine had a preset setting and they would ask the resident or family who their sleep specialist was if they had issues. Staff K stated Resident 71 did not normally complain of being tired and weak and had not been told they were, nor was the resident normally short of breath. Staff K stated they knew the resident had experienced nausea and recently had their nausea medication increased but did not know why the resident had nausea. Staff K stated they had not tried to contact Resident 71's Oncologist (a cancer specialist) to inform them of the resident's shortness of breath, loss of appetite, nausea, or weight loss, nor were they able to verbalize what chemo medication they received or what those side effects to monitor were. Staff K stated they were not aware Resident 71 was not using their bipap machine. During an interview on 03/27/2025 at 2:30 PM, Resident 71stated they did not use the bipap machine the night before (03/26/2025) because they (staff) did not come in and put it on me. The resident stated they used their bipap machine since 2017 and always used it until now. Resident 71 stated they received chemotherapy (a type of cancer treatment that used medications to kill cancer cells) treatment every three weeks for their cancer and the last treatment was on 03/05/2025 and the next treatment was scheduled for 03/31/2025. Resident 71 stated they were not sure if they would follow through with the next treatment because the last one had made them so sick. Review of the March 2025 MAR showed an order on 03/13/2025 for an anti-nausea medication that was administered three times, once on 03/23/2025, and twice on 03/24/2025. Then on 03/24/2025, was an order to increase the anti-nausea medication. Review of the 03/13/2025 through 03/25/2025 Treatment Administration Records showed an order on 03/13/2025 to assist Resident 71 with applying the bipap machine at bedtime and as needed. The order showed the bipap had been applied nightly except for missing documentation for three of the 13 nights reviewed. Review of Resident 71's 03/13/2025 discharge hospital records showed the resident received a chemotherapy treatment on 03/05/2025 with a medication called Opdivo (a brand of cancer medication). Further review of the medication showed some of the medication's side effects consisted of shortness of breath, nausea and vomiting, weight loss, and skin rashes. Review of Resident 71's 03/13/2025 baseline CP showed no resident specific information for their cancer or their cancer treatment. The CP showed no information on the chemotherapy they received, the side effects, who their Oncologist was, or what to monitor. Additionally, the CP showed no resident specific information for use of the bipap machine, what the settings were, or if issues were to arise, who to contact. Review of Resident 71's progress notes showed on 03/19/2025 the Speech Therapist (ST, a specialist who diagnoses and treats communication and swallowing problems) communicated to the LN staff that Resident 71 had a thrush like rash on their tongue and the back of their throat. The note showed the the nurse assessed and asked the MD (provider) to assess as well. Review of nursing progress notes showed: on 03/20/2025 showed Staff K documented they did not clean the bipap mask because did not use. on 03/23/2025 showed the Resident received a new order for an antifungal medication for treatment of Resident 71's thrush (four days after the LN documented they assessed and notified the provider). on 03/25/2025 showed that the [Resident 71] not feeling well so refused their medications. review of the notes showed no assessment of the resident's difficulty breathing (other than clear lung sounds) when talking, increased tiredness and weakness, or why the resident had been experiencing nausea. The records further showed no notification had been made to the Oncologist and Sleep Specialists. During an interview on 03/28/2025 at 2:44 PM, the MD stated the facility or MD had received information on Resident 71's chemotherapy medication or what to monitor after receiving that medication. The MD stated they had seen the resident on 03/13/2025 and again on 03/17/2025 and were aware of the nausea, weakness, and tiredness but it was just a wait and see if it improved. The MD had not been notified Resident 71 was not using their bipap machine. Reference: WAC 388-97-1060 (1)(3)(vi)

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on assistance for activities of daily living (ADLs, basic self-care tasks you do every day) received adequate showers/baths/bed baths, grooming, and oral care for 3 of 4 residents (Residents 41, 71, and 178) reviewed for ADLs. This failure placed the residents at risk for unmet hygiene needs. Findings included . <Resident 41> Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses to include a fracture of their right lower leg and right shoulder and diabetes (increased sugar in the blood). The 02/12/2025 comprehensive assessment showed Resident 41's cognition was moderately impaired and was dependent upon staff assistance for transfers and partial to moderate assistance from staff for bed mobility and personal hygiene. An observation and concurrent interview on 03/25/2025 at 2:09 PM, showed Resident 41 lying in bed, in a night gown and hair not combed. Resident 41 had a white hard shelled, clam shaped brace to their right shoulder and a walking boot on the floor at the end of their bed by the wall. Resident 41 stated they had only received one shower since their admission. Resident 41 stated they did not feel clean and they haven't asked me about a bath/shower, and I haven't demanded one. Resident 41 stated they were supposed to be receiving two showers a week and would be okay with a bed bath, but was lucky to get one, if any. Resident 41 stated during therapy they were told by the Occupational Therapist (OT, a health care professional who specializes in helping people with health issues that affect everyday activities) that they smelled like arm pits and it was embarrassing. Resident 41 stated the therapist removed their hard-shell brace and cleansed their shoulder and arm pit. Resident 41 stated it felt amazing. Review of Resident 41's shower documentation from 02/26/2025 through 03/26/2025 showed Resident 41 was to have received showers twice weekly on Sunday and Friday evenings per their preference. The shower schedule showed they had received two showers (03/07/2025 and 03/14/2025), one refusal (03/21/2025, with no supporting documentation in the progress notes), and the remaining documentation showed they had received a sponge bath or not applicable (N/A, did not apply to the resident). Other options to choose on the documentation showed a full-body bath which none of those had been given. During an interview on 03/26/2025 at 4:22 PM, Staff H, OT, stated Resident 41 did not have any restrictions with the shoulder brace or the walking boot while taking showers. Staff H stated the shoulder brace was a hard plastic and did not have to be removed for showers. Staff H stated they did have Resident 41 in for therapy a few weeks ago and Resident 41 required cleaning under their right shoulder brace. Staff H stated they removed the brace and cleansed the right shoulder and arm pit. Staff H stated after the therapy session they informed nursing staff that Resident 41 could have their braces removed for showers and if they needed assistance, they could ask, and they would assist them. Staff H stated no nursing staff asked about the braces or asked for assistance with Resident 41's showers. Review of an OT note on 03/07/2025 showed Resident 41 complained of significant discomfort of itching and skin hygiene issues to their right shoulder. The note showed the OT cleansed Resident 41's right armpit and shoulder and Resident 41 stated they were much relieved. The note showed Resident 41 communicated to the OT they had not had a shower since admission so the OT informed staff they were allowed to shower the Resident and remove the brace. The note showed later that day Resident 41 received a shower. <Resident 71> Review of the resident's medical records showed they admitted on [DATE] with diagnoses of respiratory failure, pneumonia (a bacterial infection in the lungs), and malignant cancer (when some of the body's cells grow uncontrollably and spread to other parts of the body) of the liver and the right eye. The 03/15/2025 comprehensive assessment showed Resident 71's cognition was intact and required partial to moderate assistance from staff with showers/bathing and substantial to maximum assistance from staff with transfers. An observation on 03/25/2025 at 9:43 AM, showed Resident 71 was lying in bed, hair uncombed and resident was wearing a hospital gown. An observation and concurrent interview on 03/26/2025 at 9:23 AM, showed Resident 71 was lying in bed, hair uncombed, not dressed. Resident 71 stated they had one shower since admission and were told they would receive two showers a week. Resident 71 stated the staff had not offered them a shower. Review of Resident 71's shower documentation from 03/13/2025 to 03/26/2025 showed Resident 71 received showers on Tuesdays and Fridays in the mornings per their preference. The documentation showed Resident 71 received one shower (03/18/2025), one refusal (03/14/2025 with no supporting documentation in the progress notes), and the remaining documentation showed they received a sponge bath or N/A. <Resident 178> Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses to include malignant cancer of the brain and aphasia (difficulty speaking or putting words together to form a sentence). The 03/21/2025 comprehensive assessment showed Resident 178's cognition was severely impaired and required substantial to maximum assistance from staff for bathing/showering and partial to moderate assistance from staff for dressing and personal hygiene. During an observation on 03/24/2025 at 2:39 PM, Resident 178 was lying in bed, dressed, hair was uncombed, fingernails were long in length with brownish/black debris under the fingernails. During an observation on 03/26/2025 at 9:35 AM, Resident 178 was lying in bed, their hair appeared greasy and uncombed, had built up white film in between their teeth, their glasses were smudged with fingerprints, and their facial hair and moustache were long and had white food crumbs stuck in it. Resident 178 was wearing a blue t-shirt and gray sweatpants (which later was identified to be the same clothes worn for multiple days). During an observation on 03/27/2025 at 11:48 AM, Resident 178 was lying in bed with their hair, teeth, nails, and facial hair in the same manner as they had on 03/26/2025. Resident 178 was wearing the same blue t-shirt and had a body odor. On the same day at 2:40 PM, Resident 178 was asked if they had their clothes changed today and they stated, as a matter of fact, I can absolutely say no, they have not changed my clothes today. Resident 178's Representative was at the bedside visiting and confirmed Resident 178 was wearing the same clothes as the previous day (03/26/2025). Review of Resident 178's shower documentation from 03/14/2025 through 03/26/2025 showed Resident 178 was to receive showers/baths on Monday, Wednesdays, and Saturday mornings per their preference. The documentation showed Resident 178 received two showers (03/20/2025 and 03/22/2025), a refusal of a shower (03/15/2025 with no supporting documentation in the progress notes) and all others were sponge baths or N/A. During an interview on 03/27/2025 at 11:50 AM, Staff L, Nursing Assistant, stated if the NAs documented a sponge bath, that would consist of cleaning them under the arm pits and washing their face and hands. Staff L stated they cut resident nails if the resident requested that or if they observed them needing to be cut but did not have a specific schedule for that. Staff L stated they would trim a resident's beard or moustache if the resident requested it, but they had themselves personally never asked a resident that question. Staff L stated the resident's clothes should be changed every morning and have their hair combed, teeth brushed, and then again if needed through out the day. Staff L stated they did not know why Resident 178 was not receiving bed baths or showers routinely. Staff L stated if a resident refused a shower/bath they would notify the LN, and the LN would talk with the resident. During an interview on 03/27/2025 at 12:36 PM, Staff M, Registered Nurse, stated when a resident refused a shower the NAs were to notify the LNs and the LNs would approach and try to see why the resident refused or if they could encourage them to take their shower maybe at a different time. Staff M then stated they were to document in the progress notes if the resident continued to refuse. During an interview on 03/27/2025 at 5:13 PM, Staff B, Director of Nursing Services, stated upon admission the residents were asked what their preferences were for bathing/showering and what their normal schedule was. Staff B stated the NAs used a daily shower board that was updated and reviewed frequently to ensure every resident was on the shower schedule. Staff B stated if a resident refused a bath/shower, the NAs should have notified the LN, and the LN should have made attempts to see why they refused and then documented the refusal. Staff B stated residents should have received showers at the least twice weekly and sponge baths and bed baths should not have been substituted for a shower/bath unless that was the resident's preference. Reference: WAC 388-97-1060 (1)(2)(c)

Based on interview and record review, the facility failed to ensure an effective or coordinated process for communication between the facility and the offsite dialysis center to ensure continuity of care and monitoring the resident ' s status for 1 of 1 resident (Resident 11), reviewed for dialysis services. This failure placed residents receiving dialysis at risk for complications and unmet care needs. Findings included . <Resident 11> Review of the resident's medical record showed they were admitted with diagnoses including. end stage renal disease (the kidneys no longer function efficiently) with dialysis, congestive heart failure (chronic condition in which the heart does not pump blood as well as it should) and anemia (a condition when there is not enough red blood cells to carry oxygen to the body). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance for activities of daily living (basic tasks necessary for self-care). Review of the March 2025 physician orders showed Resident 11 received dialysis from an offsite dialysis center three times weekly on Tuesday, Thursday and Saturday. Review of the resident's care plan dated 02/11/2025 showed an expectation that the resident was to have their vital signs (VS) checked before and after dialysis treatments. Additionally, facility staff were directed to send a dialysis communication form with the resident each time they went to the offsite center. The form consisted of pre/post dialysis VS, weights, and any other pertinent information about the resident health status. In the event the form was not completed when the resident returned to the facility, staff were expected to call the offsite dialysis center to retrieve the necessary information of the resident ' s health status. Review of Resident 11's Dialysis Communication Book from 02/02/2025 to 03/25/2025 showed eight of the 22 forms were not completed. Review of the progress notes dated 02/02/2025 to 03/25/2025 showed no documentation that facility staff had contacted the offsite dialysis center to obtain the missing information. During an interview on 03/26/2025 at 11:07 AM, Staff R, Charge Nurse, stated that the Dialysis Communication Book was sent with the residents who received dialysis at an offsite center. Staff R stated if the form was incomplete upon return from dialysis the nurses call the center, obtain the missing information and write a progress note. Staff R stated they did not normally assess Resident 11's VS when they returned from the dialysis center. During an interview on 03/26/2025 at 2:31 PM, Staff S, Nursing Assistant (NA), and Staff T, NA, stated when Resident 11 returned from dialysis they got them their meal but had not been informed to take Resident 11's VS therefore, they were not completed upon their return to the facility from dialysis. During an interview on 03/26/2025 at 3:09 PM, Staff B, Director of Nursing Services, stated the expectation for communication with the offsite dialysis center was to send the Dialysis Communication Book with the resident. If the communication forms were incomplete, then the nurses were expected to call over there ask for the information and write a progress note in the residents chart. Staff B stated the orders post dialysis were not set up to take Resident 11's VS when they returned to the facility after receiving dialysis treatments. Reference WAC 388-97-1900 (1), (6) (a-c)

Based on observation, interview, and record review, the facility failed to consistently monitor weights or implement interventions for 1 of 3 residents (Resident 71) reviewed for nutrition. This failure placed the resident at risk for continued significant weight loss and the loss of nutritional satisfaction. Findings included . Review of a policy titled Nutritional Status Policy/Procedure, dated 03/2016, showed the facility would obtain weights weekly for four weeks for new admissions and residents with weight changes would be reviewed weekly at the nutrition meeting. <Resident 71> Review of the resident's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include malignant cancer (when some of the body's cells grow uncontrollably and spread to other parts of the body) of the brain and the right eye and protein calorie malnutrition (inadequate intake of food). The 03/15/2025 comprehensive assessment showed Resident 71's cognition was intact and required setup/clean-up assistance from staff for eating. The assessment showed Resident 71 had malnutrition. During an interview on 03/25/2025 at 9:43 AM, Resident 71 stated they were unable to eat, had nausea, and did not have an appetite. During an interview and concurrent observation on 03/26/2025 at 9:09 AM, Staff L, Nursing Assistant, stated for residents who required daily weights they were obtained first thing in the morning and for all other residents they would try to obtain their weights once a week on their shower day. Staff L stated the NAs were given a weight list (a list of residents who required a weight to be obtained) of weights that had not been obtained, and they would get them immediately that day. Staff L provided the weight list document. Review of the weight list document dated 03/2025 provided by Staff L on 03/26/2025 at 9:22 AM, showed Resident 71's weight had not been obtained. The list showed two other weights of other residents had been documented but no documented date of when that weight was obtained. During an interview on 03/26/2025 at 9:28 AM, Resident 71 stated they did not eat breakfast that morning because they felt sick and had a feeling of nausea. Resident 71 stated I feel like I have lost weight and would try to drink their protein shakes (a supplement that helps with decreased intake), but they had a difficult time getting them down. During an interview on 03/28/2025 at 10:49 AM, Resident 71 stated they used to have an appetite but since becoming sick with pneumonia (a bacterial infection in the lungs that had resolved on discharge from the hospital) my appetite has gotten worse. Resident 71 stated they did not feel like they lost their appetite with the chemotherapy (a medicated treatment to treat cancer) treatment, at least not with the other treatments. Review of Resident 71's weights showed on 03/13/2025 (day of admission) the Resident's weight was 172.8 pounds (lb) and on 03/14/2025 the weight was 173.5 lb. There were no other weights obtained or documented after 03/14/2025. Review of Resident 71's 03/19/2025 Nutrition at Risk Review note showed Staff G, Registered Dietician (RD, a health professional who specialized in nutrition and develops eating plans to meet health needs), assessed Resident 71's average nutritional intake at mealtimes was zero to 25 percent of the meals eaten, they had chewing and swallowing difficulties, they currently received chemotherapy treatment, and their calorie/protein needs were not met. The note showed the RD recommended Resident 71 continue Glucerna (a brand of protein supplement) daily, to provide a diet of choice/preferences of food, and monitor intake and weight. The RD showed the weights they reviewed for this assessment were the two documented weights on 03/13/2025 and 03/14/2025. The RD showed they would follow up in one week (03/26/2025). Review of the RD's nutrition follow-up progress note dated 03/27/2025, showed the RD reviewed the same weights they reviewed on 03/19/2025 (eight days prior), Resident 71 still had a nutritional intake of zero to 25 percent of meals eaten and averaged drinking 40 percent of their Glucerna. The progress note showed Resident 71's appetite was still poor, and the Resident's Representative was present and tried to encourage the resident to eat more. The RD's plan was to update the meal preferences, continue with the Glucerna, monitor intake and weight (which were both recommendations on 03/19/2025), and encourage intake. The RD also documented they would follow-up in one month. Additional review of the 03/25/2025 weight list on 03/28/2025 at 11:02 AM, showed Resident 71's weight had been documented, undated, and the weight was 158.6 lb (which was a loss of 14.9 lbs in two weeks (an -8.59 percent weight loss which, per standards of practice a -5.0 percent weight loss over a 30-day period was considered significant weight loss). An interview and concurrent observation on 03/28/2025 at 9:04 AM, Staff B, Director of Nursing Services, stated they had reviewed Resident 71's weight on 03/27/2025 of 158.6 lb and asked for a re-weigh because the weight loss was so significant but was not sure why that had not been done or documented. The Resident's reweigh at 11:02 AM, showed Resident 71's weight at 162.4 lb (an 11.1 lb loss and an overall -6.40 percent weight loss, still a significant weight loss). During an interview on 03/28/2025 at 10:26 AM, Staff G stated when they reviewed residents with weight loss, they reviewed their weights and intake and depending on those factors would determine how often they reviewed the resident. Staff G stated on their follow-ups they would review the weights in the resident's Electronic Health Record (EHR) and if there was not a current weight in the EHR they would ask the NAs to obtain one for them right then and there [at the time requested]. Staff G also stated there was a weight list they could review that was kept in a book at the Nurse's station. Staff G stated during their assessment of Resident 71 on 03/27/2025 they did not ask the NAs to obtain an updated weight, nor did they check the weight list to see if one had already been obtained. Staff G stated they did not obtain a current weight because I knew that [Resident 71] did not have good intake [nutritional] and should have asked for a weight to be obtained but the staff were really busy. Staff G stated if they would have known Resident 71 had lost that much weight, they would have decided to review the resident again in two weeks rather than a month and stated I wouldn't have seen [Resident 71] sooner because I felt like I wasn't getting anywhere with the encouragement that was being given. Staff G stated they knew about the resident's chemotherapy treatment but did not factor in how the chemotherapy medication could potentially result in Resident 71's nausea, decreased appetite, or their weight loss. During an interview on 03/28/2025 at 12:07 PM, Staff B stated their Assistant Director of Nurses (ADON) was responsible for reviewing the weights daily and if they were missed, they would put out the weight list daily for the NAs to obtain the weights. The NAs would not put the date they obtained the weights because the ADON would review the weights, document them on the same day, and put a new weight list out daily. Staff B stated the ADON had been gone on vacation, so Staff B had put the weight list out and had not documented or reviewed it daily, nor did they put a new one out daily. Staff B stated they would have expected the RD to assess the resident thoroughly and ensure they obtained an up-to-date weight for their assessment. Reference: WAC 388-97-1060 (3)(h)

Based on observation and interview the facility failed to provide a safe, clean, and comfortable homelike environment for residents and staff for 1 of 1 laundry rooms (LR 1), and 1 of 2 dining rooms (DR 1) reviewed for a homelike environment. This failure placed residents and staff at an increased risk for not feeling safe and secure with their environment. Findings included . <Laundry Room> Observation of LR1 on 02/23/2024 at 11:52 AM showed: Two washing machines were being utilized by the facility to wash and clean all facility residents' linen/clothes. The two washing machines sat on top of I beams (refers to various structural, metal beams used for heavy loads and can be bolted to the ground) that were anchored to the LR1's floor with heavy duty, 1/2 inch (a unit of measure) diameter bolts. Each of the metal beams and bolts were covered in rust and the metal was corroding (metal being destroyed or damaged slowly by chemical action) away. Water damage mixed with a white chemical residue were noted on both washing machines and their metal beam base/floor. One of the washing machines had an anchor bolt that had completely corroded away and broken off, lying next to the washer. Behind one of the washing machines was a black three-inch drainage pipe that had been previously taped up with black tape; from it leaked out water into a torn up one-foot (a unit of measure) by two-foot section of laminate (a floor covering) flooring. The water was observed leaking out onto the bare floor, which had been seeping (the slow flow of a liquid through materials and small hole) under the linoleum making its way, spreading towards the front of the washer, coming in contact with the washing machines metal beams/bolts. During an interview on 02/23/2024 at 12:25 PM, when shown the laundry room and washers, Staff C, Maintenance Director, stated they were glad the surveyor .caught this (referring to the broken bolt, leaking pipe and ripped up flooring) because it could turn from small to big really quick. Staff C stated that at some time in the past, concrete (a hard rock-like substance that is a mixture of cement and water) was applied to the bolts that anchor the two washing machines in place, which made it hard to see if the bolts were corroding/rusting away. During a concurrent observation and interview on 02/23/2024 at 12:47 PM, showed the washing machine with the missing bolt being started up after being loaded with laundry. There was a loud squeaking noise that was coming from the washing machine that had just started up. Both Staff C and Staff D, Housekeeping/Laundry, looked at each other with confusion since neither had heard the washing machine make that noise before. As the washing machine started to shake and squeak louder, Staff C started to turn off the machine. Tremors were felt through the floor as the washing machine was slowing down and the metal beam that anchored the washing machine started forcibly vibrating up and down. During an interview on 02/23/2024 at 1:05 PM, Staff B, Director of Nursing Services, stated the washing machine was not safe to use until it was fixed and bolted back down to the ground. Staff B stated that it was dangerous to have the washing machines running with the current state of the noted water/chemical damage, corrosion, and rusted anchor bolts. Staff B stated the washing machine pipe should not be leaking water under the laminate flooring and needed to be fixed. During an interview on 02/23/2024 at 1:45 PM, Staff A, Administrator, stated they would be working on fixing the washing machine and making sure the anchor bolt was back in place. <Dining Room> During an observation in D 1 on 02/21/2024 at 11:36 AM showed residents seated at tables in the middle of DR 1 awaiting their noon meal. To the right front of the entryway at the front of the room showed numerous items stored including , three cardboard boxes sitting on the floor in the right corner. Stored on top of the boxes was a pack of screws, a pack of plastic clips, a pillow, crumpled up paper, loose disposable gloves and a gallon bucket of water based plastic primer. Additionally there were two smaller buckets (quart sized) of water based plastic primer (a substance used on walls, ceilings, or anywhere new building work and preparation is required) sitting on a table under the TV. At the other end of DR 1 toward the back of the room showed a large humidifier that was six by two feet, two cardboard boxes on the floor behind the humidifier, an upright floor lamp, and a folding black TV stand/desk. During a concurrent observation and interview on 02/22/2024 at 12:58 AM PM, Staff A, Administrator was shown the items stored in the front and back areas of DR 1 still unchanged from the previous observation on 02/21/2024 at 11:36 AM. Staff A, acknowledged that the front and back areas of DR 1 should not be used as storage as it was currently being used by residents for meals. Reference: WAC 388-97-3220(1) 39652

Based on observation, interview and record review, the facility failed to implement key components of infection control interventions intended to mitigate the risk for spread of infection, by failing to follow the manufacturer's instructions for use for disposal of single use face shields (a barrier worn from crown to chin that wraps around the face to the point of the ear that prevents infectious materials from entering the eye) for 11 of 11 Personal Protection Equipment (PPE) carts (a supply cart containing masks, gowns, gloves, and eye protection/face shields) inspected for PPE supply. There were five carts located outside of resident rooms and six carts located inside resident rooms. This failure placed residents, staff, and visitors at risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the 10/31/2022 Washington State Department of Health guidance Interim Recommendations for SARS-CoV-2 Infection Prevention and Control in Healthcare Settings showed that facilities should practice single use disposable PPE (one per resident per encounter) and discard disposable PPE after each use. Additionally, when PPE supplies were stressed, ran low, or exhausted, contingency and/or crises strategies, such as extended use of PPE, should be used temporarily. As the availability of PPE returned to normal, the facility should promptly resume standard practices. Review of the 2022 [NAME] Manufacturing Corporation's User Information & User Manual for the disposable face shields showed that the product (face shield) should not be used if it had been exposed to chemicals. Further review of the document showed that the face shield was contaminated after use and should be discarded. The following observations on 03/27/2023 showed face shields that had frayed elastic bands, foam padding that was worn, and smudges on the clear plastic shield, evidence of previous use: 8:35 AM: PPE cart located outside of room [ROOM NUMBER] contained 4 used face shields; 8:38 AM: PPE cart located outside of room [ROOM NUMBER] contained 9 used face shields; 8:40 AM: PPE cart located outside of room [ROOM NUMBER] contained 15 used face shields; 10:48 AM: PPE cart located outside of room [ROOM NUMBER] contained 5 used face shields; 11:00 AM: PPE cart located outside of room [ROOM NUMBER] contained 11 used face shields; 11:29 AM: PPE cart located inside the entrance to room [ROOM NUMBER] contained 28 used face shields; 11:31 AM: PPE cart located inside the entrance to room [ROOM NUMBER] contained 2 used face shields; 11:43 AM: PPE cart located inside the entrance to room [ROOM NUMBER] contained 2 used face shields; 11:44 AM: PPE cart located inside the entrance to room [ROOM NUMBER] contained 2 used face shields; 1:53 PM: PPE cart located inside the entrance to room [ROOM NUMBER] contained 6 used face shields; 1:58 PM: PPE cart located inside the entrance to room [ROOM NUMBER] contained 5 used face shields. During a concurrent observation and interview on 03/27/2023 at 11:07 AM, Staff I, Nursing Assistant, donned PPE to enter a COVID-19 isolation room. Staff I donned their PPE, including a face shield from the drawer of the PPE cart, and entered the isolation room. Upon exit of the isolation room, they removed their PPE and placed the used face shield into a bin labeled face shields and eye protection. Staff I stated that they put the used face shield in the bin for housekeeping staff because they washed the face shields and restocked the PPE carts. During an interview on 03/27/2023 at 11:15 AM, Staff J, Housekeeper, stated that they removed the face shields from the designated bin, disinfected them, and put them back into the PPE cart. During an interview on 03/27/2023 at 11:17 AM, Staff K, Licensed Practical Nurse, stated that the used face shields were placed in the designated bins, sanitized by the housekeepers, and then reused. During an interview on 03/28/2023 at 10:26 AM, Staff H, Maintenance Supervisor, stated that they were responsible for housekeeping services. Staff H stated that the housekeepers were cleaning the face shields with a bleach disinfectant and restocked the PPE carts with the disinfected face shields after they were dry. During an interview on 03/28/2023 at 1:08 PM, Staff G, Infection Preventionist (IP), stated that the facility did not have a shortage of PPE and did not reuse PPE. During an interview on 03/30/2023 at 9:00 AM, Staff A, Administrator, stated that there was a sanitizing and reusing process for the disposable face shields. Staff A stated that they thought it was an appropriate solution since they were cleaning the shields with bleach. They stated that the process was a carryover from the beginning of the COVID-19 pandemic when there was a PPE shortage. Reference: WAC 388-97-1320(1)(5)(b)

Based on observation, interview and record review, the facility failed to ensure the menu was prepared in advance, followed, and reviewed by the facility's Registered Dietitian for three of three meals (noon meals on 03/27/2023, 03/28/2023, and 03/29/2023) observed during the survey. This failure placed all residents at risk for unmet nutritional needs, weight gain or loss, and decreased quality of life. Findings included . Review of the week one menu cycle provided by the facility showed: Monday (03/27/2023) lunch: baked tenders (changed from baked drumsticks), corn pudding, green beans, and apple cobbler. Tuesday (03/28/2023) lunch: Salisbury steak (changed from Swiss steak), mushroom rice, Italian blend vegetables, roll, and yellow cake with caramel icing. Wednesday (03/29/2023) lunch: ham (changed from beans/ham), peas (changed from cabbage), cornbread, and fresh baked cookies. During an observation on 03/27/2023 at 11:56 AM, the trays were served in the assisted dining room. The residents received chicken tenders, potato salad (instead of corn pudding), mixed vegetables, and cream pie (instead of the apple cobbler). The menu posted outside of the dining room showed: chicken strips, potato salad, Mediterranean vegetables, and coconut cream pie. During an observation on 03/28/2023 at 12:04 PM, the trays were served in the assisted dining room. The residents received Salisbury steak, wild rice (instead of the mushroom rice), mixed vegetables, and cheesecake (instead of the yellow cake). The menu posted outside of the dining room showed: Salisbury steak, wild rice, Italian vegetables, and cheesecake. During an observation on 03/29/2023 at 9:55 AM, the lunch menu posted outside of the dining room showed: sliced ham, mashed potatoes, peas, and chocolate chip cookies. During an interview on 03/29/2023 at 10:05 AM, Staff D, Dietary Supervisor, stated that they changed the Monday lunch menu item from drumsticks to chicken tenders, and the corn pudding to potato salad. They stated that the green beans were unavailable. Staff D stated that the little potatoes for potato salad did not come in the order for that day's menu, so they made mashed potatoes. Staff D stated that they substituted peas for cabbage because the residents did not like cabbage. They stated that they substituted the cheesecake for the yellow cake because of a prep problem. Staff D stated that the menu issues were not a recent problem and would only know of unavailable stock once the supply order was placed. Staff D stated that they did not maintain a substitution log. They stated that they told the dietitian about the changes in the menu but did not have the dietitian review or sign off on any changes. During concurrent observations and interviews on 03/29/2023 at 11:30 AM, the lunch meal observation in the kitchen showed there was no cornbread. Staff F, Dietary Aide, stated that there was no cornbread on the menu. Staff D stated that the cornbread was not available because they did not have the cornbread mix. During an interview on 03/30/2023 at 9:31 AM, Staff C, Registered Dietician, stated that the menus came from an outside company. They stated that Staff D occasionally told them that they had to substitute certain items. Staff C stated that the menu changes were not reviewed with them regularly and were not aware of a substitution log. They stated that they did not sign off on the menus. Reference: WAC 388-97-1180(1)(2)(3)

Based on observation, interview and record review the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) and other contagious bacteria, were implemented for 3 of 6 residents (1, 2, and 3) reviewed for the cohorting (an infection prevention and control measure that groups together residents with the same infectious condition) of residents in semi-private rooms with Aerosol Generating Procedure ([AGP], a procedure that is likely to generate a higher concentration of infectious respiratory aerosols) activity. This failure placed the residents at risk for exposure and transmission of COVID-19. Findings included . Review of the 04/22/2022 Washington State Department of Health Interim Recommendations for [CONDITION(S)]-CoV-2 Infection Prevention and Control in Healthcare Settings, showed that residents should not be present during or following an AGP until the clearance time (three hours after the procedure had ended) had passed. Further review showed that the facility should implement policies and procedures to address how to protect other residents who request to be present during and following AGPs, including informing other residents of the risk associated with being present. Resident 1. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/10/2022, the resident was transferred to the emergency room and admitted with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was readmitted to the facility on [DATE]. The 08/21/2022 comprehensive assessment showed the resident required limited assistance of one staff for Activities of Daily Living (ADLs). The assessment also showed the resident had an intact cognition. The resident did not require the use of a continuous positive airway pressure ([[CONDITION(S)]], a machine that keeps the airway open by providing air through a mask while sleeping, an AGP) device. Resident 2. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 08/02/2022 comprehensive assessment showed the resident required extensive assistance of one staff for ADLs. The assessment also showed the resident had a moderately impaired cognition. The resident required the use of a [CONDITION(S)] device. An observation on 09/01/2022 at 10:31 AM, showed Resident 1 and Resident 2 were roommates in a semi-private room. Signage on the entrance to the room showed that the room was restricted for AGPs and aerosol contact precautions (additional personal protective equipment including an N95 respirator [a mask designed to provide a very close facial fit and very efficient filtration of airborne particles], eye protection, gloves, and gown). During a telephone interview on 09/02/2022 at 9:27 AM, Resident 1's Representative stated that they were not informed of the risk of exposure to COVID-19 prior to a conversation from the facility representative on the evening of 09/01/2022, 17 days after the resident was placed in the cohorted room. During a telephone interview on 09/02/2022 at 9:31 AM, Resident 1 stated that (the facility) did not have a conversation with them regarding the risk of exposure to COVID-19 prior to their admission to the semi-private room. The resident stated that they did have a conversation, but unfortunately it was not until a few days ago, around the 28th (of August). Record review of Resident 2's August 2022 Treatment Administration Record (TAR) showed an order that included only essential personnel should enter the room while AGP in progress and that the resident had used their [CONDITION(S)] device every night for the month of August 2022. Resident 3. Review of the medical record showed that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment also showed the resident had an intact cognition. The resident did not require the use of a [CONDITION(S)] device. Resident 4. Review of the medical record showed that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 08/18/2022 comprehensive assessment showed the resident required limited assistance of one staff member for ADLs. The assessment also showed the resident had an intact cognition. The resident required the use of a [CONDITION(S)] device. During an observation on 09/01/2022 at 10:10 AM, showed Resident 3 and Resident 4 were roommates in a semi-private room. The entrance to the room showed signage for AGPs and Aerosol Contact Precautions. During a telephone interview on 09/02/2022 at 11:21 AM, Resident 3 stated that no one talked to me about that (risk of exposure to COVID-19 and [CONDITION(S)] use), not before and not last night either. Record review of Resident 4's August 2022 TAR showed the resident had used their [CONDITION(S)] device for 30 of 31 nights in August and that only essential personnel should enter the room while AGP in progress. Resident 5. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 08/03/2022 comprehensive assessment showed the resident required extensive assistance of one to two staff for ADLs. The assessment also showed the resident had an intact cognition. The resident required use of a [CONDITION(S)] device. Resident 6. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 07/15/2022 comprehensive assessment showed that the resident required extensive assistance of one staff for ADLs. The assessment also showed the resident had a moderately intact cognition. An observation on 09/01/2022 at 10:34 AM showed Resident 5 and Resident 6 were roommates in a shared room. The entrance to the room showed two signs; AGPs and aerosol contact precautions. During a telephone interview on 09/02/2022 at 9:44 AM, Resident 6's Power of Attorney (POA) stated that they had a conversation with the facility last night (09/01/2022) about the risk of sharing a room with Resident 5, but did not know what the risks were, just that the resident was at risk for being in that room. The POA stated that there was no conversation about the risk of exposure to COVID-19 with [CONDITION(S)] use prior to the previous evening. Record review of the August 2022 TAR for Resident 5 showed only essential personnel should enter the room while AGP in progress and that the resident used their [CONDITION(S)] device every night in August. During an interview on 09/01/2022, Staff A, Administrator, stated that they recognized the failure. During a telephone interview on 09/02/2022 at 12:24 PM, the Local Health Jurisdiction Public Health Nurse stated that the facility had not contacted them regarding any roommate situation with a [CONDITION(S)] and non-[CONDITION(S)] user. They further stated that they would absolutely not recommend that (cohorting of a [CONDITION(S)] resident with a non-[CONDITION(S)] resident), especially with the situation (high transmission rate) we are in. Reference: WAC 388-97-1320(1)(2)(a)(b) This is a repeat deficiency from the Statement of Deficiencies dated 04/03/2019 and 07/19/2021.

Based on observation and interview the facility failed to maintain kitchen workspace in accordance with professional standards for food service safety. This failure placed all residents at risk of food-borne illness. Findings included . On 07/13/2021 from 9:00 AM through 10:00 AM, observations in the kitchen showed: The stove top had an accumulation of food build up that was blackened matter of approximately 1/4 inch() depth in an area approximately 2 wide by 6 long beneath the back of the stove top. The vent grates above the range had a build up of oily substance. Suspended just above the food preparation area, hung a 4 foot (') by 2' wooden information board which contained information on sheets of paper regarding residents' food preferences and choices. The board had a thick layer of dust on both the front and back which could dislodge onto the food below. The cabinet on the North side of the range was soiled on the handle and had blackened smudges on the interior and exterior of the cabinet door. The spice containers inside of the cabinet were sticky to the touch and were soiled with finger prints and food debris. A window on the East side of the kitchen contained a box air conditioner unit. The unit did not take up the entire window space and a piece of transparent plastic was inserted to fill the space (approximately 4 by 14). The plastic had deteriorated and cracked open which exposed an approximate 1 by 6 gap where insects or other pests could potentially enter. The wall to the South, just above the reach in refrigerator, had an accumulation of dust debris that was visible against the white wall. The designated hand washing sink contained water hot enough to a degree which required the surveyor's immediate removal of hands to avoid a burning sensation. Staff had to frequently touch both hot and cold water valves in an effort to wash hands at a comfortable range. Staff Q, Dietary Aide, warned Be careful, the water is really hot. Additionally, the hand washing sink's countertop, directly to the North side, did not contain a splash guard and was utilized for air drying of clean kitchenware. During a concurrent interview and observation on 07/13/2021 at 10:20 AM, Staff A, Administrator, acknowledged those areas in the kitchen that contained an accumulation of kitchen related grime and buildup. He stated, It needs a deep clean, and I see what you are seeing. Further he stated that the area above the air conditioner needed repair and that a splash guard would be placed at the sink. Reference WAC 388-97-1100 (3)

Based on observation, interview, and record review, the facility failed to a) maintain infection control practices for one of two sampled residents (68), observed for hand hygiene practices and appropriate infection control protocols during the medication administration of inhalers and eye drops, and b) maintain proper disinfection/cleaning and safe storage of respiratory equipment, continuous positive airway pressure ([CONDITION(S)]) machines for two of two sampled residents (67, 68), reviewed for respiratory devices. These failures increased the risk for the spread of infection and it's associated discomfort and potential for decline in physical condition. Findings included . Review of the 04/2016 facility Policy and Procedure Medication Administrative Standards and Principles showed to wash hands before preparing medications, use correct procedure for giving eye, ear, and inhalants .eye drops medications were to wash hands and put gloves on to administer the medication. Resident 68. Review of the medical record showed the resident was admitted to the facility with heart failure and respiratory issues. The 06/27/2021 comprehensive assessment showed the resident was alert and made his needs known. During an observation on 07/13/2021 at 7:45 AM, Staff C, Registered Nurse (RN), did not use hand hygiene to remove the resident's medication from the medication cart. Staff C removed the medications bare handed to include the resident's inhalants, eye drops and she was also observed to flip through many of the residents' medication punch cards to find and retrieve oral medication cards. Staff C failed to wash her hands after she removed the resident's oral medications, the eye drops and inhalants from the medication cart. Continuing an observation of the medication pass on 07/13/2021 at 07:50 AM, Staff C failed to wash her hands when she entered Resident 68's room and placed all medications and inhalants on the resident's bedside table after she removed his breakfast tray. She did not use a barrier to place the medications on the resident's bedside table. Staff C then primed the aerosol inhalant and handed it to the resident to use without instruction, washing her hands, or using gloves. She failed to instruct the resident to rinse his mouth after using the inhaler. She then handed the antibiotic eye drops to the resident to use himself without providing instruction. Staff C then gave the resident's nasal spray to him, without washing her hands or using gloves. Staff C then returned the eye drops and inhalants to the medication cart without disinfecting them. During an interview on 7/13/2021 at 8:15 AM, the Director of Nursing Services (DNS), stated that Staff C did not follow the facility's infection control protocols for hand hygiene or glove use for proper medication administration. Resident 68. Review of the medical record showed the resident admitted on [DATE]. The resident's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no evidence of when or how to clean the [CONDITION(S)] machine. During an observation on 07/07/2021 at 12:21 PM, the [CONDITION(S)] machine was on the resident's bedside table. The mask was placed in the drawer, not covered. The mask was touching the wood on the bottom of the drawer without a barrier. During observations on 07/08/2021 at 9:21 AM and 07/09/2021 at 10:10 AM, the [CONDITION(S)] machine was in the same location, on the bedside table and the mask, again, was not covered in the drawer. During an observation on 07/12/2021 at 4:26 PM, the [CONDITION(S)] mask was in the bedside drawer with other miscellaneous items, the mask continued to not have a protective barrier. During an interview on 07/13/2021 at 10:47 AM, Staff S, Nursing Assistant (NA), stated that the NA's do not provide cleaning or maintenance of the [CONDITION(S)] machines. During an interview on 7/14/2021 at 3:41 PM, Resident 68 stated that his daughter had purchased an automated cleaning system that disinfected the [CONDITION(S)] mask and tubing, but it was still at his personal residence. He stated that he had not seen anyone clean his [CONDITION(S)] machine since he had admitted to the facility. During an interview on 7/14/2021 at 4:29 PM, Staff B, DNS, stated that the [CONDITION(S)] machines were cleaned by the licensed nurses as needed and the masks were cleaned daily and changed out monthly. Staff B stated that the facility did not have a policy for [CONDITION(S)] use. Resident 67. Review of the medical record showed the resident admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/25/2021 assessment showed the resident was cognitively intact. During an observation on 07/07/2021 at 12:11 PM, the resident was observed seated at the side of the bed. The mask portion of the [CONDITION(S)] was in the bedside table drawer, resting and touching the bottom of the drawer. During an observation and interview on 07/12/2021 at 3:25 PM, the mask portion of the [CONDITION(S)] was observed on the floor. The [CONDITION(S)] was not labeled to indicate when the water reservoir had been changed. During an observation on 07/13/2021 at 10:08 AM, the [CONDITION(S)] mask and tubing portion of the unit was hanging off the resident's trapeze bar and was uncovered and exposed to air. At the foot of the bed was a cardboard box which contained an automated [CONDITION(S)] cleaner, a device used to clean and sanitize the mask. He stated he did not know where the device came from. The resident stated that the only assistance staff had provided, in regard to the [CONDITION(S)], was to add water to the reservoir. Review of the resident's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/14/2021 at 4:50 PM, Staff B, DNS, stated that the facility did not have a policy regarding [CONDITION(S)] usage and maintenance. She stated that when not in use, the mask needed to be stored in a bag for infection control purposes and directive for maintenance and usage should be indicated in the care and treatment plan. Reference WAC 388-97-1320(1)(c)

Based on observation, interview, and record review, the facility failed to ensure care plans were developed and implemented, to address bed mobility for two of two sampled residents (40, 58) , reviewed for bed mobility and repositioning; both residents were dependent on staff for mobility and repositioning. Failure to provide a care plan for mobility and reposition needs placed both residents at risk for skin breakdown, poor respiratory expansion, and contractures. Findings included . Resident 40. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/28/2021 comprehensive assessment showed the resident was alert, able to make her own decisions and required extensive assistance with most activities such as bed mobility and repositioning, dressing, bathing, toileting, transfers, and hygiene. The resident required a Hoyer lift (mechanical lift) to transfer out of bed. Additionally, the resident was on oxygen per nasal cannula as needed. During an observation and interview on 07/07/2021 at 9:39 AM, the resident was lying on her back in bed with the head of the bed up at a 90-degree angle and leaning towards the left side of the bed. The resident's right lower leg was elevated on a pillow. Additionally, the resident's body was scrunched down in the bed. She stated she had problems with being re-positioned and leaning to the left. The resident stated this had been a problem since she had been at the facility. The resident stated that the Nursing Assistants, (NA) were not able move her without two or more staff to assist her. She stated the male nurse on the night shift was strong enough to move her back to a more upright position. Continuing the 07/07/2021 interview at 9:45 AM with Resident 40, she stated there were no assistive devices on her bed to help her turn. The resident explained she had staff place a chair on the left side of her bed so she would not fall out, due to leaning on the left side of the bed. The resident stated she cannot re-position herself without help. Review of the 01/11/2021 care plan showed the resident had limited physical mobility due to weakness, and required two person assistance to turn in bed. The 01/11/2021 care plan showed that due to pain an intervention was added to encourage the resident to reposition herself. The 01/28/2021 care plan showed the resident was at risk for pressure ulcers due to decreased functional mobility. Observation times of resident's inability to maintain an up right position in bed. (Resident observed leaning to the left side while in bed). *07/07/2021- 11:00 AM, 12:45 PM, 2:40 PM *07/08/2021- 8:30 AM, 10:00 AM, 12:00 PM, 2:25 PM, 4:45 PM *07/09/2021- 8:40 AM, 10:45 AM, 11:33 AM *07/12/2021- 8:45 AM, 12:53 PM, 1:01 PM, 2:00 PM, 4:00 PM *07/13/2021- 7:15 AM, 10:45 AM, 2:00 PM *07/14/2021- 9:00 AM, 11:15 AM, 1:40 PM *07/15/2021- 8:45 AM, 10:19 AM, 2:00 PM, 3:30 PM During an interview and observation on 07/09/2021 at 11:33 AM, the resident stated she needed the bed pan and needed to be pulled up in bed. She was leaning to the left side of her bed with the bedside table over the bed. During an interview on 07/12/2021 at 1:01 PM, Resident 40 stated she had problems repositioning herself in bed. She had told the staff many times and they give me a pillow to place on the left side of my body, but it doesn't work. During an interview on 07/12/2021 at 3:32 PM, Staff J, Registered Nurse, (RN) stated the resident used a pillow to elevate her right foot due to [CONDITION(S)], (excessive swelling of the lower extremities). She stated the resident did lean to the left in bed and they did try a pillow to the left side of the resident's body but that did not work. During an interview on 07/15/2021 at 11:25 AM, Staff R, Nursing Assistant (NA) stated, We used a pillow on her (Resident 40) left side, but the resident did not like it. She stated, that during transfers the resident was able to help with re-positioning and she was able to turn. Staff R stated that it sometimes took three staff with a Hoyer lift to transfer her. Staff R stated since COVID-19 she had not been out of bed and suggested a trapeze bar could help her to move her position. Resident 58. Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also showed that the resident had developed several pressure injuries and skin tears to her feet, left leg and right arm. Review of the resident's most recent comprehensive assessment for a significant change in condition, dated 06/04/2021, showed the resident required extensive assistance of two staff for positioning and was to be turned every two hours. The resident was a high risk for pressure injuries. Review of the 06/04/2021 care plan showed an intervention to keep the resident off her back, to reposition every two hours with two people, and to have a bulb ( modified adaptive pressure sensitive)call light. An observation on 07/09/2021 at 9:30 AM, showed the resident lying in her bed positioned onto her back with two pillows under her head which caused her neck to be bend in a position in which her chin was touching her chest. An observation on 07/09/2021 at 11:30 AM, showed the resident in bed again, on her back with one of the pillows moved off to the side and her neck was no longer kinked downward. A bulb call light was not observed, the resident had a push button call light at her side. An observation on 07/12/2021 at 1:42 PM, showed Resident 58 lying on her left side with her head kinked down toward the left. She asked for some water, and she was unable to push the call light. During a concurrent observation and interview on 07/12/2021 at 1:49 PM, Staff R, NA, came in and asked what the resident needed, and the resident stated water. Staff R, repositioned the resident by herself, sat her up and assisted her with some water. When asked if Resident 58 could use the call light, Staff R stated that she could not use the call light, but she could yell or hit the table with the call light. During an observation on 07/13/2021 at 8:13 AM, Resident 58 was lying on her right side and slightly on her back with the facility's standard push button call light by her side. At 11:00 AM the resident was lying in the same position. At 1:47 PM, the resident was still lying in the same position. During an observation on 07/14/2021 at 11:57 AM, Resident 58 was lying on her back with her head kinked downward toward the right. During an interview on 07/15/2021 at 9:19 AM, Staff DD, NA, stated that the resident could not use her light but could yell when she needed something. However, now that the doors had been closed due to the pandemic, so she was not sure how the resident would let people know when she needed something. During an interview on 07/15/2021 at 2:28 PM, Staff D, RN, stated that the NA's are to reposition the resident every two hours and she tried to keep track of when the resident was repositioned. Resident 58 was moved from another room in May 2021, and she did have a bulb call light at that time but the call light must not have gotten moved with her. In addition, Staff D stated that the resident required two person assist because she could become combative, and that she had fragile skin. During an interview on 07/16/2021 at 12:21 PM, Staff B, Director of Nursing Services, stated that her expectation was that Resident 58 stayed off her back and would be repositioned every two hours. Reference: WAC 388-97-1020(1), (2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed the resident at risk for potential infection and a decline in health status. Findings included . Resident 67. Review of the medical record showed the resident admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/25/2021 assessment showed the resident was cognitively intact. During an observation and interview on 07/12/2021 at 3:25 PM, the resident was observed seated in bed. A [CONDITION(S)] device was on the bedside table. The mask portion of the [CONDITION(S)] was observed on the floor. The [CONDITION(S)] was not labeled to indicate when the water reservoir had been changed. The resident stated that friends brought in the [CONDITION(S)] to him about a week ago and that staff had filled the water reservoir. He stated that he had been using the machine at night, during sleep. Review of the resident's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/12/2021 at 2:00 PM, Staff O, Registered Nurse (RN), stated that she was aware the resident utilized a [CONDITION(S)] but did not know how it got here and that the resident had recently moved (within previous two weeks) from the facility's rehabilitation unit. During an interview on 07/12/2021 at 3:57 PM, Staff N, RN/Charge Nurse, stated that she was responsible for obtaining orders and for oversight of the resident's care needs. She stated that she had not been previously aware that the resident had a [CONDITION(S)]. She stated that the resident was in the hospital for a couple of months, but there was not an order. During an interview on 07/14/2021 at 4:50 PM, Staff B, Director of Nursing Services (DNS), stated that the facility did not have a policy regarding [CONDITION(S)] usage and maintenance. She stated that when not in use, the mask needed to be stored in a bag for infection control purposes and directives for maintenance and usage should be indicated in the care and treatment plan. She acknowledged Resident 67 had been using a [CONDITION(S)] in the facility without an order. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview and record review, the facility a) failed to document and/or correctly assess the oral/dental status on the Minimum Data Set (MDS), an assessment tool, for two of three sampled residents (24,49) reviewed for dental issues, and b) failed to assess for a seat belt alarm as a potential resident restraint for one of one resident (49), reviewed for restraints. This failure placed Residents 24 and 49 at risk of not receiving dental services necessary for oral hygiene and nutritional needs, and additionally, placed Resident 13 at risk for potential restraint and skin breakdown. Findings included . Resident 24. Review of the medical record showed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/07/2021 at 9:25 AM, the resident stated he had a vegetarian diet, had no upper front teeth and had to eat soft foods. He showed that his teeth were missing in the front and stated he had not had a dental referral from the facility. During a review of the resident's comprehensive assessment for 02/12/2021 and 05/13/2021, it showed the resident had no dental issues. During an interview on 07/12/2021 at 3:20 PM, Staff J, Registered Nurse (RN), stated she must have mis-coded the MDS comprehensive assessment on 02/12/2021 and 05/13/2021 concerning dental status of the resident's missing teeth. She was unaware that the resident wanted a dental referral. Staff J stated she did not observe the resident's mouth. Resident 49. Review of the comprehensive assessment, dated 06/13/2021, showed the resident did not have any problems with abnormal mouth tissue, cavities, or inflammed gums. During an interview on 07/08/2021 at 9:36 AM, Resident 49 stated that he had quit going to the dentist except for extractions and fillings and he presently had a cavity causing him not to be able to eat hard food items. The resident stated he missed eating nuts and that he would like to see a dentist. During an interview on 07/15/2021 at 10:40 AM, Staff EE, RN, stated that she did not know that Resident 49 needed to see a dentist but if she had been aware, she would have made him an appointment. During an interview on 07/15/2021 at 3:02 PM, Staff J, RN/MDS Nurse, stated that she did not do an oral assessment on the residents and only referenced the admission paperwork and admission assessment. She further clarified that she did not ask about mouth pain. Resident 13. Review of the 04/28/2021 assessment showed the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 07/08/2021 at 3:48 PM, the resident was observed seated in his wheelchair with a belt which fastened at his waist. Review of the October 2019, version 3.0 of the Resident Assessment Instrument, Section P, which provided guidance to the facility for completion of the MDS and included the following definition: Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident's needs and the medical symptom(s) that the restraint is being employed to address. If a physical restraint is needed to treat the resident's medical symptom, the nursing home is responsible for assessing the appropriateness of that restraint . During an interview on 07/13/2021 at 1:40 PM, Staff J, RN, stated that in November of 2020 the resident was issued a seat belt alarm because he was a fall risk. She then reviewed the April 2021 MDS for coding accuracy of the seat belt. She stated I must have missed it and that she would submit a correction to the MDS. Reference: WAC 388-97-1000 (1)(b)

Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than 5% during the medication observation task. Of the 25 medication opportunities, two were in error resulting in an error of 8% which effected one of six residents (69) observed for medication administration. This placed residents at risk for side effects and/or reduced medication effectiveness due to improper administration. Findings included: Review of the 04/2016 facility policy, Medication Administration, showed to follow special directions in drug administration such as, .crushing .do not cut tablets unless scored . Reisdent 69. The 06/28/2021 comprehensive assessment showed the resident was cognitively impaired, required extensive assistance in all activities of daily living (ADL), and was not always able to make needs known. Review of the July 2021 medication orders showed the resident was ordered an anti-depressant medication in the morning and an anti-[CONDITION(S)] medication in the morning by mouth. During a medication administration obervation on 07/13/2021 at 7:33 AM, Staff C, Registered Nurse (RN), crushed the anti-depressent, [MEDICATION(S)] tablet that was not scored (not to be split or crushed) and crushed the anti-[CONDITION(S)] medication, [MEDICATION(S)], that was an intermediate time released tablet. She then placed the crushed medications in an unmarked medication cup in the medication cart. Staff C stated she would give the crushed medications later mixed with pudding with the resident's breakfast. Review of the 02/21/2020 list of the Insitute for Safe Medication Practices, and the 2017 Federal Drug Administration, dated 2017, showed that [MEDICATION(S)] intermediate release cannot be crushed, split or chewed. The [MEDICATION(S)] was not a scored tablet and was not to be split or crushed. During an interview on 07/13/2021 at 8:15 AM, Staff B, Director of Nursing Services stated that Staff C was incorrect in crushing the intermediate release [MEDICATION(S)] and [MEDICATION(S)]. Reference WAC 388-97-1060(3)(k)(ii)

Based on interview and record review, the facility failed to ensure the development of individualized target behaviors and to accurately monitor resident behaviors for the use of [CONDITION(S)] medications (medications that affect the mind or behavior), for three of five residents (2, 13, 35), reviewed for unnecessary medication. These failures put the residents at risk for experiencing adverse side-effects and complications from the unnecessary medications. Findings included . Resident 2. Review of the medical record showed the resident readmitted to the facility on [DATE] with diagnoses of [CONDITION(S)], depression, kidney disease, diabetes, and stroke. Review of the 06/28/2021 comprehensive assessment showed the resident was cognitively impaired, required total assistance with bed mobility, and extensive assistance with dressing, personal hygiene, and toileting. Record review of the primary care provider's 04/24/2018 visit showed, the resident had been on [MEDICATION(S)] (anti-depressant) 20 milligrams (mg) orally every day and increased the dose to 40 mg orally everyday due to the residents mood was easily changed from being calm to becoming demanding and irritable for no real cause. Record review of the March, April and May 2021 behavior sheets showed the target behaviors to monitor were anger, sadness, refusal of cares and frustration. The target behaviors were documented by the Licensed Nurses on the Medication Administration Record (MAR) or by Social Services (SS) in the SS progress notes. During an interview with Staff H, Registered Nurse (RN), she stated that the target behaviors on the MAR did not always coincide with the care plan and were very vague. She stated, if the resident shows anger and they are frustrated and it's not an issue I do not chart it. Record review of the 01/24/2018 care plan for alteration in mood patterns related to depression, tearfulness or negative statements the goal of the resident's identified mood symptoms would be improved and resolved with use of behavioral interventions. The interventions for alteration in mood patterns, included to administer the anti-depressant, encourage resident to attend activities, if the resident verbalizes negativity or tearfulness check for pain or discomfort and express encouragement to the resident. During an interview on 07/13/2021 at 3:12 PM with Staff F, SS Supervisor, stated that she filled out the behavior summary sheet for their monthly [CONDITION(S)] meetings. The Behavior Summary sheet showed the number of target behaviors the resident experienced in the time frame on each shift. Additionally, SS quantified the number of target behaviors to determine the effectiveness of the anti-depressant medication on the resident's mood. Staff F stated the resident did not have any targeted behaviors charted and that there have been zero incidences of those behaviors. The behaviors were not clearly defined in the resident's MAR as individualized target behaviors, and there were multiple other behaviors that were not reflected in the care plan. During an interview on 07/13/2021 at 3:30 PM, Staff J, RN, stated that the Director of Nursing Services (DNS), the Assistant DNS (ADNS), SS Supervisor and Activities Supervisior met on a monthly basis to conduct the [CONDITION(S)] meetings. During an interview on 07/13/2021 at 3:45 PM, the DNS stated that the pharmacist sent their recommendations and any other irregularities. The DNS sent the pharmacy recommendations to the physician. The physician and pharmacist were not involved in any [CONDITION(S)] meetings. The [CONDITION(S)] meeting team made recommendations to the physician. Resident 13. Review of the resident's medical record showed the resident admitted on [DATE] with diagnoses to include [CONDITION(S)] disease (a progressive disease of the nervous system), dementia and left sided paralysis. Review of the 04/28/2021 quarterly assessment showed the resident required extensive assistance from staff for all care needs, had severely impaired cognition and was prescribed and administered medications which included anti-psychotic, anti-depressant and an opioid. Review of the physician orders, dated 09/26/2020, showed the resident received [MEDICATION(S)] (anti-depressant medication) and [MEDICATION(S)] (anti-psychotic medication) once daily. Review of the Pharmacy Consultation Report, dated 03/22/2021, showed a recommendation that the record contain, .specific target behavior(s), desired outcome(s), and the effectiveness of individualized nonpharmacological interventions . Review of the facility's February and March 2021 behavior monitoring documentation for Resident 13 showed no documentation of behaviors nor non-pharmacological interventions. During an interview on 07/15/2021 at 11:00 AM, Staff F, SS Supervisor, stated that her process for the [CONDITION(S)] review was to talk back and forth with Staff N, Registered Nurse/Charge Nurse. She stated that she talks with the Nursing Assistants (NAs) but unfortunately the staff had not monitored and documented behaviors in the medical record. Resident 35. Review of the medical record showed the resident was admitted to the facility on [DATE] with multiple medical and psychiatric conditions. Record review of Resident 35's PRN medication review for 06/23/2021 through 07/07/2021 showed, that the resident had [CONDITION(S)] medications prescribed to treat excessive worrying and anxiety. The resident's MAR for June and July 2021, identified general behaviors to monitor that included: restlessness and agitation, inability to sit still and remain calm, social withdrawal and isolation, and excessive worrying. The June and July 2021 MAR's showed documentation that the resident had not experienced any of the target behaviors. During an interview with Staff F on 07/16/2021 at 10:34 AM, she stated that the documentation on target behaviors was not accurate, showing the resident did not have any documented behaviors. During an interview on 07/16/2021 at 12:24 PM, Staff B, DNS, stated that she would expect that the behaviors of the resident to be documented to reflect the resident's current behavior status. Reference WAC-388-97-1060 (3)(k)(i)

Based on observation, interview, and record review the facility failed to ensure one of one resident (42) reviewed for [CONDITION(S)] (filtering of the blood to rid the body of toxins), received necessary monitoring and assessment post [CONDITION(S)] visits. This failure placed the resident at risk for infection and illness related to secondary complications as the facilty was not monitoring the [CONDITION(S)] access site after-[CONDITION(S)] treatment. Findings included . Review of the facility's Specialty Care/[CONDITION(S)] Services policy, dated 3/2016, showed the policy intent was to outline care and services for [CONDITION(S)] residents in order to prevent infections and other [CONDITION(S)]-related complications. Section 5 of the policy showed .Fistula ([CONDITION(S)] access that connects an artery to a vein)/shunt (catheter/[CONDITION(S)] access into the main artery of the heart),) site will be checked every shift for bruits(sound/indicator of how well [CONDITION(S)] access is functioning), bleeding, increased pain, and signs of infection . Resident 42. Review of the medical record showed the resident readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 06/04/2021 quarterly assessment showed the resident was cognitively intact, required two person assistance for bed mobility and received [CONDITION(S)] three times per week. During an observation on 07/12/2021 at 7:14 PM, the resident had just returned from a [CONDITION(S)] appointment. She stated that she was very fatigued. Her skin was observed to be pale and bluish gray in color. She then showed this surveyor an area on her right upper chest where she had a [CONDITION(S)] catheter/access site, and the area was covered with a transparent, adhesive tape. Review of the resident's 07/12/2021 orders did not identify the [CONDITION(S)] catheter site nor provide direction/monitoring for signs and/or symptoms of infection or complications related to the catheter site. During an interview on 07/13/2021 at 11:03 AM, Staff H, Assistant Director of Nursing Services, stated that the resident required monitoring of the catheter site twice per day for signs of infection. I think there was confusion and it was not added to the order. During an interview on 07/14/2021 at 9:27 AM, Staff B, Director of Nursing Services, stated that monitoring of the resident's catheter should have been on the treatment record and there needed to be an order we missed it. Reference: WAC 388-97-1900(1), (6)(a-c)

Based on interview and record review, the facility failed to honor choices, a) for one of two sampled residents (40), for a requested medication time change due to receiving a medication at 4:00 AM which disturbed her sleep, and was unable to go back to sleep, and b) for one of one sampled resident (68), for notification of scheduled times of therapy services. This failure caused Resident 40 to experience sleep deprivation and disallowed Resident 68 to make choices about aspects of his life in the facility that were significant to him. Findings included . Resident 40. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/28/2021 comprehensive assessment showed the resident was alert and able to make her own decisions, and required extensive assistance with most activities such as bed mobility, dressing, bathing, toileting, transfers, and hygiene. During an interview on 07/07/2021 at 9:51 AM, the resident stated that the nurses woke her up at 4:00 AM to give her [CONDITION(S)] medication. She stated the staff were waking her up too early in the morning and this had been happening for a long time. She stated she had asked them not to wake her so early in the morning because she had trouble failing back to sleep. The resident stated breakfast was served between 7:30 AM to 8:00 AM. Review of the resident's July 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Mosby's 2021 Nursing Drug Reference, 34th edition showed that [CONDITION(S)] medication was best absorbed on an empty stomach from 30 minutes to an hour before a meal. Review of the resident's care plan, dated 01/14/2021, showed the resident took an anti-depressant which was for depression and [CONDITION(S)] due to the resident's inability to go back to sleep after being awake. During an interview 07/14/2021 at 1:00 PM, Staff J, Registered Nurse (RN), stated that the resident did have problems sleeping and that 4:00 AM was too early to give the [CONDITION(S)] medication. She stated it was assigned to the night nurse to give the resident the medication at least an hour before breakfast. Resident 68. Review of the resident's medical record showed the resident was admitted to the facility on [DATE]. The record showed the resident had diagnosed including, diabetes, heart disease, depression, and had potential for mood problems, and was able make his needs known. During an interview on 07/09/2021 at 9:08 AM, Resident 68 stated that he recieved physical and occupational therapy, but had not received a schedule for therapy services. He felt that he had to stay in his room, not go anywhere and wait for one of the therapists to come. Additionally, he stated that they usually come sometime in the morning and sometime in the afternoon and stated he felt like a [NAME] (being passed back and forth). He stated he had wanted to get his hair cut on Wednesday, but was not able because he was in therapy, now he would have to wait another week. He explained that the barber only came to the facility on Wednesday afternoons. Additionally, he did not not participate in activities because he did not know when they were going to come and get him for therapy. During an interview on 07/15/2021 at 10:46 AM, Staff AA, Physical Therapist, stated that the therapy department did not have set schedules for residents who received therapy and that residents received therapy when the staff were available. Resident 68 was seen twice a day for physical and occupational therapy. During an interview on 07/15/2021 at 11:03 AM, Staff V, Occupational Therapist, stated that she was not aware that the resident wanted to be on a schedule. Reference WAC 388-97-0900(1)-(4)

Based on observation, interview, and record review, the facility failed to provide consistent, respectful resident care in a manner that promoted the resident's dignity and maintained or enhanced the quality of life for two of three residents (270, 68), reviewed for dignity. This failure placed the residents at risk for embarrassment, diminished self-esteem, and a decrease in quality of life. Findings included . Record review of the policy and procedure titled Activities of Daily Living - Bowel and Bladder Evaluation, dated 07/2015 showed, .to offer a structured, goal-oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence . Resident 270. Review of the resident's medical record showed he admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission assessment, dated 07/08/2021, showed he was able to make his needs known and was dependent on staff for toileting needs, but was continent of bowel and bladder. During an observation on 07/13/2021 at 2:55 PM, Resident 270's call light was on, his wife was with him at his bedside, and he was upset yelling at his wife to Get help! Resident 270 was moaning and stated, Come on, I need somebody now. At 3:08 PM, a licensed nurse came out of the room across the hall and turned right, she looked up at the light but did not address the light. The wife went out to the hall and told the nurse that her husband needed to use the bed pan. The nurse stated that she would get someone to help. During an observation on 07/13/2021 at 3:10 PM, Staff W, Nursing Assistant (NA), entered the room and was unable to locate a bed pan in the room and left to find one. Staff W came back with the bed pan and asked Resident 270's wife if the resident could move independently, or if he needed assistance. The wife was unsure, and she offered to help Staff W turn the resident. Resident 270 cried out, I cannot hold it anymore. Staff W then told the resident to have the bowel movement in his briefs and told the resident's wife to use the call light when the resident was done. Staff W came back in the room at 3:30 PM to get the resident cleaned up. During an interview on 07/13/2021 at 4:41 PM, Staff W stated that he would normally check the care plan that was located in each of the residents' closets which described the resident's activity levels. However, Staff W stated he did not have enough time to check the paper prior to assisting the resident, and that it was too late anyway, because the resident had already had the bowel movement in his brief. During an interview on 07/14/2021 at 3:48 PM, Resident 270 stated that when someone was in a facility to be cared for, they should not have to have a bowel movement in their pants, .like I need my mommy. The resident also stated that he was embarrassed and that it should not have happened. During an interview on 7/15/2021 at 12:00 PM, Staff Y, Director of Staff Development, stated that she was responsible for the ongoing training of staff. She stated that it was not acceptable to tell a resident to soil themselves. Additionally, she stated that her expectation was that if there was not enough help, that all staff (Directors and Licensed Nurses) needed to help the NAs. She further explained that she would do some training on dignity and that Staff W was new and needed additional training. During an interview on 07/16/2021at 12:13 PM Staff B, Director of Nursing Services, stated that telling a resident to soil themselves in their brief was not acceptable. Resident 68. Review of the medical record showed the resident was admitted to the facility on [DATE] and was being prepared for discharge. The resident's record showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the 06/21/2021 comprehensive assessment showed the resident was alert and able to make his needs known. An observation on 07/13/2021 at 2:55 PM, showed the resident was being assisted in the bathroom by Staff FF, Physical Therapy Assistant. The resident was informed by Staff FF, while he was on the toilet and unable to sign at that time, that he no longer qualified for funding due to an insurance decision. Staff FF further explained that he could appeal the discharge decision and she would leave a form on his bed which contained a number he could call to appeal the decision. During an observation on 07/13/2021 at 4:57 PM, the facility's Notice of Medicare Non-Coverage, was on the resident's bed on his pillow, with a phone number highlighted on the form and it was not signed by the resident. During a concurrent observation and interview on 07/14/2021 at 3:05 PM, Resident 68 was heard making phone calls to Assisted Living Facilities and home health agencies. The resident then showed a list of numbers and stated This is the list of phone numbers the facility gave me so I could call because I need help when I am discharged .I need to have some place to go when I get discharged . He further stated that he made calls to find out how much each facility would cost but then was told he was asking the wrong questions and he should have asked if they had a room available. He stated, I don't know, this is very frustrating. During an interview on 07/15/2021 at 3:36 PM, Resident 68 stated that he was frustrated, his phone was not working, and that he had not received any assistance from Social Services. During an interview on 07/15/2021 at 11:54 AM, Staff B, Director of Nursing Services, stated that it was not an acceptable process to give discharge instructions to a resident while they were on the toilet. Reference: WAC 388-97-0180 (1-4)

Based on observation, record review, and interviews the facility failed to identify and implement interventions to ensure a safe environment for 5 of 26 residents (#'s 2,3,4,5,6) that occupied beds near baseboard heaters. This resulted in actual harm to Resident #2 as he sustained second degree burns to his knees, which came into contact with the baseboard heater in his room. Findings include: Resident #2: Review of the medical record revealed he was admitted to the facility on [DATE] for end of life care. Other [DIAGNOSES REDACTED]. Review of the facility investigation report, dated 05/10/17, noted the resident was alert and oriented to self only. He had generalized weakness; swelling to both legs, required extensive one person assistance with transfers and two assist with bed mobility; and was unable to walk. He was at high risk for falls, thus was placed on a concave mattress (reduced the risk of falling out of bed) with a pad alarm to his bed and wheelchair to notify staff if he attempted to get up unassisted. Per above investigation report the resident was found by Staff C (Nursing Assistant - NA) on 05/06/17 at approximately 2:30 a.m. lying on his right side at the edge of his bed. The resident's right knee was touching the face of the baseboard heater, and the left, inner knee was resting on top of the heater. The resident, who had last been observed by Staff C lying on his back at 2:15 a.m., had turned himself onto his right side. Staff C immediately summoned Staff D (Licensed Nurse - LN), and together they placed the resident's legs back onto the bed. Reddened areas measuring 7 by 8 centimeters (cms) to the right knee, and 5 by 10 cms to the left knee were noted. Later that same day a nursing assessment revealed the above reddened areas had started to blister (second degree burns), thus prescribed treatments were ordered by the physician. An interview on 05/12/17 at 11:30 a.m. and 05/31/17 at 10:20 p.m. with Staff C revealed the resident's bed was approximately 1.5 feet away from the baseboard heater at the time of the above incident. She stated she was aware the bed was to be away from the heater, but on the night shift residents were generally sleeping so she did not pay much attention regarding bed placement. Staff D, who was interviewed on 05/12/17 at 11:27 a.m. and 05/31/17 at 5:47 a.m., stated the resident's pad alarm on his bed did not sound as it was only his legs that were out of the bed. She stated the bed was approximately 1.5 feet away from the baseboard heater, as she was able to get between the bed and heater to reposition the resident. It was general knowledge that nothing was to be pushed up against the heater, and most of the night stands were between the beds and heaters. She was not aware of any facility policy regarding bed placement in relation to the heaters in residents' rooms, nor had she received any training. Per interview with Staff E (Director of Nursing) on 05/12/17 at 9:58 a.m., she stated that following the burn incident on 05/06/17 staff found four additional residents (#'s 3,4,5, 6), with beds approximately 1.5 feet away from the heaters, with no night stands between the bed and heater. In addition, signs were placed above the heaters with a warning that it was a hot surface and to keep the bed away from the heater. Resident #3: review of the resident's medical record revealed [REDACTED]. Review of the quarterly nursing assessment, dated 05/01/17, revealed the resident was oriented to self only, memory deficits, and required staff assistance with activities of daily living. Review of his plan of care, dated 02/18/14, noted he had limited mobility, impaired balance, unaware of safety needs, and had a history of [REDACTED]. Review of Progress Notes (PNs) on 01/01/17 noted the resident had an unwitnessed fall from his bed at 12:05 a.m. He had rolled out of bed when attempting to stand up, lost his balance, and slid to the floor between his bed and the heater. He sustained an abrasion to the back of his arms. Following the investigation bolsters (long pillows or cushions) were to be placed on both sides of his bed. Observation of the resident on 05/26/17 at 12:30 p.m. noted he was eating lunch in bed. There were no bolsters on either side of his bed. Resident #4: Review of the resident's plan of care, dated 01/23/17, noted she was at risk for falls, and had sustained a hip fracture following a fall at her home. An interview with the resident on 05/26/17 at 11:46 a.m. revealed she was using the window sill to help herself reposition in bed. At that time the bed was very close to the window. Staff had never discussed with her any risks involving the baseboard heaters, until a sign was placed above the heater. Resident #5: review of the resident's medical record revealed [REDACTED]. Review of the resident's plan of care, dated 10/11/13, noted he had impaired cognition, unable to make his needs known, required total assistance with activities of daily living, and was at risk for falls due to his rocking type movements. The resident was observed at 1:10 p.m. on 05/26/17 seated in his wheelchair. He was rocking himself back and forth with continuous movements of his arms. Resident #6: review of the resident's medical record revealed [REDACTED]. Review of her plan of care, dated 12/15/15, noted she was at risk for falls due to being unaware of safety needs, confusion, wandering behaviors, and history of falls. Per interview with Staff E on 05/26/17 at 10:30 a.m. , she stated prior to the burn incident on 05/06/17 she tried to remind staff night stands were to be placed between the residents' beds, and the baseboard heaters. During stand-up meetings (attended by department heads) they talked about it, especially during the winter months. Residents and families (with the exception of one) had never been informed relative to the risks of burns/fire hazards due to the baseboard heaters, nor was it addressed on their plans of care. In addition, there was no evidence of a facility policy, or training relative to the risks associated with baseboard heaters. Interviews conducted on 05/26/17 between 11:00 a.m. to 12:02 p.m. with Resident #'s 1,4,7,8,9 (all who occupied beds near baseboard heaters), revealed staff had never discussed with them (prior to 05/06/17) the risks associated with the heaters and the need to keep their beds a specified distance away from the heaters. Interviews conducted on 05/25/17 between 10:53 a.m. and 1:28 p.m. with Staff F (Maintenance Supervisor), Staff G (Housekeeping Supervisor), Staff H, I (NAs), Staff J, K, L, M, N (LNs), revealed that prior to 05/06/17, they had not received training relative to the baseboard heaters, and the need to place night stands between the beds and heaters. They denied being aware of any facility policy with bed placement relative to heaters. They were aware they needed to keep beds away from heaters, but there was no specified plan to prevent injuries. Reference: (WAC) 388-97-1060(3)(g)

Based on observation, interviews, and record reviews, the facility failed to provide necessary supervision to ensure resident care was provided in accordance with the plan of care for 1 of 2 sampled residents (#1) reviewed who required staff assistance with their meals. Failure to follow the resident's plan of care resulted in actual harm to Resident #1, who sustained second degree burns from hot chocolate. Findings include: Resident #1. An assessment dated [DATE] by the Speech Therapist revealed the resident had been one to one tray assistance due to impulsivity and poor safety awareness. A second assessment dated [DATE] stated the resident was able to feed himself 90-100% of the time with constant supervision. The resident tended to be impulsive, thus required staff to cue him to slow down. Review of an assessment dated [DATE] by Social Services noted the resident had extensive care needs due to a brain condition, dementia, and stroke with left sided weakness. The resident was alert and oriented only to self. His short and long term memory was poor, and decision making severely impaired. Review of the resident's plan of care, dated 9/19/14, noted he had a problem with swallowing and was to eat only with supervision. He required tray assistance by staff in his room or the dining room. Review of the facility investigation report and resident's medical record revealed during the dinner meal on 7/4/16 the resident's meal tray was delivered by Staff A, Nursing Assistant, to his room and placed on the table at the side of his bed. Leaving all food and beverage items uncovered Staff A left the room to obtain a clothing protector for the resident. Before he returned to the room the resident had reached for the hot chocolate, removed the plastic lid, and spilled most of the hot beverage onto his shirt. Staff A immediately removed the wet shirt and placed a clean gown on the resident. The following morning at 11:08 a.m. on 7/5/16 (approximately 17 hours after the incident) the resident was found with redness and blisters (second degree burns) to his upper chest. The redness was V-shaped and measured 8.0 by 3.2 centimeters (cms) at the top of the V, and 15.0 by 3.8 cms at the bottom. The two blistered areas measured 3.5 by 1.6 cms and 3.0 by 1.7 cms. The physician was notified on 7/5/16 and orders were received to apply a medicated cream to the resident's burns. An interview on 7/8/16 at 11:45 a.m. with Staff B, Food Service Manager, revealed the hot water used in making the resident's hot chocolate was approximately 180 degrees at the spicket. The hot beverage was the last item placed on the resident's meal tray just prior to staff taking the meal tray directly from the kitchen to the resident's room. Staff A stated on 7/8/16 at 2:23 p.m. he obtained the resident's meal tray and placed it on the table next to his bed. He left the room and when he returned, less than a minute later, the resident had spilled three quarters of his hot chocolate onto his shirt. The resident rarely spoke at any time he had cared for him. He changed the resident's shirt, briefly saw his skin, (which had no problems), but was focused on cleaning him up. Staff A did not visualize the resident's skin later in the shift, and did not report the incident to anyone, as he did not realize the hot chocolate was hot enough to burn him. Observation of the resident's skin on 7/8/16 at 11:30 a.m. noted a reddened area over the right side of his chest with a white cream covering it. The resident was observed on 7/8/16 at 12:47 p.m. eating independently with staff supervision in the dining room. He was able to pick up his cup and utensils without difficulty.

Based on observation, interview and record review the facility failed to A) provide sufficient supervision to prevent falls for 1 of 3 sampled residents (#34) reviewed for falls with injuries, and B) ensure a safe environment and adequate supervision was provided during 3 of 4 dining room observations that included residents #66 and #156. This failed practice resulted in actual harm to Resident #34 who sustained a fractured left hip and dislocated left shoulder following a fall. Findings included: A) Resident #34: admitted to the facility on [DATE] from the hospital following surgery on 02/26/13 for a fractured right hip sustained following a fall at his home. Other [DIAGNOSES REDACTED]. Review of a nursing assessment dated [DATE] noted the resident had unsteady balance and gait. He required two staff members to assist with transfers and had a tendency to lean backwards during the transfer. On 03/06/13 documentation revealed the resident was oriented to self only with confusion noted, had right lower extremity weakness, unsteady gait, and required two staff members for transfers and toileting to provide weight bearing support. Review of the Fall Risk Assessment form dated 03/01/13 revealed the resident was at high risk for falls as evidenced by a score of 21 (above 10 denoted high risk). Review of the initial assessment dated [DATE] by the Occupational Therapist (OT) noted his standing duration was less than 30 seconds, oriented to self only, and was totally dependent on staff for his toileting needs and transfers. On 03/08/13 the OT noted the resident was fatigued with extended sitting on the edge of his bed. Review of the resident's plan of care revealed he was at risk for falls due to his history, dialysis treatments, weakness, visual impairment (hearing loss and wore glasses), pain issues, poor weight bearing, stiffness, and unsteady gait. He was disoriented to place, time, and his room and exhibited memory impairment. He required two staff to assist with transfers, non-ambulatory with staff, and was incontinent of bowel and bladder. Review of the facility investigation report revealed on 03/09/13 at 2:20 a.m. Staff EE Nursing Assistant (NA) had walked into the resident's room and found him walking to his bathroom. She assisted him to the toilet and asked him to put his call light on when he had finished. She then left the resident's room to inform a second NA she was taking a break. Shortly after the resident got up from the toilet and started walking without any assistive device. He fell in the doorway of his room on his left side. Due to complaints of pain in his left shoulder and hip he was transferred to the emergency room that morning where x-rays revealed a fractured left hip and dislocated shoulder. A telephone interview on 04/01/13 at 3:50 p.m. with Staff Member EE revealed on the morning the resident fell (03/09/13) she had come over to the south unit, (where the resident resided) to inform the NA working on that unit she was going on her lunch break. She observed the resident ambulating to the bathroom thus she assisted him to the toilet. She stated she had never worked with the resident before and did not know him. She stated she thought he was going to pull his call light and ask for help. Despite Staff Member FF Licensed Nurse (LN) being directly across from the resident's room at that time she did not inquire as to whether the resident could be left alone on the toilet or not. Rather she exited the resident's room leaving him seated on the toilet and informed the other NA she was taking her lunch break and the location of the resident. During a telephone interview on 04/01/13 at 3:11 p.m. with Staff Member FF, (nurse in charge of the resident's care on 03/09/13), she stated she was doing her charting at the nursing station, located directly across from the resident's room, at the time the resident fell . She stated within minutes after being placed on the toilet he was on the floor. The resident had never been up out of bed on previous night shifts. She stated that due to his fall history he never should have been left alone by staff while seated on the toilet. At the time Staff Member EE left the resident's room to go on her lunch break Staff Member FF was unaware he was still on the toilet. An interview on 03/28/13 at 1:45 p.m. with Staff Member G Resident Care Manager revealed the resident had returned from dialysis at approximately 4:30 p.m. the afternoon prior to his fall. She stated he was always more confused and weaker following his dialysis treatments. He required two staff members to assist with transfers and never should have been left alone on the toilet without staff in attendance. Despite the resident's significant history of injuries with falls, confusion with memory deficits, weakness and fatigue associated with dialysis treatements, need for two staff members to assist with transfers, and unsteady gait and balance; the resident was left seated on the toilet with no staff in attendance at which time he self-transferred and fell sustaining significant injuries due to lack of staff supervision. Resident #156. admitted on [DATE] with [DIAGNOSES REDACTED]. The current 12/17/12 care plan addressed his multiple and ongoing skin tears and bruises on his hands, arms, and/or legs. Due to weakness and impaired gait and standing balance, he required a wheelchair for mobility. On 03/20/13 at approximately 7:30 a.m., Resident #156 was observed as he was set up by Nursing Assistant (NA), Staff Member P, at the dining room table. He was seated in his wheelchair with the foot rests extended. As Staff Member P pushed him up to the table, his right knee hit the table edge where it remained. The resident was not assisted in backing the knee away from the table edge. He called out "oww! Help me I can't get my knee down." Staff Member P turned to look at him and then left the room without futher assist. No other staff came to assist. The resident moved his right leg putting his foot/leg under the foot rest. When interviewed on 03/20/13 at 1:30 p.m. the resident was unable to answer questions, including about hitting his knee on the table at breakfast. On 03/21/13 at 11:30 a.m., Resident #156 was observed seated at the dining room table awaiting the noon meal service. His wheelchair leg rests were extended, preventing him from being closely seated to the table as his left knee was slightly bent and about 1/2-1 inch above the table edge. Although not touching the edge, it was within a couple of inches from it. The resident's right knee was approximately 1/2 inch below the edge of the table. The resident looked at his right knee, touched it, and said "you can't get in there." He then moved his legs so that both were below and under the leg and foot rests. He continued to move his legs above and below the leg/foot rests. Upon being served his meal, a NA did lower the leg rests and position the wheelchair to prevent the resident from hitting the table with his lower legs. However, the resident had remained at risk of accidentally striking the table with his lower legs due to the original positioning. Other Nursing Assistants were in and out of the dining room bringing residents to the meal and there was no one supervising the resident's positioning for approximately ten minutes. Resident #66. admitted [DATE] with a stroke causing [DIAGNOSES REDACTED] (weakness on left side of the body), spinal stenosis, and dementia. The current 05/11/12 care plan identified his ability to feed himself with "good tray set-up" and the need for staff to "make sure I am sitting upright for all meals, notify my charge nurse of any s/s (signs) of choking or difficulty swallowing." With a declining medical condition, the resident was on comfort care, had nausea and vomiting, had had difficulty tolerating foods and fluids. On 03/27/13 at 4:05 pm, the resident was observed positioned at the dining room table in a reclined angle in his wheelchair. He was reaching down his body to the table in order to get a bite of food and feed himself. Assistive devices were on the table, out of reach. When a NA walked by, the resident asked what food items he was eating, stating he "can't see it." The NA left to assist other residents. Still reclined at 4:10 p.m., he ate a spoonful of ice cream and coughed. At 4:15 a NA returned to ask if she could help him. He said yes and she moved him to the assisted eating table where he was scooted back in his chair by NAs and the chair back was raised so he was at a more upright position. He continued to feed himself after the repositioning. Resident #66 was not free of a hazard risk on 03/27/13. Facility staff did not ensure the resident's environment and assistive device (wheelchair) was adjusted for proper positioning at the table in order to avoid a choking hazard with potential aspiration of food items.