Every finding on record at Park Shore

Based on observation, interview, and record review, the facility failed to ensure handrail/support bars in resident bathrooms were maintained and were safe to use for 3 of 4 residents (Residents 23, 24 & 25) and failed to ensure plastic bags were not used as light switch pullcords for 2 of 4 residents (Residents 24 & 11), reviewed for environment. Additionally, the facility failed to ensure a homelike environment when medications were administered in the dining room for 1 of 11 residents (Resident 2), reviewed for medication administration. These failures placed the residents at risk for injury, a less than homelike environment, and a diminished quality of life.Findings included. Review of the facility's undated policy titled, Physical Environment, Maintenance, and Housekeeping Policy and Procedure, showed that the facility shall maintain a clean, well-maintained, hazard-free environment that supports resident health, safety, infection prevention, and quality of life. Review of the facility's policy titled, Homelike Environment Policy, revised on 01/01/2025, showed that the facility will ensure that the physical environment is safe, clean, orderly, and as homelike as possible. It further showed that the facility will promote a person-centered care environment that minimizes institutional characteristics while maintaining compliance with life safety, infection prevention, and resident safety standards. RESIDENT 23Observations on 12/02/2025 at 11:00 AM and on 12/03/2025 at 11:06 AM showed that the handrail/support bar in Resident 23's bathroom was not secured and was coming away from the wall. RESIDENT 24 & 25 (room [ROOM NUMBER])Observation on 12/02/2025 at 1:48 PM and on 12/03/2025 at 11:50 AM showed the light switch pullcord above Resident 24's bed had a plastic bag tied to it. It further showed that the handrail/support bar in Resident 24 and Resident 25's bathroom was loose/wobbly. RESIDENT 11Observation on 12/02/2025 at 11:28 AM and on 12/03/2025 at 12:00 PM showed the light switch pullcord above Resident 11's bed had a plastic bag tied to it. In an interview and joint observation on 12/03/2025 at 2:09 PM, Staff S, Certified Nursing Assistant (CNA), stated that if the handrails in a resident's bathroom were loose/wobbly they would notify the nurse and put in a maintenance request. Staff S stated that the plastic bags were being used to extend the light switch pullcord so residents could reach it. Joint observation of Resident 24's room showed a short light switch pullcord attached to a plastic bag. It further showed the handrail/support bar in Resident 24 and Resident 25's bathroom was loose/wobbly. Staff S stated, it's [it is] a little wobbly, could be tighter. Joint observation of Resident 11's room, showed Staff S pointed at the light switch pullcord and stated that it has the plastic bag attached. Joint observation of Resident 23's bathroom handrail/support bar showed that it was not secure, and Staff S stated, it looks like it's coming off [from the wall] a little. In an interview and joint observation on 12/03/2025 at 11:53 AM, Staff T, Director of Facilities, stated that they checked resident rooms weekly. Staff T stated that they expected staff to put in a work order if they noticed anything in disrepair. Joint observation at 3:15 PM with Staff U, Maintenance Supervisor, showed that the bathroom handrail/support bar in Resident 23's bathroom was not secured and was coming away from the wall. Staff U stated, looks like the dry wall is cracking, definitely not safe, need to replace the wall. Joint observation of Resident 24 and Resident 25's bathroom showed that the handrail/support bar was loose/wobbly. Staff U stated that the handrail was for sure loose, needs to be tightened. It might need to be replaced. It further showed that there was a plastic bag attached to the light switch pull cord above the beds of Resident 24 and Resident 11. Staff U stated that the plastic bags were added by CNAs to make the light switch easier to pull. Staff U further stated that they had connectors that could be used instead and the plastic bags shouldn't [should not] be used. In an interview on 12/08/2025 at 8:16 AM, Staff A, Administrator, stated they expected maintenance to do some walkthroughs [of resident rooms] and as needed. Staff A stated they expected loose/wobbly handrails in resident bathrooms to be reported to maintenance if they need to be tightened. When asked about the plastic bags tied to the light switch pull cords in some of the resident rooms, Staff A stated, I never heard of that. Joint observation of Resident 24's room showed a short light switch pullcord attached to a plastic bag. Staff A stated, it's not ideal. RESIDENT 2Observation on 12/02/2025 at 12:20 PM, Staff F, Registered Nurse, administered Morphine Sulfate (medication to treat pain) to Resident 2 who was sitting upright in their wheelchair at the dining room table with food in front of them and one other unknown resident at the dining room table. In an interview on 12/02/2025 at 12:22 PM, Staff F stated Resident 2 did not take their medications in the dining room and that they should not have administered their medications in the dining room. Review of Resident 2's comprehensive care plan and physician orders printed on 12/03/2025 showed no documentation that Resident 2 received their medications in the dining room. In an interview and joint record review on 12/03/2025 at 2:05 PM, Staff B, Director of Nursing Services, stated that a resident could take their medications in the dining room if they agreed and if it was care planned. Joint record review of Resident 2's physician orders, care plan, and nursing tasks did not show Resident 2 could take their medications in the dining room. Staff B stated they did not see it in the physician orders, care plan, or nursing tasks to give Resident 2's medications in the dining room and that it should have been care planned that they agreed to take it in the dining room. Reference: (WAC) 388-97-0880 (1) .

Based on observation, interview, and record review, the facility failed to ensure medications were secured for 2 of 2 medication carts (Medication Cart 1 and Medication Cart 2), reviewed for medication storage. This failure placed the residents at risk to have unintended access to medications and biologicals that should have been locked and/or compromised medications.Findings included.Review of the facility's policy titled, Medication Administration-General Guidelines, revised in January 2023, showed that the medication cart is kept closed and locked when out of sight of the medication nurse or aide.Observation on 12/02/2025 at 11:21 AM, showed Medication Cart 1 and Medication Cart 2 were unlocked, parked, and unattended at the nurse's station.In an interview and joint observation on 12/02/2025 at 11:26 AM, Staff F, Registered Nurse, stated that the medication cart should have been locked when they were not near them. Joint observation showed Medication Cart 1 and Medication Cart 2 were unlocked. Staff F stated they should have been locked.In an interview on 12/03/2025 at 2:05 PM, Staff B, Director of Nursing Services, stated that when the nurse leaves the medication cart, it should be locked. Staff B stated they expected Medication Cart 1 and Medication Cart 2 to have been locked as any resident or someone could get into the medication cart and access it if it was unlocked.Reference: (WAC) 388-97-1300 (2).

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 5 of 5 refrigerators (PM [Evening] Production Floor Refrigerator, Walk-in Main 2 Refrigerator, Dairy Healthcare (HC)/Assisted Living (AL)] Dressing 3 Refrigerator, Second Floor Kitchen Refrigerator & Second Floor Resident Supplement Refrigerator), reviewed for food services. The failure to label and discard food items past the use by/best by date, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included. Review of the facility's policy titled, Date Marking for Food Safety, revised on 08/01/2025, showed, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The policy showed, The individual opening and preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The policy further showed, The Head [NAME] or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. PM PRODUCTION FLOOR REFRIGERATORIn an interview and joint observation on 12/02/2025 at 9:11 AM, Staff M, Cook, stated that any food items that have been opened needed to be labeled with an open date and expiration date. Staff M stated that if food items were past the use by or expiration date, it should be discarded. Joint observation showed one uncovered container of green peas with no label or use by date. Staff M stated that it should have been covered and labeled. WALK-IN MAIN 2 REFRIGERATOR Joint observation and interview on 12/02/2025 at 9:15 AM with Staff M, showed the following:-One plastic container of celery with use by date of 12-1 [12/01/2025].-One large plastic container labeled Casserole Sauce with use by date of 11-28-25 [11/28/2025].-One plastic container labeled Limon [Lemon] with use by date of 12/01/2025.-One plastic container labeled Pepperoncini with use by date of 11/30/2025.-One plastic container of Pico de Gallo [salsa] with use by date of 11/30/2025.Staff M stated that food items that were past the use by date should have been thrown out as soon as it was noticed. Staff M further stated that everyone was responsible for checking. DAIRY HC/AL DRESSING 3 REFRIGERATORJoint observation and interview on 12/04/2025 at 10:48 AM with Staff L, Executive Chef, showed the following items:-One plastic container labeled Romaine lettuce with use by date of 12/02/2025.-One plastic container labeled Mandarin Oranges with use by date of 11/30/2025.-One opened container of Dannon (brand name) Vanilla low fat yogurt labeled with preparation date of 11/11 [11/11/2025] with no use by date. Further observation showed that the container had a best if used by date of 11/28/2025.-Four unopened containers of Dannon Vanilla low fat yogurt with best if used by date of 11/28/2025.-Three unopened Yoplait [brand name] original yogurt with best by date of 12/02/2025. Staff L stated that if food items were past the use by or best by date, they would be discarded. Staff L further stated that the above items should have been discarded and that the opened container of Dannon Vanilla low fat yogurt should have been labeled with the use by date. SECOND FLOOR KITCHEN REFRIGERATORJoint observation and interview on 12/05/2025 at 2:24 PM with Staff N, Dietary Manager, showed one red raspberry Yoplait yogurt with best by date of 12/03/2025. Staff N stated that it should have been discarded. In an interview on 12/05/2025 at 3:23 PM, Staff A, Administrator, stated that they expected food items to be labeled and those that were past the used by/best by date should be discarded. SECOND FLOOR RESIDENT SUPPLEMENT REFRIGERATORJoint observation and interview on 12/03/2025 at 8:35 AM with Staff C, Assistant Director of Nursing, showed that the Second Floor Resident Supplement Refrigerator in the medication room had four unopened Swiss Miss (brand name) butterscotch puddings with a use by date of 10/07/2025 on the bottom shelf. Staff C stated that the four puddings with the use by date of 10/07/2025 should have been discarded.In an interview on 12/03/2025 at 2:00 PM, Staff A stated they expected the four puddings to have been discarded. Staff A stated food items expired or past the use by date should have been discarded.Reference: (WAC) 388-97-1100 (3) .

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precaution (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 2 of 9 residents (Residents 5 & 2), and failed to ensure Transmission Based Precautions (TBP- measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield] before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 1), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included. EBPReview of the facility's policy titled, Enhanced Barrier Precaution, revised on 08/01/2025, showed that EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact care activities. It further showed that an order for EBP will be obtained for residents that have indwelling medical devices such as central lines (a long, flexible tube that provides access to a person's blood supply for various purposes). Review of the facility's policy titled, Handwashing-Hand Hygiene, revised on 08/01/2025, showed that hand washing/hand hygiene was regarded as the single most important means of preventing the spread of infections. The policy showed hand washing/hand hygiene should be performed after incontinence care, after contact with blood, urine, feces, oral secretions, mucous membranes, or broken skin. The policy further showed the use of gloves did not replace handwashing. RESIDENT 5Review of Resident 5's comprehensive care plan initiated on 12/03/2025 showed that Resident 5 was on enhanced barrier protection related to IV [intravenous-in a vein] antibiotic [a medication that treats infections]. It further showed the intervention to use gown and gloves during high-contact resident activities. Observation on 12/03/2025 at 1:31 PM, showed Staff Q, Occupational Therapist, working with Resident 5 in the resident's room (EBP room). Staff Q provided range of motion exercises to Resident 5, which included touching the resident's arms, wrists, and hands. Staff Q touched a gauze bandage on the resident's left arm. Staff Q was not wearing a gown or gloves while working with Resident 5. Staff Q left Resident 5's room, did not perform hand hygiene and went to the nurse's station, where they touched the counter with their hands. In an interview on 12/03/2025 at 1:31 PM, Staff Q stated that they go by the chart or sign, to know if a resident was on any precautions. Staff Q stated that Resident 5 has a line [central line] and that they had been doing range of motion exercises and extensions with the resident. Staff Q stated they had had close contact with Resident 5 and that yes, they should have worn gloves and gown when working with the resident. Staff Q further stated that they should have performed hand hygiene after leaving Resident 5's room. In an interview on 12/08/2025 at 9:00 AM, Staff C, Infection Preventionist, stated that EBP was used for anybody who has a wound, catheter [a semi-flexible tube inserted into the bladder to drain urine], or IV. Staff C stated that they expected staff to use appropriate PPE if having high contact with a resident [on EBP]. Staff C stated that touching a resident while doing range of motion exercises with them was considered high contact. Staff C stated they expected Staff Q to wear PPE while working with Resident 5. Staff C further stated that they expected staff to practice hand hygiene when leaving an EBP room and that any healthcare worker should be doing proper hand hygiene. In an interview on 12/08/2025 at 11:16 AM, Staff B, Director of Nursing Services, stated that if a resident was on EBP, they expected staff to wear appropriate PPE if providing care including doing range of motion exercises with a resident. Staff B further stated that they expected staff to perform hand hygiene after leaving an EBP room. RESIDENT 2Review of Resident 2's physician orders printed on 12/08/2025, showed an order for EBP due to a left outer ankle and coccyx (tailbone) pressure ulcer (bedsore). Review of Resident 2's EBP care plan revised on 11/03/2025, showed Resident 2 was on EBP for left outer ankle and coccyx pressure ulcer. The care plan further showed interventions for proper hand washing or use of alcohol base hand rub before and after caring for resident and use of gown and gloves during high-contact activities such as transferring, changing briefs, and providing wound care. Observation on 12/04/2025 at 1:27 PM, showed Staff I, Certified Nursing Assistant (CNA), and Staff J, CNA, wearing a gown and gloves to transfer Resident 2 from their chair into bed using a mechanical lift. After transferring Resident 2 into bed, Staff I took the trash bin, placed it next to them and removed a wet wipe and placed it on top of its package while they removed Resident 2's foam boots. Staff I then removed Resident 2's soiled brief and took the wet wipe and began to clean Resident 2's peri-area (private area) in a downward motion, using a different wipe each time and then cleaned Resident 2's bottom. Staff I removed their gloves, applied new gloves, and then applied a barrier cream to Resident 2's bottom. Staff I then removed their soiled gloves and applied new gloves and put on a clean brief on Resident 2. Staff I did not remove their gloves when they touched and moved the trash bin, before providing peri-care to Resident 2, and did not perform hand hygiene between glove use. On 12/04/2025 at 2:03 PM, Staff I stated they should do hand hygiene before and after taking care of a resident. Staff I stated that they thought it was necessary to have their gloves removed after they touched the trash bin and performed hand hygiene. Staff I further stated it was important to perform hand hygiene to kill any bacteria or germs on their hands. Observation on 12/05/2025 at 2:12 PM, Staff E, Licensed Practical Nurse, performed hand hygiene prior to applying PPE to provide wound care for Resident 2. Staff E uncovered Resident 2's feet, removed their foam boot, and placed a trash bag in the trash bin. Staff E removed their gloves and applied new gloves. Staff E prepared the wound care supplies on a barrier on Resident 2's bed and changed their gloves. Staff E removed Resident 2's sock and used an adhesive remover to remove the old dressing. Staff E cleaned Resident 2's wound and waited for it to dry and applied the new dressing. Staff E changed their gloves and finished putting supplies away and repositioned Resident 2. Staff E did not perform hand hygiene between glove use. On 12/05/2025 at 2:22 PM, Staff E stated that they would change gloves and use hand sanitizer between different tasks. Staff E stated that they did not perform hand hygiene between glove use for Resident 2's wound care because the wound was closed and the dressing was more of a preventative measure. Staff E stated they would have performed hand hygiene between glove use if the wound had been open. On 12/05/2025 at 3:34 PM, Staff C stated they would expect staff to perform hand hygiene before and after doing resident care, before and after glove use, and whenever gloves were soiled. Staff C stated that Staff I should have changed their gloves after they touched the trash bin as it was considered contaminated and performed hand hygiene between glove use during care for Resident 2. Staff C further stated that Staff E should have performed hand hygiene between glove use during wound care for Resident 2. On 12/08/2025 at 10:25 AM, Staff B stated they expected staff to perform hand hygiene between different tasks, especially with hygiene care and between glove use. TBPRESIDENT 1Review of a face sheet printed on 12/03/2025 showed that Resident 1 was admitted on [DATE] with diagnoses that included pneumonia (lung infection) due to Methicillin Susceptible Staphylococcus Aureus (MSSA- highly contagious bacteria). Review of Resident 1's physician orders printed on 12/03/2025 showed an order to maintain droplet precautions (measures taken to prevent the transmission of infections spread through respiratory droplets when a person coughs, sneezes, talks, or breathes) every shift with a start date of 10/20/2025. Review of Resident 1's respiratory infection care plan revised on 10/31/2025 showed an intervention to Maintained droplet precautions. All staff and visitors must wear full PPE when entering the room. Educate visitors on how to properly don [put on]/doff [remove] PPE as needed. Observation on 12/03/2025 at 1:16 PM, showed a droplet precaution signage by Resident 1's door. The signage showed that EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. Staff F, Registered Nurse, performed hand hygiene and entered Resident 1's room wearing a mask. Staff F administered Resident 1's medication while Resident 1 was in bed. When Resident 1 was done taking their medication, Resident 1 coughed. When Staff F was done administering Resident 1's medication, Staff F performed hand hygiene and left the room wearing their mask. Staff F did not put on a face shield prior to entering Resident 1's room and did not remove their mask prior to leaving Resident 1's room. In another observation on 12/03/2025 at 1:23 PM, showed, Staff O, Housekeeper, entered Resident 1's room wearing gloves. Resident 1 was lying in bed asleep. Staff O placed a new trash bag in a trash bin that was by the entrance door. Staff O then took a trash bag that was by Resident 1's bed and placed the trash bag in their cart that was outside Resident 1's room. Staff O mopped Resident 1's bedroom and bathroom floor and wiped the windowsill. When Staff O was done cleaning Resident 1's room, Staff O removed their gloves and performed hand hygiene. Staff O did not wear a mask and face shield when they entered Resident 1's room. In an interview and joint observation on 12/03/2025 at 1:43 PM, Staff O stated that they did not wear PPE when cleaning resident's rooms. Joint observation of the droplet precaution signage on Resident 1's door showed to wear a mask and a face shield prior to entering the room. Staff O stated they did not wear a mask or a face shield when cleaning the resident's room because they did not provide resident care. In an interview and joint record review on 12/03/2025 at 1:55 PM, Staff F stated that Resident 1 was on droplet precaution due to MSSA. Staff F stated they would wear a mask, gown, face shield, and gloves when entering the resident's room. Joint record review of Resident 1's physician orders showed that they were to maintain droplet precautions every shift. Staff F stated that if the droplet precaution signage instructed them to wear a mask and a face shield, they should have used the appropriate PPE when they entered Resident 1's room. In a follow-up interview on 12/08/2025 at 10:20 AM, Staff F stated that staff should remove their mask prior to leaving a droplet precaution room and should apply a new one. In an interview on 12/08/2025 at 10:22 AM, Staff C stated that they expected staff to follow infection control precautions posted on residents' doors and to wear the appropriate PPE. Staff C stated that they expected staff to properly apply/remove PPE and perform hand hygiene when leaving the resident's room. Staff C further stated that they expected Staff F and Staff O to have followed the signage on Resident 1's door, wore the proper PPE, and removed their PPE appropriately prior to leaving Resident 1's room. In an interview on 12/08/2025 at 11:03 AM, Staff B stated that staff should be following the infection control signage posted on residents' doors and should be wearing the appropriate PPE. Reference: (WAC) 388-97-1320 (1)(a)(c) .

Based on observation, interview, and record review, the facility failed to ensure resident dignity was maintained related to indwelling urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) use for 1 of 2 residents (Resident 8), reviewed for dignity. This failure placed the resident at risk for decreased self-worth and a diminished quality of life.Findings included.Review of the facility's policy titled, Resident Rights Policy, revised on 08/01/2025, showed that the resident has the right to a dignified existence. It further showed the resident has a right to be treated with respect and dignity.Review of the admission Minimum Data Set (an assessment tool), dated 11/21/2025, showed that Resident 8 had an indwelling urinary catheter.Observations on 12/02/2025 at 9:57 AM and at 1:36 PM showed Resident 8 with an uncovered catheter drainage bag with yellow colored urine visible from the hallway. There was no privacy bag covering the drainage bag.In an interview and joint observation on 12/02/2025 at 3:30 PM, Staff R, Certified Nursing Assistant, stated that if a resident had a urinary catheter, we put [it] in a [privacy] bag, cover it and try to hide it. Staff R stated that it should not be visible from the hallway. Joint observation showed that Resident 8's catheter drainage bag was uncovered and visible from the hallway. Staff R stated that it should be in a [privacy] bag, it's [it is] not covered. I will cover it and went to get a privacy bag to cover it.In an interview on 12/08/2025 at 11:18 AM, Staff B, Director of Nursing Services, stated that they expected the catheter drainage bag to be covered and that a resident's urine should not be visible from the hallway.Reference: (WAC) 388-97-0180 (1)(2).

Based on interview and record review, the facility failed to provide a written transfer/discharge notice with the required information for 2 of 3 residents (Residents 5 & 3), reviewed for discharge process. This failure placed the residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights and a diminished quality of life.Findings included.Review of the facility's policy titled, Transfer and Discharge (Including AMA [Against Medical Advice] Policy, revised on 08/01/2025, showed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided . d. an explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The name, address (mailing and email) and phone number of the representative of the Office of the State Long-Term Care Ombudsman [an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations]. The policy further showed, Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because. b. The resident's health improves sufficiently to allow a more immediate transfer or discharge, c. An immediate transfer or discharge is required by the resident's urgent medical needs .RESIDENT 5Review of a progress notes dated 10/13/2025 showed that Resident 5 had a change of condition and was transferred to the hospital. Review of the discharge Minimum Data Set (MDS- an assessment tool) dated 10/13/2025 showed that Resident 5 was discharged to a short term general hospital. Review of Resident 5's Electronic Health Record (EHR) did not show documentation that a written notice of transfer/discharge was provided to Resident 5 and/or their representative. Review of Resident 5's facility provided document titled, Transfer/Discharge Report printed on 12/08/2025, did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required.RESIDENT 3Review of the progress note dated 11/25/2025 showed that Resident 3 was discharged to the community. Review of the discharge MDS dated [DATE] showed that Resident 3 was discharged to Home/Community.Review of Resident 3's EHR did not show documentation that a written notice of transfer/discharge was provided to Resident 3 and/or their representative. Review of the facility's document titled, Recapitulation [summary] of Stay with an effective date of 11/20/2025, did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required.In an interview on 12/08/2025 at 8:43 AM, Staff G, Social Services Coordinator, stated that it was their understanding that they would provide the State Nursing Home Transfer or Discharge Notice [a form that included a statement of the resident's appeal rights and Ombudsman contact information] form to residents who were being evicted from the facility, if they could not meet the needs of the resident, or if the resident was transferred to another facility. Staff G stated that on a resident/representative-initiated discharge, they would review the Recapitulation of Stay with the resident and/or representative. Staff G stated that when a resident transferred to the hospital, they did not complete the State Nursing Home Transfer or Discharge form, and that nursing staff would complete another form and would place it in the discharge packet that was given to the resident and/or their representative. When asked if Resident 5 and Resident 3 were provided a transfer/discharge notice with the required information, Staff G stated that Resident 5 was provided with the facility's Transfer/Discharge Report and Resident 3 was provided with the facility's Recapitulation of Stay.In a joint record review and interview on 12/08/2025 at 9:25 AM with Staff G and Staff A, Administrator, showed Resident 5's Transfer/Discharge Report printed on 12/08/2025 did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Staff A stated that their Transfer/Discharge Report did not have information regarding the resident's appeal rights. Staff G stated that they would do the Recapitulation of Stay for Resident 3 and that it did not include the resident's appeal rights and Ombudsman contact information. In a follow up interview at 11:17 AM, Staff A stated that they agreed that Resident 3's Recapitulation of Stay that was provided to Resident 3 at discharge did not include the resident's appeal rights and Ombudsman contact information. Staff A further stated that they would start including it with their transfer/discharge paperwork. Reference: (WAC) 388-97-0120 (2)(a-d).

Based on interview and record review, the facility failed to accurately assess 1 of 8 residents (Resident 10), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included.Review of the facility's policy titled, MDS - 3.0 - Completion, revised on 08/01/2025, showed, According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument- a guide directing staff on how to accurately assess the status of residents] specified by the State. The policy further showed all disciplines would follow guidelines in Chapter 3 of the current RAI Manual for coding each assessment.According to the Long-Term Care RAI 3.0 User's Manual, Version 1.20.1, dated October 2025, showed coding instructions to code all high-risk drug class medications according to their pharmacological (drug's uses, effects, and modes of actions) classification and not how they are being used.Review of Resident 10's face sheet printed on 12/08/2025, showed they admitted to the facility on [DATE] with a diagnosis of insomnia (a common sleep disorder that makes it hard to fall asleep or stay asleep).Review of Resident 10's physician orders printed on 12/05/2025, showed an order started on 10/31/2025 for Trazadone (an antidepressant that can help with low mood, insomnia, or problems concentrating) at bedtime for insomnia.Review of Resident 10's admission MDS Section N0415 (High-Risk Drug Classes: Use and Indication) dated 11/07/2025, showed antidepressant was not coded.In a phone interview and joint record review on 12/05/2025 at 9:39 AM, Staff D, MDS Nurse, stated they followed the RAI manual and that the medication Trazadone was an antidepressant that should be coded as an antidepressant. Joint record review of Resident 10's admission MDS Section N0415 dated 11/07/2025, showed antidepressant was not coded. Staff D stated Resident 10 started Trazadone upon admission on [DATE] and should have been coded as a yes.On 12/08/2025 at 9:53 AM, Staff B, Director of Nursing Services, stated they would expect staff to follow the RAI manual and that Trazadone should be coded as an antidepressant in the MDS.Reference: (WAC) 388-97-1000 (1)(b).

Based on interview and record review, the facility failed to develop a care plan for 2 of 8 residents (Residents 5 & 16), reviewed for comprehensive care plans. The failure to develop a care plan for antibiotic (medication to treat infections) use and discharge plan placed the residents at risk for unmet care needs and a diminished quality of life.Findings included . Review of the facility's policy titled, Comprehensive Resident Centered Care Plans, revised on 08/01/2025, showed, The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights.that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial [interaction between social and mental factors] needs that are identified in the comprehensive assessment. The policy showed that the facility must develop and implement a comprehensive person-centered care plan for each resident and describe in consultation with the resident and the resident's representative their goals for admission, desired outcomes, preferences and potential for discharge. The facility must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and discharge plans in the comprehensive care plan. The policy further showed that the care plan will be updated and/or revised when there are new diagnosis, new medications or abnormal labs [laboratory results]. RESIDENT 5Review of a face sheet printed on 12/04/2025 showed that Resident 5 was readmitted to the facility on [DATE] with diagnoses that included bacteremia (bacteria in the bloodstream). Review of Resident 5's November 2025 and December 2025 Medication Administration Record (MAR) showed an order for the following:-Ceftriaxone (antibiotic medication) two grams (unit of measurement) intravenously (administered through the vein) once a day for bacteremia for 28 days with a start date of 11/07/2025.-Metronidazole (antibiotic medication) 500 milligrams (unit of measurement) give one tablet by mouth two times a day for purulent (thick yellow liquid that comes from an infection) skin and soft tissue infection for 28 days with a start date of 11/06/2025. Further review of November 2025 and December 2025 MAR showed that Resident 5 received Ceftriaxone and Metronidazole from 11/07/2025 through 12/04/2025. Review of Resident 5's comprehensive care plan printed on 12/04/2025 did not show a care plan for antibiotic use. In an interview on 12/05/2025 at 3:37 PM, Staff P, Registered Nurse, stated that Resident 5 received antibiotics when they returned from the hospital. In an interview and joint record review on 12/05/2025 at 3:50 PM, Staff C, Assistant Director of Nursing, stated that antibiotic use would be care planned. Joint record review of Resident 5's comprehensive care plan did not show a care plan for antibiotic use. Staff C stated that they did not see one and that it should have been part of Resident 5's care plan for its use and adverse side effect monitoring. In an interview on 12/08/2025 at 11:03 AM, Staff B, Director of Nursing Services, stated that they expected a care plan for residents who were on antibiotics to monitor for adverse side effects. Staff B further stated that Resident 5 should have had a care plan for antibiotic use. RESIDENT 16Review of Resident 16's comprehensive care plan printed on 12/02/2025 did not show whether Resident 16 and/or their representative wished for them to stay long-term in the facility or any discharge care plan. In an interview and joint record review on 12/08/2025 at 9:08 AM, Staff G, Social Services Coordinator, stated they would document the resident's discharge goals in their care conference notes and in the resident's care plan. Staff G stated that Resident 16's representative wished for them to stay in the facility long term. Joint record review of Resident 16's comprehensive care plan did not show a discharge care plan to reflect this. Staff G stated that they had just updated the care plan and were not sure why it was not there. On 12/08/2025 at 12:25 PM, Staff B stated Resident 16 was a long-term care resident. Staff B further stated they expected staff to follow their comprehensive care plan policy. Reference: (WAC) 388-97-1020 (1)(2)(a)

Based on observation, interview, and record review, the facility failed to monitor residents taking diuretic (used to treat fluid retention or swelling) medications and/or failed to notify the provider of weight loss/gain for 3 of 4 residents (Residents 4, 10 & 11), reviewed for weight monitoring. The failure to obtain/monitor weights and measure abdominal girth (measurement around the abdomen) placed the residents at risk for unrecognized weight loss/gain, medical complications, and a diminished quality of life.Findings included. Review of the facility's policy titled, Weight Assessments, revised on 07/16/2025, showed Each resident will be weighed on a regular basis to monitor for weight gain or loss. The policy showed residents would be weighted when they are admitted to the facility and once per week and recorded in their medical record. The policy showed the nurse will compare the current weight to the previous weights to determine if significant weight loss or gain was occurring. The policy further showed that if a weight was four or more pounds more or less than the previous weight the nurse would reweigh, and if a true weight loss or gain had occurred, the nurse would notify the physician, registered dietitian, and responsible party and document it in the progress notes. Review of the facility's policy titled, Medication Administration-General Guidelines, revised on 01/01/2023, showed that Monitoring of side effects or medication-related problems occurs continually, but particularly after medication administration and especially after the first few doses of a new medication. The risk for adverse consequences increases with both the number of medications being taken and with the medication from specific pharmacological classes including diuretics. RESIDENT 4Review of Resident 4's physician order's printed on 12/05/2025, showed an order for furosemide (diuretic) 20 milligrams (mg-unit of measurement) in the morning for Congestive Heart Failure (CHF- a chronic condition where the heart muscle weakens, failing to efficiently pump blood to meet the body's needs causing blood and fluid to back up leading to shortness of breath, swelling, and fatigue). Review of Resident 4's weights printed on 12/04/2025 showed the following:-On 08/28/2025, they weighed 186.3 pounds (lbs-unit of measurement).-On 09/05/2025, they weighed 166.4 lbs.-On 09/15/2025 at 1:53 PM, they weighed 184 lbs and at 3:57 PM, they weighed 196.2 lbs.-On 09/18/2025, they weighed 166 lbs.-On 09/25/2025, they weighed 164 lbs (12 percent [%] weight loss or 22.3 lbs less from 08/28/2025 weight). In a joint record review and interview on 12/05/2025 at 1:31 PM with Staff C, Assistant Director of Nursing, showed Resident 4's weights:-On 08/28/2025, they weighed 186.3 lbs.-On 09/05/2025, they weighed 166.4 lbs.-On 09/15/2025 at 1:53 PM, they weighed 184 lbs and at 3:57 PM, they weighed 196.2 lbs.-On 09/18/2025, they weighed 166 lbs.-On 09/25/2025, they weighed 164 lbs (12% weight loss or 22.3 lbs less from 08/28/2025 weight). Staff C stated that Resident 4 was taking a diuretic for CHF and that they had an order for weekly weights on Thursdays. Staff C stated that there were a lot of inconsistencies, in Resident 4's weights and that they had both significant weight gain and weight loss. Staff C further stated they would expect more weight monitoring if Resident 4's weights were not stable and that they would have expected the nurse to notify the provider of the weight gain/loss. In an interview and joint record review on 12/08/2025 at 9:57 AM, Staff B, Director of Nursing Services, stated they expected nursing staff to monitor the residents' weights. Joint record review of Resident 4's weights from 08/28/2025 to 11/23/2025, showed consistent warnings for weight loss/gain in their electronic health record. Staff B stated that there was a lot of weight gain and weight loss and that it was a red flag. Staff B further stated they would have expected the nursing staff to reweigh Resident 4, notify the doctor, and to ensure accurate weights. RESIDENT 10Review of Resident 10's face sheet printed on 12/08/2025, showed they were admitted to the facility on [DATE]. Review of Resident 10's physician orders printed on 12/05/2025, showed an order for bumetanide (diuretic) 0.5 mg to be given twice a day for hypertension (high blood pressure)/chronic venous stasis (a condition where leg veins struggle to send blood back to the heart, causing blood to pool in the lower legs)/autonomic dysreflexia (a sudden, dangerous increase in blood pressure caused by a stimulus below the level of a spinal cord injury). Further review of the physician orders did not show an order to obtain weights. Review of Resident 10's weights printed on 12/04/2025, showed the following:-On 11/03/2025, they weighed 139.4 lbs.-On 11/06/2025, they weighed 139.2 lbs.-On 11/14/2025, they weighed 146.8 lbs (5.3% weight gain or 7.4 lbs more from 11/03/2025 weight).-On 11/23/2025, they weighed 152 lbs (9% weight gain or 12.6 lbs more from 11/03/2025 weight). Review of Resident 10's potential for dehydration (occurs when the body uses or loses more fluid than it takes in) or potential fluid deficit related to diuretic use care plan initiated on 10/31/2025, showed an intervention for Weight per facility protocol. Review of Resident 10's nursing progress note dated 11/17/2025, showed an SBAR (Situation, Background, Assessment, and Recommendation- a communication tool used primarily in healthcare) was left to the provider for review regarding Resident 10's representative's concerns of increased confusion, lower extremity (legs) edema (swelling) and blisters, and request for treatment and cause of Resident 10's increased confusion. Review of Resident 10's provider progress note dated 11/18/2025, showed Resident 10's bilateral (both) lower extremities had worsened gradually over the last one to two weeks, and ordered to increase bumetanide to twice a day. In an interview and joint record review on 12/05/2025 at 10:39 AM, Staff E, Licensed Practical Nurse, stated that if a resident was a new admission they would be weighed for the first three days and if the residents refused, they would document why. Staff E stated that there would also be an order to weigh the residents after admission. Staff E stated they were expected to follow the resident's care plan and that everyone was responsible for monitoring a resident's weight. Staff E stated that they would expect to notify the provider if there were any discrepancies. Joint record review of Resident 10's weights from 11/03/2025 through 11/23/2025, showed a weight gain of 12.6 lbs or 9% gain. Staff E stated that they did not believe that was accurate and that the scale was not always accurate if a resident was not standing in the middle. In an interview and joint record review on 12/05/2025 at 1:07 PM, Staff C stated, weight per protocol, meant to obtain weight upon admission for three days and then on a weekly basis unless specified in the order. Staff C stated they expected staff to follow the care plan, and that nurses would record the resident's weight and if the resident refused, they would reattempt and/or document why the resident refused and notify the provider. Joint record review of Resident 10's weights from 11/03/2025 through 11/23/2025, showed a weight gain of 12.6 lbs or 9% gain. Staff C stated that Resident 10 was not weighed per protocol the first three days of upon admission. Staff C stated they had a nutrition meeting on 11/21/2025 with a recommendation for a reweight and had not obtained it prior to the next weight on 11/23/2025. Staff C stated that they did not see that the provider was notified of the weight gain in the progress notes, just of Resident 10's edema. Staff C further stated that the nurse should be notifying the provider of significant weight gain/loss. On 12/08/2025 at 9:57 AM, Staff B stated residents should be weighed for the first three days upon admission and then there should be an order for weekly weights. Staff B stated they would expect staff to document why Resident 10 did not get weighed for the first three days upon admission. Staff B stated they expected staff to follow the residents' care plan and obtain a reweight if there was a discrepancy. Staff B further stated that staff should have notified the doctor that Resident 10 was gaining weight. RESIDENT 11Review of Resident 11's diagnosis list printed on 12/08/2025, showed a diagnosis of ascites (the buildup of excess fluid in the abdomen). Review of Resident 11's physician orders, printed on 12/03/2025, showed the following orders:- Daily weights for three days upon admission, then weekly, and must be taken by a licensed nurse every Thursday.- Furosemide oral tablet 20 mg. Give 1 tablet by mouth one time a day.- Spironolactone (a diuretic medication) oral tablet 25 mg. Give 1 tablet by mouth one time a day. Review of Resident 11's ascites care plan, revised on 10/02/2025, showed a goal that Resident 11 would remain free of signs/symptoms of fluid overload (too much fluid in the body) as evidenced by the decrease in or absence of edema/ascites. It further showed an intervention to weigh Resident 11 per orders/facility protocol. Review of the facility's document titled, Weights and Vitals Summary, printed on 12/05/2025, showed that Resident 11 was last weighed on 11/20/2025 (15 days prior). Review of the November 2025 Medication Administration Record (MAR) showed that a R [Resident Refused] was documented on 11/27/2025. Review of the December 2025 MAR showed a 9 [nine-indicating other/see progress notes] was documented on 12/04/2025. Review of the progress notes from 11/27/2025 through 12/05/2025 showed no documentation that Resident 11 had refused their weight or that any follow-up had been done. Review of a physician note dated 11/18/2025, showed the plan to monitor weight, abdominal girth for Resident 11. Review of a physician note dated 12/04/2025, showed the plan to monitor weight, abdominal girth and reminded nursing for weekly weight for Resident 11. Observation on 12/04/2025 at 8:59 AM, showed Resident 11 had a distended [swollen or enlarged] abdomen and stated, no one has measured it. Another observation on 12/05/2025 at 9:58 AM, showed Resident 11 had a distended abdomen and stated that nursing did not measure their abdomen. When asked how often they had weights done, Resident 11 stated, I think the doctor put in an order to do weekly but was not necessarily being done weekly. In an interview on 12/05/2025 at 10:40 AM, Staff E stated if a resident refused getting weighed, they would follow up, try three times and write a progress note. Staff E stated they would care for a resident who was on a diuretic by monitoring if a resident was gaining or losing weight. Staff E stated that they would care for a resident with ascites by measuring the abdomen, if [the measurement] was going up or down and there should be an order to put in [document] the measurement. When asked if they should follow an order for weekly weights, Staff E stated that yes would expect that to be done. Staff E further stated that resident care plans should be followed. In an interview and joint record review on 12/05/2025 at 11:45 AM, Staff C stated that they expected staff to follow orders and resident care plans. Staff C stated that they expected weights to be done as written on the MAR. Staff C stated that weight per protocol meant that weights should be done upon admission for three days and then weekly. Staff C stated that if a resident refused to get their weight done the staff should document the refusal. Staff C stated that if a resident had ascites they would expect staff to measure abdominal girth and would expect them to document it. Joint record review of Resident 11's diagnosis list showed that Resident 11 had ascites. Joint record review of Resident 11's physician orders showed that they were on two diuretics, Furosemide and Spironolactone and showed an order for weekly weights. Joint record review of the weights and vitals summary showed that the last weight was done on 11/20/2025 (15 days prior). Joint record review of the November 2025 MAR showed an R documented on 11/27/2025. Staff C stated that it indicated resident refused. Joint record review of the December 2025 MAR showed a 9 documented on 12/04/2025. Staff C stated that it indicated other, see progress note. Joint record review of the progress notes from 11/27/2025 through 12/05/2025 showed no documentation that Resident 11 had refused their weight or that any follow-up had been done. Staff C stated, there's [there is] nothing about refusals documented in the progress notes. Joint record review of Resident 11's ascites care plan, revised on 10/02/2025, showed an intervention to weigh Resident 11 per orders/facility protocol. When asked if the care plan had been followed, Staff C stated, no, it wasn't [was not]. Joint record review of a physician note dated 12/04/2025, showed the plan to monitor weight, abdominal girth and reminded nursing for weekly weight for Resident 11. Staff C stated, I would expect the weights to be done and we should monitor abdominal girth by measuring the abdomen. Stated C stated that measuring Resident 11's abdominal girth had not been done. In an interview and joint record review on 12/08/2025 at 11:16 AM, Staff B stated that they expected staff to follow care plans and to follow orders [physician orders]. Staff B stated that if there was an order for weekly weights then they would expect staff to weigh the resident. Staff B stated that if a resident refused to be weighed, they would expect staff to attempt again at another time and to document it in the progress notes. Staff B stated that if a resident was on a diuretic it's very important to check weights. Staff B stated that if a resident had ascites, they would check abdominal girth. Joint record review of Resident 11's diagnosis list showed a diagnosis of ascites. Joint record review of Resident 11's physician orders showed orders for Furosemide and Spironolactone. Staff B stated, it's very important [to weigh residents] if they have ascites and [were] on diuretics, [they] could be retaining fluid. Reference: (WAC) 388-97-1060 (1) .

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 1 of 2 residents (Resident 22), reviewed for respiratory care. The failure to properly store oxygen and nebulizer (medical device that turns liquid medication into a fine mist that can be inhaled through a mouthpiece or mask) equipment placed the resident at risk for respiratory infections, and related complications.Findings included .Review of the facility's policy titled, Oxygen Administration, revised on 07/08/2025, showed, Place cannula (prongs) or mask in place with date written on label attached to tubing. O2 [Oxygen] tubing should be changed every week with new cannula or mask.Review of the facility's policy titled, Nebulizer policy, revised on 01/01/2025 showed, Nebulizer equipment will be maintained in a clean, functional condition. The policy further showed, Rinse nebulizer components with sterile or distilled water after each use, disinfect daily, replace tubing weekly, dedicate equipment to each resident, and comply with.infection-control standards.Review of a face sheet printed on 12/03/2025 showed that Resident 22 was admitted to the facility on [DATE] with diagnoses that included idiopathic pulmonary fibrosis (scarring of the lungs which leads to difficulty breathing), lung transplant (surgical procedure to replace a diseased or failing lung with a healthy lung) status and acute nasopharyngitis (common cold).Review of Resident 22's physician orders printed on 12/03/2025 showed an order for the following:- HyperSal Inhalation Nebulization Solution [medication used to help thin mucus in the lungs, making it easier to cough up and clear from the airways] four milliliters (unit of measurement) inhale orally via nebulizer once a day for idiopathic pulmonary fibrosis and acute nasopharyngitis with a start date of 11/26/2025.- Oxygen one to two liters (unit of measurement) per minute via nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) every shift with a start date of 11/25/2025.Observations on 12/02/2025 at 9:50 AM, on 12/03/2025 at 8:19 AM and at 12:06 PM, showed Resident 22 was lying in bed receiving oxygen via undated nasal cannula. Further observation showed an undated and uncovered nebulizer tubing/mouthpiece was laying on top of a hamper.In an interview and joint observation on 12/03/2025 at 2:01 PM, Staff F, Registered Nurse, stated that they would change the nasal cannula when they were soiled and that they would clean the nebulizer mouthpiece/mask and leave them to dry on a table. When asked if they would store it in a bag when not in use, Staff F stated, no. Staff F stated that residents did not have a physician's order to regularly change the tubing/nasal cannula and nebulizer equipment. Joint observation showed Resident 22's undated and uncovered nasal cannula was laying on the bed. Further observation showed Resident 22's undated and uncovered nebulizer tubing/mouthpiece was laying on top of a hamper. Staff F stated that the nebulizer tubing/mouthpiece should be stored in a clean area. Staff F further stated that Resident 22's nasal cannula should have been stored in a bag when not in use for infection control.In an interview on 12/05/2025 at 11:25 AM, Staff C, Assistant Director of Nursing, stated that they expected the nebulizer tubing/mouthpiece to be changed weekly. Staff C stated that the mouthpiece/mask should be cleaned after each use, airdried on a clean paper towel and placed it in a bag when not in use. Staff C stated they expected the nasal cannula to be dated, changed weekly and stored in a bag when not in use. Staff C further stated that Resident 22's nasal cannula and nebulizer tubing/mouthpiece should have been dated and stored in a bag when not in use.In an interview on 12/05/2025 at 2:35 PM, Staff B, Director of Nursing Services, stated that they expected the nebulizer mouthpiece/mask to be cleaned after each use, placed on a clean towel to airdry and stored in a clean bag when not in use. Staff B further stated that the nasal cannula should be stored in a bag when not in use.Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on interview and record review, the facility failed to ensure 2 of 5 residents (Resident 4 & 16) were free from significant medication errors. The failure to document and/or provide medications placed the residents at risk for complications, decline in medical condition, and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication Administration-General Guidelines, revised on 01/01/2023, showed Medications are administered in accordance with written orders of the prescriber. The policy showed the individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) directly after the medication is given. The policy further showed if a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, nursing would document an explanatory note and notify the physician and their response.RESIDENT 4Review of the facility's document titled, Pharmacist's Report to Nursing, recommendation for Resident 4 dated 10/24/2025, showed the MAR had missing documentation for medication administration on 10/08/2025 for the following:-Furosemide (diuretic-primarily used to treat fluid retention and swelling and Congestive Heart Failure [CHF- a chronic condition where the heart muscle weakens, failing to efficiently pump blood to meet the body's needs causing blood and fluid to back up leading to shortness of breath, swelling, and fatigue]).-Losartan (used to treat high blood pressure).-Metamucil (fiber supplement).-Vitamin D3 (vitamin for bone health).-Quetiapine (an antipsychotic medication that helps balance chemicals in the brain that regulate mood, thoughts, and behaviors).The recommendation further showed each medication should be documented at the time of administration, indicating that each medication had been administered, refused, or unavailable.Review of Resident 4's October 2025 MAR printed on 12/04/2025, showed missing/blank documentation for day shift on 10/08/2025 for furosemide, losartan, Metamucil, vitamin D3, and quetiapine. The October 2025 MAR further showed Resident 4 had behaviors on 10/08/2025 evening shift including use of foul language.Review of Resident 4's nursing progress notes dated 10/08/2025 did not show why furosemide, losartan, Metamucil, vitamin D3, or quetiapine were not administered or that the physician was notified.On 12/05/2025 at 10:28 AM, Staff E, Licensed Practical Nurse, stated that after medication they would document in the MAR. Staff E further stated that it was important to document to show whether a resident took their medication or if they refused.In a joint record review and interview on 12/05/2025 at 2:57 PM with Staff C, Assistant Director of Nursing, showed Resident 4's October 2025 MAR, had missing/blank documentation for day shift on 10/08/2025 for furosemide, losartan, Metamucil, vitamin D3, and quetiapine. Staff C stated that the day shift nurse did not sign for those administrations and that meant if they were not signed, they were not given. Staff C stated that Resident 4 was placed at risk for behaviors, constipation, and effects on their blood pressure. Staff C stated that Resident 4 had behaviors documented on 10/08/2025 evening shift. Staff C further stated that they would expect the staff to document a reason why each medication was not given.RESIDENT 16Review of the facility's document titled, Pharmacist's Report to Nursing, recommendation for Resident 16 dated 09/22/2025, showed hydroxychloroquine (medication used for rheumatoid arthritis [an autoimmune disease that causes pain, stiffness, and swelling in the joints]) was documented as unavailable in the electronic MAR. The recommendation showed the orders should be promptly reordered, pulled from the Medbank (an automated medication dispensing system used to manage and secure on-site medications), house supply, or requested from the family to prevent missed doses and to document any delays. The recommendation further showed to notify the provider of missed doses.Review of Resident 16's September 2025 MAR, showed an order for hydroxychloroquine sulfate tablet was documented as code 11 (Medication not available) on 09/05/2025, 09/07/2025, 09/08/2025, 09/09/2025 and code 5 (Hold/See progress notes) on 09/06/2025.Review of Resident 16's nursing progress notes showed the following documentation for hydroxychloroquine:-On 09/05/2025, showed staff documented medication was on order from pharmacy- placed a call- waiting for call back.-On 09/06/2025, showed medication was on order pharmacy aware.-On 09/07/2025, showed medication was on order.-No documentation for 09/08/2025 and 09/09/2025.Further review of the progress notes did not show Resident 16's representative or provider were notified the medication was unavailable.On 12/05/2025 at 9:56 AM, Staff E stated nurses on the floor were responsible for reordering medication. Staff E stated that if medication was unavailable, they would call the pharmacy to have it delivered and notify the resident and provider the medication was not available. Staff E stated they did not document the follow-up they did regarding Resident 16's unavailable medication.In a phone interview on 12/05/2025 at 11:18 AM, Staff H, Consultant Pharmacist, stated that hydroxychloroquine was long acting and that missing five doses in a row would be significant with possible return of rheumatoid arthritis symptoms such as stiffness, pain, and inflammation.In a joint record review and interview on 12/05/2025 at 3:11 PM with Staff C, showed Resident 16's September 2025 MAR order for hydroxychloroquine sulfate tablet. Staff C stated that Resident 16 missed five doses of their hydroxychloroquine sulfate medication because the medication was not available. Staff C stated missing five doses of the medication could be significant because it could put the resident at risk for pain from arthritis. An additional joint record review of Resident 16's nursing progress notes from 09/05/2025 through 09/09/2025, did not show that the provider was notified that the medication was not available. Staff C stated staff should have notified the provider. Staff C further stated it was the staff's responsibility to reorder medication and follow up with the pharmacy to ensure residents had their medication. On 12/08/2025 at 10:07 AM, Staff B stated that staff should use the emergency supply medication or call the pharmacy when medication was unavailable. Staff B stated that staff should have notified the doctor and Resident 16's representative when they did not receive their medication. Staff B further stated that missing five doses in a row of Resident 16's hydroxychloroquine medication was significant and would be considered a medication error.Reference: (WAC) 388-97-1060(3)(k)(iii).

Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 30 of 30 days (11/08/2025 to 12/08/2025), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.Findings included.Review of the facility's policy titled, Nurse Staffing Posting Information, revised on 03/28/2025, showed the nurse staffing sheet would be posted daily and include the following: facility name, current date, current resident census, actual hours worked by categories of licensed and unlicensed staff per shift.Observations on 12/02/2025 at 9:08 AM, on 12/03/2025 at 10:54 AM, on 12/04/2025 at 9:10 AM, on 12/05/2025 at 9:27 AM, and on 12/08/2025 at 8:32 AM showed the daily nurse staff posting was posted outside the facility's therapy gym without the total number and actual hours worked by licensed Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants.In an interview and joint record review on 12/08/2025 at 8:39 AM, Staff K, Medical Records Coordinator, stated they were responsible for the daily nurse staff posting. Joint record review of the 12/08/2025 posting showed no total number or actual hours worked by staff. Staff K stated they would not expect the schedule to have actual hours posted, and that they expected to have scheduled hours posted because the actual hours would not show until after the shift had occurred.Record review of the facility provided nurse staff posting documents dated from 11/08/2025 through 12/08/2025, did not show the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.In a joint record review and interview on 12/08/2025 at 11:19 AM with Staff A, Administrator, showed the facility's nurse staff posting documents dated from 11/08/2025 through 12/08/2025, did not show the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Staff A stated they would expect the daily nurse staff posting to reflect the total number and actual hours staff worked and to make changes in real time to reflect the staff on duty accurately.Reference:(WAC) 388-97-1620(2)(b)(i).

Based on observation, interview and record review, the facility failed to provide routine and as needed medications as prescribed by the physician to meet the needs of 3 of 3 residents (Residents 1, 2 & 3), failed to ensure controlled drugs were accurately accounted for and timely discarded for 2 of 2 residents (Residents 1 and 4), reviewed for medication management and controlled drugs. In addition, the facility failed to document medication administration in accordance with professional standards for 1 of 1 resident (Resident 5), reviewed for medication administration. These failures placed residents at risk for uncontrolled pain, medication errors, negative outcomes, and placed the facility at risk for potential loss and/or drug diversion of the controlled medications.Findings included.Review of the facility's document titled, Medication Administration-General Guidelines, revised on [DATE], showed, Medications are administered in accordance with written orders of the prescriber. The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.Review of the facility's policy titled, Medication Destruction (Narcotic [or controlled medications]) Policy, revised on [DATE], showed, It is the policy of this Skilled Nursing Facility to ensure the safe, timely, and compliant destruction of all unused, discontinued, or expired controlled medications in accordance with [NAME] Administrative Code (WAC 246-865-060) and federal regulations. All other discontinued/unused controlled substances: Destroyed within 90 days.MEDICATION MANAGEMENTRESIDENT 1Resident 1 was admitted to the facility on [DATE] with diagnosis that included dementia (conditions that cause a decline in cognitive abilities, such as memory, thinking, and reasoning).Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated [DATE], showed Resident 1 had severe cognitive impairment and was dependent on staff with all aspects of care. It further showed that Resident 1 had a chronic disease that may result in a life expectancy of less than six months and was on hospice (comfort-focused care for people who are terminally ill and can no longer be cured by treatment).Review of the [DATE] MAR showed Resident 1 had an order for Morphine sulfate (a controlled pain medication) every six hours for pain and shortness of breath. Further review of the MAR showed that Resident 1 received their routine morphine on the evening of [DATE] at 8:00 PM but the medication was not taken out from the controlled drug box or signed out in the controlled drugs logbook.Review of the [DATE] MAR showed Resident 1 had an order for Morphine sulfate every four hours for pain and shortness of breath. Further review of the MAR showed that Resident 1 received their routine morphine on the evening of [DATE] at 8:00 AM but the medication did not show it was taken out from the controlled drug box or signed out in the controlled drugs logbook in page #007.RESIDENT 2Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia and pain.Review of the quarterly MDS dated [DATE], showed Resident 2 had severe cognitive impairment and was dependent on staff with all aspects of care. It further showed that Resident 2 had a chronic disease that may result in a life expectancy of less than six months and was on hospice.Review of the [DATE] MAR showed Resident 2 had an order for Pregabalin (a pain medication for nerve pain) at bedtime for pain. Further review of the MAR showed Resident 2 received their routine Pregabalin on [DATE], [DATE], [DATE], [DATE], [DATE] at 8:00 PM but the medication did not show it was taken out from the controlled drug box or signed out in the controlled drugs logbook for the above dates.RESIDENT 3Resident 3 was admitted to the facility on [DATE] with diagnosis that included gout (sudden, severe attack of pain, swelling, and redness in a joint).Review of the admission MDS dated [DATE], showed Resident 3 had intact cognition and had occasional pain that was treated with scheduled and as needed pain medication.Review of the [DATE] MAR showed Resident 3 had an order for oxycodone (a controlled pain medication) 5 milligram (mg - unit measurement) as needed daily for pain. Further review of the MAR showed that Resident 3 received 5 mg of oxycodone on [DATE] at 6:00 PM but the medication did not show it was taken out from Resident 3's oxycodone stored in the controlled drug box or signed out in the controlled drugs logbook in page #109.Review of the facility investigation document titled, Medication Error, dated [DATE] showed Resident 3 did receive a wrong dose of oxycodone 2.5 mg from Resident 4's medication on [DATE].In an interview on [DATE] at 10:29 AM, Resident 3 stated that they were not aware that they had received a wrong dose of oxycodone on [DATE].CONTROLLED DRUGS MANAGEMENTRESIDENT 1During a joint observation and interview on [DATE] at 1:41 PM with Staff C, Licensed Practical Nurse, showed Resident 1's liquid Morphine sulfate revealed it had 15 millimeters (ml - unit measurement) remaining in the bottle. A joint record review of the controlled substance record book page #007 showed Resident 1's remaining amount of morphine sulphate was 11 ml (documented 4 ml lower than the actual amount in the bottle). Staff C was asked about the 4 ml discrepancy between the actual amount of morphine sulphate and the amount recorded in the book. Staff C stated there was always an extra amount in the bottle and they would be worried if the actual amount was below the documented amount. RESIDENT 4Review of Resident 4's electronic health record printed on [DATE] showed that Resident 4's oxycodone order was discontinued on [DATE].Review of the facility investigation document titled, Medication Error, dated [DATE] showed Resident 4's oxycodone 2.5 mg was administered to Resident 3 on [DATE] [Resident 4's oxycodone was not discarded and was left in the controlled drugs box].MEDICATION ADMINSTRATIONResident 5 was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease (a brain disorder that affects movement, balance, and other functions).Review of the [DATE] MAR showed Resident 5 had an order for Carbidopa-Levodopa (a medication used to treat the symptoms of Parkinson's disease) to be administered at 8:00 AM, 2:00 PM and 8:00 PM.Observation on [DATE] at 1:07 PM showed Staff C was preparing to administer Resident 5's medication. Staff C pulled Carbidopa-Levodopa pills form the medication cart and placed it in a pill cup and recorded in the Resident 5's Electronic Medication Administration Record (EMAR) as Yes [medication administered]. Staff C walked to Resident 5's room to administer the medication but the resident was in their bathroom. Staff C returned to the medication cart, placed Resident 5's medication cup in the cart, locked the cart, and went to assist another resident. At 1:24 PM Resident 5 was observed leaving the center with their family members without taking their medication for medical appointment.In an interview and joint record review on [DATE] at 1:35 PM, Staff C stated that they would document medication administration after the medication was administered. Staff C stated Resident 5 did not take their Carbidopa-Levodopa and left for their appointment. A joint record review of the EMAR showed that Carbidopa-Levodopa was documented as administered. When asked about Resident 5's EMAR documentation of the medication, Staff C stated they would correct the Carbidopa-Levodopa EMAR by marking it as wrong chart. Staff C further stated the EMAR should not have been marked as administered before the resident received the medication.In an interview and joint record review on [DATE] at 1:05 PM, Staff B, Interim Director of Nursing, stated that their expectation was for the staff to follow the physician order, to administer medication, and to document. Staff B stated that they expected staff to record medication administration on the EMAR directly after the medication was given. Staff B stated that they expected controlled drug counts to be accurate without discrepancy. A joint record review of the [DATE] MAR showed that Resident 1 received their routine morphine on [DATE] at 8:00 AM. Joint record review of the controlled drugs logbook page #007 showed no documentation that the Morphine Sulfate was removed from the controlled box at 8:00 AM. Staff B stated, If it is not documented, it is not done. Staff B further stated that controlled medications should be destroyed when it discontinued and Resident 4's oxycodone should have been destroyed when it was discontinued in [DATE].Reference: (WAC) 388-97-1300 (1)(b)(ii)(3)(a).

Based on interview and record review, the facility failed to conduct a thorough investigation for 3 of 4 residents (Resident 1, 2 & 3), reviewed for incident investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life.Findings included .Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences . All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations.If the suspected perpetrator is staff, interview the other residents the staff person was assigned to.Review of the facility's policy titled, Policy and Procedure Abuse/Neglect, revised on 03/31/2025, showed, It is this facility's policy that all suspected, alleged, or actual cases of resident abuse including injuries of unknown origin, shall be thoroughly investigated, and reported according to State and Federal regulations. The policy further showed that it is the facility's investigation procedure that conducts interviews of all the people involved, including the residents. RESIDENT 1Resident 1 was admitted to the facility on [DATE] with diagnosis that included dementia (conditions that cause a decline in cognitive abilities, such as memory, thinking, and reasoning). Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 08/01/2025, showed Resident 1 had severe cognitive impairment and was dependent on staff with all aspects of care. It further showed that Resident 1 had a chronic disease that may result in a life expectancy of less than six months and was on hospice (comfort-focused care for people who are terminally ill and can no longer be cured by treatment).Review of the July 2025 Medication Administration Record (MAR) showed Resident 1 had an order for Morphine sulfate (a pain medication) every six hours for pain and shortness of breath. Further review of the MAR showed that Resident 1's routine morphine was signed as received on the evening of 07/29/2025 at 8:00 PM but the medication was not taken out from the controlled drug box or signed out in the controlled drugs logbook. Review of the facility investigation document titled, Medication Error, dated 07/30/2025 showed Resident 1 did not receive their routine morphine on the evening of 07/29/2025 at 8:00 PM. The investigation showed Staff D, Registered Nurse (RN), was interviewed and the staff stated they were unaware that they missed giving the scheduled morphine to Resident 1. Further review of the investigation did not show if interviews of other residents Staff D was assigned to was conducted or abuse or neglect was ruled out. RESIDENT 2Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia and pain. Review of the quarterly MDS dated [DATE], showed Resident 2 had severe cognitive impairment and was dependent on staff with all aspects of care. It further showed that Resident 2 had a chronic disease that may result in a life expectancy of less than six months and was on hospice care.Review of the July 2025 MAR showed Resident 2 had an order for Pregabalin (a pain medication for nerve pain) at bedtime for pain. Further review of the MAR showed Resident 2's routine Pregabalin was signed as received on 07/19/2025, 07/21/2025, 07/23/2025, 07/28/2025, 07/29/2025 at 8:00 PM but the medication was not taken out from the controlled drug box or signed out in the controlled drugs logbook for these five days. Review of the facility investigation document titled, Medication Error, dated 07/30/2025 showed Resident 2 had several missed doses of routine Pregabalin. The investigation showed Resident 2 did not receive their routine Pregabalin scheduled at 8:00 PM from the following contract staff assigned to the resident:-On 07/19/2025 and 07/21/2025 Staff E, RN-On 07/23/2025 and on 07/28/2025 Staff F, RN-On 07/29/2025 Staff DThe investigation showed Staff D, Staff E, and Staff F were interviewed but the investigation did not show if interviews with other residents assigned to these staff were conducted.In an interview on 08/20/2025 at 10:29 AM, Collateral Contact 1 (CC1), stated that they witnessed an unknown contract license nurse attempting to administer wrong medication to Resident 2. CC1 further stated they stopped the staff and reported the incident to the facility. RESIDENT 3Resident 3 was admitted to the facility on [DATE] with diagnosis that included gout (sudden, severe attack of pain, swelling, and redness in a joint). Review of the admission MDS dated [DATE], showed Resident 3 had intact cognition and had occasional pain that was treated with scheduled and as needed pain medication. Review of the July 2025 MAR showed Resident 3 had an order for oxycodone (a pain medication) 5 milligram (mg - unit measurement) as needed daily for pain. Further review of the MAR showed Resident 3's oxycodone 5 mg was signed as received on 07/28/2025 at 6:00 PM but the medication was not taken out from Resident 3's oxycodone was not taken out from the controlled drug box or signed out in the controlled drugs logbook.Review of the facility investigation document titled, Medication Error, dated 07/28/2025, showed Resident 3 did receive a wrong dose of oxycodone 2.5 mg from another resident's medication on 07/28/2025. The investigation showed Staff F's statement was obtained and Staff F stated Resident 3 was given a wrong dose of oxycodone that belonged to another resident. Further review of the investigation did not show if interviews with other residents Staff F was assigned to were conducted. In an interview on 08/20/2025 at 10:29 AM, Resident 3 stated that they were not aware that they had received a wrong dose of oxycodone on 07/28/2025. In an interview and joint record review on 09/12/2025 at 11:27 AM, Staff A, Health Services Director, stated that the purpose of completing incident investigation was to find out the root cause of the incident, to determine any actions needed to be taken, and to rule out abuse/neglect. Staff A stated that if the suspected perpetrator was a staff member, interviews with other residents the staff person assigned would be conducted. A joint record review of Resident 1's investigation dated 07/30/2025 and Resident 2's investigation dated 07/30/2025 did not show interviews of other residents Staff D, Staff E, or Staff F were assigned to. A joint record review of Resident 3's investigation dated 07/28/2025 did not show if Resident 3 was notified of receiving a wrong oxycodone dose or an interview of other residents conducted that Staff F was assigned to. Staff A stated that Residents 1 and 2 were not interviewable and no other residents interviewed. Staff A further stated they spoke with other residents but was not documented in the investigations. Reference: (WAC) 388-97-0640 (6)(a)(b).

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of fruit flies (small insects that are attracted to ripe, rotting, or fermenting fruits and vegetables) in the kitchen area of the facility. This failure placed residents at risk for infection, maggot infestation (small, worm like bugs that hatch from fly eggs) and a diminished quality of life. Findings included . Review of the facility's policy titled, Policy and Procedure - Pest Control, revised on 01/02/2024, showed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Observation on 10/15/2024 at 10:30 AM, and at 10:43 AM showed fruit flies in the dish washing and hand wash areas of the kitchen. Another observation on 10/15/2024 at 11:04 AM showed flies in the kitchen fridge area (where ready to eat cold food were stored). During a joint observation and interview on 10/15/2024 at 11:07 AM with Staff N, Executive Chef, showed that one trash can was full and overflowing, while another trash can was unclean and had dark stains on the lid. Further joint observation showed flies on the wall near the trash can and landed on unwashed utensils that were returned from breakfast. Staff N stated that they would ensure the area was cleaned immediately and that there should have been no flies in the kitchen. On 10/16/2024 at 11:56 AM, Staff C, Assistant Director of Nursing/Infection Preventionist, stated that there should be no insects in the kitchen as that was unacceptable. On 10/16/2024 at 2:33 PM, Staff A, Health Services Administrator, stated that having flies in the kitchen is unacceptable and that they would arrange for the pest control team to come and inspect. Reference: (WAC) 388-97-3360 (1)

Based on observation, interview, and record review, the facility failed to ensure foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional standards for food safety for 2 of 2 refrigerators (Dairy Refrigerator and Main Walk-In Refrigerator) and 1 of 1 freezer (Walk-In Freezer), reviewed for food services. This failure placed the residents at risk for food borne illness [caused by the ingestion of contaminated food or beverages] and a diminished quality of life. Findings included . Review of the facility's policy titled, Date Marking for Food Safety, revised on [DATE], showed that the food items would be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The policy further showed, the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. DAIRY REFRIGERATOR Joint observation and interview on [DATE] at 8:13 AM with Staff M, Lead Cook, showed an unopened coleslaw dressing with a manufacturer expiration date of [DATE]. Follow up observation on [DATE] at 9:05 AM with Staff M, showed butter for bread prepared on [DATE] with a use by date of [DATE]. Further observation showed four jugs of hollandaise sauce with no dates. Staff M stated that both the coleslaw and butter should have been discarded. Staff M stated that the hollandaise sauce came in a box with a manufacturer date on it, but they were unsure where the box was. Staff M further stated that they would need to put dates on the hollandaise sauce when they unbox and place them on the shelf. MAIN WALK-IN REFRIGERATOR Joint observation and interview on [DATE] at 8:27 AM with Staff M, showed one opened and undated container of heavy whipping cream, and a half can of cheese with a preparation date of [DATE] and a use by date of [DATE]. Staff M stated that the heavy whipping cream should have been dated when it was first opened, and the expired cheese should have been discarded. WALK-IN FREEZER Joint observation and interview on [DATE] at 8:45 AM with Staff M, showed seven bags of diced carrots with use by date of [DATE] and with shelf life of [DATE]. Staff M stated that the dates did not seem accurate, but the diced carrots were still considered good to use. In an interview on [DATE] at 2:33 PM, Staff A, Health Services Administrator, stated that it was their expectation for the kitchen staff to maintain food safety according to State and Federal guidelines. Staff A further stated that the kitchen staff should have followed the facility's food safety and storage policies. Reference: (WAC) [DATE] (3)

Based on observation, interview, and record review, the facility failed to ensure glucometers (portable device used to measure blood sugar) were disinfected properly for 2 of 2 residents (Residents 168 & 14), clean insulin [medication that works by lowering levels of sugar in the blood] pen rubber seal prior to attaching a needle for 2 of 2 residents (Residents 168 & 14), and ensure Enhanced Barrier Precautions (EBP- gown and glove use to protect residents from multidrug-resistant organism [germ that is resistant to medications that treat infections]) practices were followed for 2 of 5 residents (Residents 12 & 68), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed for 3 of 7 residents (Residents 168, 15 & 7), reviewed for medication administration, and for 2 of 2 staff (Staff J and I), reviewed for dining observations. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Glucometer Disinfection, revised on 04/01/2024, showed that the purpose for the disinfection of glucometers was to prevent transmission of blood borne diseases to residents and employees. The policy showed that the glucometers would be disinfected with a wipe pre-saturated with an EPA (Environment Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus- a virus [a tiny infectious agents that requires a host cell to replicate and survive] that attacks the body's immune system), Hepatitis [inflammation of the liver] C and Hepatitis B Virus. Review of the facility's policy titled, Handwashing-Hand hygiene, revised on 02/07/2024, showed hand hygiene should be performed before and after entering a resident's room, before performing invasive procedures, before and after manipulation of an IV [Intravenous - a flexible tube is inserted into a vein, to deliver medicine or fluids into the bloodstream] device before and after handling indwelling catheters [a medical device used to drain urine from the bladder], to include handling the catheter drainage bags and/or tubing. The policy further showed that the use of gloves did not replace handwashing. Review of the facility's policy, Insulin Injection, revised 01/02/2024, showed that when attaching the pen needle, the insulin pen rubber seal must be wiped with an alcohol pad first before screwing on the pen needle onto the insulin pen. The policy further showed that gloves must be worn when administering insulin. Review of the facility's policy titled, Enhanced Barrier Precaution, revised on 04/11/2024, showed EBP referred to a set of infection control practices that involve wearing gowns and gloves during high-contact care of residents in nursing homes. High contact resident care activities included dressing, transferring, providing hygiene, and device care or use (such as central lines, urinary catheters). DISINFECTING GLUCOMETERS In a joint observation and interview on 10/14/2024 at 10:44 AM, showed Staff H, Licensed Practical Nurse, was cleaning the glucometer for Resident 168 with alcohol pads. At 10:48 AM, Staff H was observed cleaning the glucometer with alcohol wipes after checking Resident 14's blood sugar. Staff H stated that they were out of Clorox [brand, disinfectant] wipes and had to use alcohol wipes to clean the glucometer. In an interview on 10/16/2024 at 2:06 PM, Staff B, Director of Nursing, stated that the facility cleaned the glucometers with alcohol wipes and not with disinfectant wipes. INSULIN ADMINISTRATION RESIDENT 168 Review of the October 2024 Medication Administration Record (MAR) showed Resident 168 had an order for Insulin Lispro injection 100 units per milliliter (mL-unit of measurement) inject 8 units subcutaneously (in fatty tissue under the skin) with meals. An observation on 10/14/2024 at 11:38 AM, showed Staff H placed a needle onto the insulin pen rubber seal without cleaning the rubber seal first. Staff H entered Resident 168's room and injected the insulin into their arm. Staff H did not perform hand hygiene and did not wear gloves when giving the insulin injection. Staff H stated they did not wear gloves when giving insulin to Resident 168. RESIDENT 14 Review of the October 2024 MAR showed Resident 14 had an order for Insulin Lispro Injection 100 units per mL inject 6 units subcutaneously with meals. An observation and interview on 10/14/2024 at 11:42 AM, showed Staff H placed a needle to the insulin pen without cleaning the insulin pen rubber seal. Staff H stated they did not wipe the insulin pen rubber seal because it belonged to Resident 14 and that they cleaned the surface of the pen. Staff H entered the room and administered the insulin to Resident 14. Staff H did not perform hand hygiene before and/or after entering the room and did not wear gloves to administer the insulin to Resident 14. An interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be hand sanitizing [in between tasks] and wear gloves when giving insulin injection. ENHANCED BARRIER PRECAUTIONS RESIDENT 12 Review of the October 2024 MAR showed Resident 12 had an order for Cefazolin [treats infections] 2 grams [unit of measure] intravenously [through a vein] every 8 hours for bacteremia [infection in the bloodstream]. The MAR further showed that the resident had a Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein) line. An observation on 10/14/2024 at 1:48 PM, showed an EBP signage outside of Resident 12's door that directed staff to use gloves and gowns when handling a PICC line. Staff H did not put on a gown when handling Resident 12's PICC line. On 10/16/2024 at 2:06 PM, Staff B stated that when there was an EBP precaution sign at the door and that staff were expected to wear gloves and gown. RESIDENT 68 Observations on 10/15/2024 at 8:05 AM of Staff H and Staff L did not show they wore gowns when they provided high contact resident care activities that included repositioning, emptying the catheter bag, handling a condom (urine collection device) catheter and changing soiled reusable incontinent pad for Resident 68. On 10/15/2024 at 8:24 AM, Staff H stated that Staff A, Health Services Administrator, had just informed them that they should be wearing a gown when care was being provided. Staff H stated that they have to improvise and that they knew they should be wearing a gown. Staff H then told Staff L they needed to wear a gown. On 10/15/2024 at 8:30 AM, Staff H was observed connecting the IV antibiotics to Resident 68's PICC line without wearing a gown. In an interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be gowning before providing resident care [on EBP precautions]. MEDICATION PASS RESIDENT 168 Observation on 10/14/2024 at 10:41 AM, showed Staff H was entering Resident 168's room, donned gloves, checked the resident's blood sugar level, removed the soiled gloves, and then left the room. Staff H did not do hand hygiene before entering/after leaving the room and before and after glove use. RESIDENT 15 Another observation on 10/14/2024 10:46 AM, showed Staff H entered Resident 15's room without performing hand hygiene. Staff H was observed donning a pair of clean of gloves and then walked over to the medication cart (outside of the room) to retrieve a lancet [small needle used to make a tiny prick on the skin] from the medication cart. Staff H then removed their soiled gloves and donned a new pair. No hand hygiene was observed between glove change. RESIDENT 7 Observation on 10/14/2024 at 10:46 AM, showed Staff H was adjusting the magnetic door holder before they entered Resident 7's room. Staff H gave Resident 7 their oral medications, picked up their breakfast tray, and carried it out of their room. Staff H closed Resident 7's door with their hand and left the room. Staff H did not perform hand hygiene before entering or after leaving the resident's room. In an interview on 10/14/2024 at 2:20 PM, Staff H stated that they were to use gloves during resident care, when checking blood sugars, and administering injections. Staff H stated that the appropriate times to sanitize their hands was when they remove their gloves and when they exit the resident's room. In an interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be hand sanitizing, then gloving and gowning before providing resident care. An interview on 10/16/2024 at 1:56 PM, Staff A stated that hand hygiene should have been done before and after resident's care and between gloving. An interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be hand sanitizing [do hand hygiene in between tasks (and between glove change) for Residents 168, 15 & 7]. 47218 DINING ROOM OBSERVATION STAFF J Observations on 10/10/2024 at 12:16 PM and on 10/14/2024 at 11:51 AM, showed Staff J, CNA, was holding a sandwich with their bare hands and brought it up to Resident 11's mouth. On 10/16/2024 at 8:43 AM, Staff J stated they used their bare hands to hold Resident 11's sandwich when assisting them with eating and that their hands were clean. Staff J further stated they did not know they needed to wear gloves prior to touching Resident 11's food. MEAL TRAY PASS OBSERVATION STAFF I On 10/11/2024 at 11:34 AM, Staff I, CNA, was observed delivering meal trays to residents' room from a meal rolling cart. Staff I delivered Resident 10's lunch to their side table, moved the side table closer to the resident, and left their room without performing hand hygiene. Staff I then delivered Resident 5's lunch to their side table, Staff I moved Resident 5's trash can to their left side, uncovered the plate and pushed it closer to the resident, touched Resident 5's shoulder, then donned gloves to cut resident's quesadilla with utensils, and left the room. Staff I, then went to the dining room, took a meal tray, delivered it to Resident 7's side table, and left the room. Staff I did not perform hand hygiene before entering and/or after leaving the room for Residents 10, 5 and 7. On 10/11/2024 at 11:49 AM, Staff I stated that hand hygiene should have been performed before entering and after leaving Residents 10, 5, and 7's room. Staff I further stated that hand hygiene should be performed before serving lunch, after providing resident care, and when they touched the resident or their environment. On 10/16/2024 at 8:53 AM, Staff H stated that it was not okay for staff to touch the resident's food with their bare hands and that gloves should have been worn. Staff H further stated that staff [Staff I] should have performed hand hygiene before entering and after leaving residents' room, after touching the resident and their environment, and after removing their [used/soiled] gloves. On 10/16/2024 at 9:24 AM, Staff C stated that Staff J should not have touched Resident 11's food with their bare hands. Staff C further stated they expected staff to perform hand hygiene before entering and after leaving the residents' room, after providing care, after removing soiled gloves, and after touching the residents' and their environment. On 10/16/2024 at 11:25 AM, Staff B stated that Staff J should not have touched Resident 11's food with their bare hands and that they should have used a fork or gloves when assisting the resident with their meals. Staff B further stated that Staff I should have performed hand hygiene prior to entering/after leaving the rooms for Residents 10, 5 and 7, and after touching the residents' and their environment. Reference: (WAC) 388-97-1320 (1)(a)(c)(5)(c)

Based on interview and record review, the facility failed to accurately assess 1 of 10 residents (Resident 11), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding active diagnosis placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable . Active Diagnoses- Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). Resident 11 admitted to the facility on [DATE]. Review of the physician orders printed on 10/11/2024, showed Resident 11 was receiving a medication [for depression (or mood disorder)] for diagnosis of anxiety and pain that started on 08/03/2024. Review of Resident 11's quarterly MDS dated [DATE], showed that anxiety was not marked on the diagnoses section (Section I) of the MDS. Joint record review and interview on 10/16/2024 at 10:35 AM with Staff D, Resident Care Manager/MDS Coordinator, showed Resident 11's physician's order had an antidepressant order for anxiety and pain. Staff D stated that anxiety was the diagnosis for Resident 11's antidepressant medication. Joint record review of the quarterly MDS dated [DATE], showed anxiety was not marked on Section I. Staff D stated that Resident 11's MDS should have had anxiety marked in Section I and that the MDS was inaccurate. On 10/16/2024 at 11:45 AM, Staff C, Assistant Director of Nursing, stated that they expected MDS assessments to be accurate and that Resident 11's MDS was not accurate. On 10/16/2024 at 11:53 AM, Staff B, Director of Nursing, stated they expected the MDS assessment to be accurate and have accurate diagnoses. Reference: (WAC) 388-97-1000(1)(b)(j)

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASARR - a federally required screening of all individuals who has both an Intellectual Disability [ID] or Related Condition [RC] and a Serious Mental Illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 3 of 5 residents (Residents 11, 14 & 68), reviewed for unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnosis or disability. Findings included . Review of the facility's policy titled, PASARR, revised on 04/01/2023, showed that the facility would ensure all residents had a PASARR level I completed on admission and would ensure PASARR Level II referrals were made in accordance with State requirements. The document further showed that the facility's social services team would review the Level I PASARR for accuracy within 72 hours on all admissions. If the PASARR level I was inaccurate, a new accurate Level I PASARR would be immediately completed. If the PASARR Level I screening identified possible SMI or ID or RC, the social services team member would notify the DDA (Developmental Disability Administration) and/or mental health PASARR evaluator so a Level II evaluation can be conducted. RESIDENT 11 Review of the face sheet printed on 10/11/2024, showed Resident 11 admitted to the facility on [DATE]. Review of the physician orders printed on 10/11/2024, showed Resident 11 was receiving an antidepressant medication for diagnosis of anxiety and pain that started on 08/03/2024. Review of Resident 11's Level I PASARR dated 08/27/2024, showed the diagnosis of anxiety was not marked in Section I (SMI/ID/RC). Joint record review and interview on 10/16/2024 at 10:02 AM with Staff E, Social Services Coordinator, showed Resident 11's physician order had an order for an antidepressant medication for diagnosis of anxiety and pain since 08/03/2024. Staff E stated that anxiety was the diagnosis for Resident 11's antidepressant medication. Another joint record review and interview on 10/16/2024 at 10:02 AM with Staff E, showed no diagnosis of anxiety was listed under Section IA [SMI] of Resident 11's Level I PASARR dated 08/27/2024. Staff E stated that the diagnosis of anxiety should have been listed in Resident 11's Level I PASARR. Staff E further stated that Resident 11's Level I PASARR was not referred to the PASARR evaluator for a PASARR level II evaluation and it should have been. On 10/16/2024 at 1:17 PM, Staff A, Health Services Administrator, stated they expected the PASARR forms to be accurate. Staff A further stated that Resident 11's most current Level I PASARR form should have had a diagnosis of anxiety marked in the SMI section and that it should had been sent to the PASARR evaluator for a PASARR level II evaluation upon completion. 48899 RESIDENT 14 Review of a face sheet showed Resident 14 admitted to the facility on [DATE]. Review of Resident 14's Level I PASARR form dated 09/18/2024, showed the name of the resident and the hospital staff member who completed the form. Further review of the Level I PASARR form did not show the required four sections (Sections I to IV) were completed or filled out. In an interview and joint record review on 10/15/2024 at 3:17 PM, Staff E stated that they ensured the Level I PASARR be completed upon admission. A joint record review with Staff E showed Resident 14's Level I PASARR form did not have the four sections completed. Staff E stated that Resident 14's Level I PASARR form was incomplete and that it needed to be redone properly. In an interview on 10/16/2024 at 2:33 PM, Staff A stated that Resident 14's Level I PASARR was not reviewed properly, and it should have been. :33 PM, Staff A stated that Resident 14's PASARR Level I was not reviewed properly, and it should have been. 50891 RESIDENT 68 A review of Resident 68's face sheet showed they admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder. A review of Resident 68's Level 1 PASARR form dated 10/07/2024 showed that mental mood disorders and anxiety disorders were marked in the SMI section. Further review of the document showed the SMI Indicators section was marked yes [has SMI] and no [does not have SMI]. In an interview and joint record review on 10/16/2024 at 10:19 AM, Staff E stated that they reviewed the Level I PASARR either on the day the resident arrives to the facility or the day before. Staff E stated that they had reviewed Resident 68's Level I PASARR form multiple times and did not know how they missed that Section IA and that it was mismarked. In an interview on 10/16/2024 at 1:56 PM, Staff A stated that their expectations included the PASARR forms to be reviewed prior to a new resident's admittance. Staff A further stated that any new admit with a mental health diagnosis, they would review and update the PASARR activity according to standard. Reference: (WAC) 388-97-1915 (1)(2) (a-c) (4), 1975(1)(4)

Based on interview and record review, the facility failed to develop and implement care plans for 3 of 8 residents (Residents 14, 2 & 6), reviewed for comprehensive care plan. The failure to implement care plans for Activities of Daily Living (ADL), use of medication to reduce swelling, and use of psychoactive [mind-altering] medication to include target behaviors and non-pharmacological interventions placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Resident Centered Care Plans, revised on 02/09/2024, showed the facility must develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objections and periods to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the facility's policy titled, Policy and Procedure - Psychoactive Drug use, revised on 07/01/2024, showed, Care plan documentation will include measures to monitor, avoid and prevent decline in function and a plan to attempt other alternatives . Each resident's behavior monitoring record will be identifying the specific symptoms for which the drug is being used . Documentation of the behaviors will be quantitative and objective. ACTIVITIES OF DAILY LIVING RESIDENT 2 Review of the face sheet showed that Resident 2 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 08/09/2024 showed Resident 2 had severe cognitive impairment and required total assist with showering/bathing. Review of the ADL care plan printed on 10/10/2024, showed Resident 2's showers were scheduled for twice a week on Tuesdays and Fridays. The care plan further showed that hospice [a type of end -of-life care that provides comfort, dignity, and peace for people who are dying] services would provide Resident 2 a shower/bath every Monday morning. Review of the facility provided undated and untitled document, showed that room [ROOM NUMBER] (Resident 2's room) was scheduled for a shower on Mondays and Fridays. Further review of the undated document showed that the hospice bath aide would come every Monday to provide shower to Resident 2. Review of the July 2024 to September 2024 Documentation Survey Report [documentation for shower/bath], showed Resident 2 received showers on 07/03/2024 (Wednesday) and 07/12/2024 (Friday). The document further showed that Resident 2 did not receive any showers in August 2024 and received one shower on 09/27/2024. Further review of the document showed no documentation to show Resident 2's refusals for shower. On 10/10/2024 at 10:55 AM, Collateral Contact 1 (CC1) stated that Resident 2 received one shower a week for 10 consecutive weeks. CC1 mentioned that when they reported their concern to the nurse manager [Staff C, Assistant Director of Nursing], the manager responded that they had instructed the aides to offer one shower a week. In an interview on 10/14/2024 at 1:12 PM, Staff K, Certified Nurse Assistant (CNA), stated that Resident 2 required total assist with showering/bathing. In an interview and joint record review on 10/15/2024 at 3:01 PM, Staff D stated that Resident 2 was scheduled for two showers a week. A joint record review with Staff D showed Resident 2 received showers on 07/03/2024 and 07/12/2024 for the month of July 2024, did not receive any showers in August 2024, and received one shower on 09/27/2024 for the month of September 2024. Staff D stated that Resident 2 should have received two showers a week and that the care plan should have been followed. In an interview and joint record review on 10/15/2024 at 10:21 AM, Staff C, stated that Resident 2's shower schedule was initially for Tuesdays and Fridays but was recently changed to Mondays and Fridays. Staff C stated, It seems that while the resident had been receiving showers, the NACs [CNAs] have not documented it properly. Staff C further stated that there was no documentation that showers were provided twice a week. A joint record review and interview on 10/16/2024 at 12:01 PM with Staff B, Director of Nursing, showed that Resident 2 received two showers in July 2024, no showers in August 2024, and one shower in September 2024. When asked if the care plan was followed, Staff B stated it was not and it should have been followed. USE OF MEDICATIONS RESIDENT 14 Review of the face sheet showed Resident 14 admitted to the facility on [DATE]. Review of Resident 14's September 2024 Medication Administration Record showed an order for a diuretic (helps to reduce fluid buildup [edema or swelling] in the body) medication 1 milligram (unit of measurement) take three tablets by mouth twice a day for edema that started on 09/19/2024. Review of Resident 14's comprehensive care plan printed on 10/14/2024, did not show a care plan for diuretic use. Observations on 10/11/2024 at 9:23 AM and on 10/14/2024 at 10:17 AM, showed Resident 14 had swelling to both legs. In an interview on 10/15/2024 at 3:01 PM, Staff D, Resident Care Manager/Minimum Data Set [Assessment] Coordinator, stated that Resident 14 had been on diuretic medication for edema since 09/19/2024. Staff D stated that a diuretic care plan was just added on 10/15/2024. In an interview and joint record review on 10/15/2024 at 10:21 AM, Staff C stated that residents on diuretic medication needed a care plan when they started using it. A joint record review with Staff C showed that Resident 14's care plan for diuretic use was developed on 10/15/2024. Staff C stated that the care plan should have been developed immediately after the medication was started [09/19/2024]. On 10/16/2024 at 12:01 PM, Staff B stated that they were aware Resident 14 was on a diuretic medication. Staff B stated that they expected a care plan was developed as soon as Resident 14 started using diuretics. 51090 RESIDENT 6 Resident 6 admitted to the facility on [DATE]. Review of Resident 6's physician orders printed on 10/15/2024, showed an order for a medication for depression [persistent feeling of sadness, loss, anger, or frustration that interferes with everyday life]) 50 milligram (mg-unit of measurement) tablet by mouth in the morning dated 08/15/2024. Review of Resident 6's antidepressant medication care plan, revised on 08/27/2024 did not show there were target behaviors and non-pharmacological interventions identified and/or listed in the care plan. In an interview on 10/16/2024 at 10:18 AM, Staff B stated they expected target behaviors and non-pharmacological interventions for Resident 6 to be in place and that they should have been included in Resident 6's antidepressant medication care plan when the antidepressant medication was started. Reference: (WAC) 388-97-1020 (1) (2)(a)(3)

Based on interview and record review, the facility failed to ensure fall interventions were updated, to ensure care was provided to residents at the care level they were assessed to required, and that care staff had access to fall prevention interventions for 1 of 2 resident (Resident 8) reviewed for falls. This failure caused harm to Resident 8 who fell while ambulating and experienced a fractured left humerus (long bone in the arm that runs from the shoulder to the elbow). In addition, the facility failed to ensure 1 of 1 housekeeping storage rooms, reviewed for accident hazards, was locked. These failures placed all residents at potential risk for avoidable falls, injury, unsafe exposure to potentially hazardous cleaning chemicals, and a diminished quality of life. Findings included . <Falls> The Purple Book Nursing Home Reporting Guidelines, dated October 2015, showed that injuries of an unknown source, such as substantial, substantial reasonable related, and unknown superficial injuries, should be reported to the Department of Social and Health Services (DSHS) Hotline and require DSHS notification within five days. Repeated injuries, even when related to condition, may become abuse or neglect if preventive measures are not taken. All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect. Review of the facility policy titled, Fall Management, revised on 04/01/2023, showed that revisions to the care plan will be documented in the chart and communicated to caregivers. The facility will have in place a fall management protocol utilizing assessments and interventions to minimize the risk of falling for residents to reduce and prevent the number of falls and number of injuries related to falls for residents. Preventative interventions will include identifying if proper equipment is being used, identifying if other environmental factors place the resident at risk for falls and them implementing interventions based on findings. Review of Resident 8's Electronic Medical Record (EMR) showed they were admitted to the facility on [DATE] with diagnoses that included low back pain, fracture of lower end of left humerus, difficulty in walking, edema (swelling) on both legs, and a history of left rib fractures of ribs eight to ten. Review of Resident 8's Morse Fall Scale assessment tool [determines fall risk factors], dated 01/14/2023, showed a score of 65. A score of 45 or higher indicated the resident was considered a high fall risk. Review of Resident 8's physician notes, dated 01/26/2023 and 04/10/2023, showed the resident had a diagnosis of recurrent falls. Review of Resident 8's EMR, showed the resident fell on [DATE] which caused a laceration to their forehead that required sutures. Review of Resident 8's EMR, showed Resident 8 had an unwitnessed fall on 04/07/2023 which resulted in a left arm fracture. Review of Resident 8's self-care performance care plan, dated 02/07/2023, showed Resident 8 ambulated (walked) independently with a walker. Review of Resident 8's quarterly Minimum Data Set (MDS, an assessment tool), dated 02/10/2023, showed Resident 8 used a walker for ambulation and required supervision of one person with transfers, supervision with set-up with walking in their room and/or in the corridor, and supervision with set-up with locomotion on unit and off unit. Review of Resident 8's progress notes, dated 02/27/2023, showed the resident had an unwitnessed fall in the facility's Assisted Living Facility (ALF- located above the nursing facility). Review of Resident 8's Morse Fall Scale assessment, dated 02/27/2023, showed the resident had a fall risk score of 80, a high fall risk. Review of Resident 8's care plan, showed no additional interventions were implemented for the 02/27/2023 unwitnessed fall or the increase the Morse Fall Scale assessment. Review of Resident 8's progress noted, dated 03/17/2023, 18 days after the resident fell on [DATE], showed Staff X, former Social Services, and an ALF staff member, showed Resident 8 was spoken to regarding needing an escort (to and from) if they wished to have meals in the ALF. Review of the care plan did not reflect this new intervention. Review of Resident 8's progress note, dated 04/07/2023, showed Resident 8 was found on the floor by the nurse's station at 7:10 AM. The note showed the resident fell while using their walker and lost their balance. Resident 8 complained of pain and was not able to move their left arm. Review of Resident 8's physician progress note, dated 04/07/2023, showed the resident had fallen which resulted in a left humerus fracture. The resident was non-weight bearing (to place no weight on the injured arm), precautions to their left upper extremity, and had a splint (device used to protect and support broken or injured bones and joints) in place. Review of the May 2023 incident report log form showed no documentation or the facility had reported (called) Resident 8's 04/07/2023 fall with injury to the state agency. Review of Resident 8's fall care plan, initiated on 05/13/2021 and revised on 05/03/2023, showed a goal of will not sustain serious injury through the next review. A care plan intervention directed staff to ensure the resident wore appropriate footwear when ambulating with a walker. In an interview on 06/16/2023 at 9:29 AM, Staff H, Certified Nursing Assistant (CNA), stated they worked regularly with Resident 8. Staff H stated that prior to Resident 8's fall in April 2023, Resident 8 walked on their own using a walker. Staff H stated they followed the residents' care plan when providing care to residents. Resident 8's care plan was reviewed with Staff H. Staff H showed a charting screen for the staff to chart on how much help the resident needed during care, there were no specifics for how much help Resident 8 required with transfers, bed mobility, toileting, ambulation, and/or eating. Staff H stated they did not know where to look for information on what kind of care they needed to provide to Resident 8. When Staff H was showed Resident 8's care plan, [under the Kardex tab, a type of care plan-that directs CNA staff on how to provide care to a resident, Staff H stated they did not know if they had access to it. In an interview on 06/16/2023 at 11:52 AM, Staff G, Licensed Practical Nurse (LPN), stated the amount of assistance Resident 8's required was in their care plan. Staff G accessed Resident 8's fall care plan and stated the CNAs do not have access to that care plan. In an interview on 06/16/2023 at 12:15 PM, Staff C, Resident Care Manager (RCM)/MDS Coordinator, stated Resident 8's falls should have previous falls with interventions from each fall in it. Staff C stated that there should be a new intervention with each fall placed in the care plan. Staff C stated CNAs do not have access to the care plan, but there was a different care plan available for them to access. Staff C did not know how to access Resident 8's CNA care plan (Kardex). Staff C stated that CNAs have access to tasks if they were attached to the Kardex by a K' symbol next to it. Staff C stated that Resident 8's walking and transfers tasks did not have information on how much help Resident 8 needed with transfers or walking. During a joint review of Resident 8's quarterly MDS, dated [DATE], showed that Resident 8 required supervision assist with set up for transfers and ambulation in room/in corridor. Staff C sated that Resident 8 should have had supervision assist with ambulation prior to the fall on 04/07/2023. Staff C stated that supervision assist with ambulation should have been in Resident 8's care plan and that CNAs did not have access to the care plan. In an interview on 06/16/2023 at 12:58 PM, Staff B, Director of Nursing, stated they expected to see falls included in the resident's care plan with interventions for each fall. Staff B stated, Staff C and RCM's update the resident's care plans. Staff B stated they were still in the learning process and were not able to access the CNAs documentation where they would find the fall interventions for residents. 46829 <HOUSEKEEPING STORAGE ROOM> In an observation on 06/13/2023 at 9:18 AM, 06/13/2023 at 11:48 AM, and 06/13/2023 at 2:21 PM, showed the housekeeping storage room was closed but not locked, the door had a sign posted that stated, This door must always be kept locked. The room was observed with cleaning supplies: One home pest control spray bottle, a high-performance neutral floor cleaner bottle, restroom cleaner spray, all-purpose cleaner spray bottle, vacuum device, batteries, trash bags, wipes, and other items. In a joint observation and interview with Staff B on 06/13/2023 at 2:21 PM, showed the housekeeping storage room door was closed but not locked and the room was observed with multiple potentially hazardous housecleaning supplies. Staff B stated they expected the housekeeping storage room door to be closed and locked. Refer to CFR 483.12 (b)(c)(1) - F-609 Reporting of Alleged Violations for additional information. Refer to CFR 483/12 (C)(2)(3)(4) - F-610 Investigate/Prevent/Correct Alleged Violation for additional information. REFERENCE: WAC 388-97-1060(3)(g) This is a repeat citation from 04/27/2022

Based on observation, interview, and record review, the facility failed to comprehensively assess, initiate appropriate and timely fall interventions, failed to provide adequate supervision and follow the plan of care for 2 of 2 residents (1 and 2) reviewed for accident hazards and falls. Additionally, the facility failed to comprehensively assess and follow written policy and procedures to ensure safety and minimize the risk for 1 of 1 resident (3) reviewed for avoidable accidents (burn). The facility's failure to provide adequate supervision, failure to initiate timely and appropriate fall interventions, and/or the failure to follow written plan of care, policies and procedures caused harm to Resident 1, Resident 2 and Resident 3. Resident 1 and Resident 2 suffered falls with major injuries (head injury and fracture) that required emergency services and hospital evaluation. Resident 3 suffered a substantial burn that resulted in skin redness and pain. Findings included: FALL WITH MAJOR INJURIES According to the Center for Disease Control, (CDC), a fall can cause an injury such as a broken bone or a head injury. These can be very serious, especially if the person is taking certain medicines like blood thinners. Such injuries can make it hard for a person to get around and do everyday activities. A review of the facility policy titled, Fall Management, dated 10/25/17, showed the facility would have a fall management protocol utilizing assessments and interventions to minimize the risk of falling for residents. The policy directed the facility staff to: A. The fall assessment form will be completed on a quarterly basis for all residents or upon change of condition. B. If a resident is identified to be at high risk for falls, a physician order for [REDACTED]. C. The resident will be referred to the Restorative Nursing program as appropriate. D. Revisions to the care plan will be documented in the chart and communicated to caregivers. E. The completed Fall Assessment and any related assessments will be placed in the resident's chart and attached to any investigation following a fall. RESIDENT 1 Resident 1 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had severe cognitive impairment and needed one person assistance with bed mobility, transfers, toileting and personal hygiene needs. Review of the resident's most recent fall risk assessment dated [DATE] showed the resident was at high risk for falls. Review of the resident's fall care plan dated 08/07/18, showed the resident was at high risk for falls related to [MEDICAL CONDITION], weakness and impaired mobility. The care plan directed the facility staff to: A. Follow facility fall protocol. B. Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Further review of the resident's care plan (Activities of Daily Living and Communications) showed interventions to encourage the resident to use bell to call for assistance and Resident does not use her call light, prefers to call out for help or just gets up on her own; check on her frequently. The care plan intervention had conflicting information, was not resident-centered, and had interventions that were not appropriate for the resident due to her limitations. Review of the resident's Kardex (care directives to staff) showed the resident should be on every 1 hour safety check when in bed for safety. During the initial tour of the facility on 02/15/19 at 11:05 AM, the resident was observed at the nurse's station sitting in her wheelchair. The resident's entire face was severely bruised (mixed dark and light purple bruises), and the resident's right hand was bruised (dark purple) and wrapped with a dry dressing. The resident was grimacing and was observed holding/guarding her right hand. During a joint interview and record review on 02/15/19 at 11:23 AM, Staff C, Licensed Practical Nurse (LPN), stated the resident fell last week around midnight. Staff C stated the fall was a unwitnessed fall and the staff found the resident on the floor right next to her bed. According to Staff C, the resident was found to be confused and was observed to have severe facial bruising and right hand bruising with a skin tear. Staff C stated the resident was transported to the hospital for evaluation after the fall and later returned to the facility. Staff C further stated the resident was at high risk for falls, impulsive, and was not able to recognize and call for help. In an interview on 02/15/19 at 11:30 AM, the resident was not able to remember what happened to her and why she had a huge bruise on her face and hand. The resident reported pain and discomfort to her face and right hand. The resident was not aware of a call light and was not aware she needed any help from staff. Review of the incident investigation dated 02/09/19 showed that on 02/09/18 at 12:05 AM, the resident was found on the floor in her room calling for help. The incident report documented, resident sustained [REDACTED]. When resident asked what happened, res (resident) replied I wanted to go to the bathroom and fell . Interventions initiated documented resident call light within reach, Staff to ensure resident is wearing non-slip socks, check resident every 2 hours for toileting need, offer fluid, snacks when awake. The investigation also documented the resident was last seen and cared for on 02/08/19 at 11:30 PM. Review of the staff witness statements showed no evidence that the resident received care and/or was visually seen and checked by a staff member as directed by the resident's plan of care. The witness statement completed by the facility administrator was not dated, was missing information on when the resident was last seen or cared for and who was the staff writing the statement or being interviewed related to the incident. Further review of the resident's clinical records showed no evidence the resident had received care from staff between 02/08/19 at 9:00 PM to 02/09/19 at 12:05 AM when the resident was found on the floor in her room. The only documented hourly check and Activities of Daily Living (ADL) care provided to the resident before the incident was on 02/08/19 at 8:19 PM. Additionally, the facility failed to complete a fall and pain assessment after the resident fall as directed by the facility fall policy. The resident's clinical records also showed the resident had several falls in the past as follows: A. Unwitnessed fall with substantial injury (14cm long back/sacrum abrasion) on 01/17/19. The investigation summary documented, Resident was attempting to return herself to the WC (wheelchair) after she used the toilet. Call light was within reach, but due to her [DIAGNOSES REDACTED]. Care plan update/intervention included: Do not leave resident unattended when using the toilet. The resident had known history of falls and unsafe transfers, was assessed to be at high risk for falls due to impaired memory and cognition and had known history of inability to use or not using call lights to call and alert staff for help was left unattended and unsupervised in the bathroom by the facility staff. B.Unwitnessed fall on 11/07/18. The investigation summary documented the resident was ambulating unassisted while attempting to self-toilet. The new intervention included: every one hour safety check when in bed. The investigation also showed, Resident has a history of ambulating unassisted as she cannot remember to use call light due to dementia. The investigation documented, ways to prevent reoccurrence: will check Res. (resident) more frequently q30 min (every 30 minutes), anticipate needs - offer to toilet more often. However, the investigation and the care plan changes made was for every one hour safety check and did not include this specific plan/intervention. Additionally, the facility failed to complete a fall and pain assessment timely as directed by the facility policy. The resident had a fall on 11/07/18, however the fall and pain assessments were not completed until 11/20/18 (13 days after the incident.) The facility failed to conduct a thorough investigation, failed to rule out and address the root cause of the incident and failed to rule out abuse/neglect. (Refer to F610 - Investigate/Prevent/Correct Alleged Violation for more information.) Review of the resident's clinical records showed no referral or therapy order was obtained to review and address the resident's increased/high risk for fall as directed by the facility policy and plan of care. During a meeting and joint record review on 12/15/19 at 4:25 PM with the Administrator and the Director of Nursing, (DNS), the resident's incident reports and clinical records were reviewed. Both the Administrator and the DNS stated the facility had no documented records that showed the staff had provided adequate supervision to the resident as directed by the resident's plan of care. The administrator and DNS were not able to provide an answer on why the facility policy was not followed related to completing a timely fall and pain assessment for the resident's fall on 02/09/19. The resident had a fall with injury and required emergency services and hospital evaluation on 02/09/19. However, the fall and pain assessment was completed before the meeting with the surveyor on 12/15/19 at 2:45 PM. Both the staff members were not able to say why the facility staff left the resident unattended/unsupervised on the 01/17/19 when staff were aware that the resident had impaired memory/cognition with a history of inability to use or not using the call light to call for staff. Both the Administrator and the DNS, when asked why the facility investigations were not thorough and missing information about the root cause of each incident, specifically the resident's toileting needs/attempts to toilet, both the stated, I think we had tunnel vision on the falls. The Administrator and the DNS stated they didn't look at the resident's fall history and the circumstances of the incident, rather they were more focused on minimizing the resident's injury. (F609 - Reporting of Alleged Violations and F610 - Investigate/Prevent/Correct Alleged Violation for more information.) A review of the hospital report summary dated 02/09/19, showed the resident was seen and treated status [REDACTED]. The facility failed to provide adequate supervision to Resident 1 resulted to a fall with substantial injuries. RESIDENT 2 Resident 2 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE] showed the resident had impaired cognition and needed one person assistance with bed mobility, transfers, toileting/dressing and personal hygiene needs. Review of the resident's most recent fall risk assessment dated [DATE] showed the resident was at high risk for falls. Review of the resident's fall care plan dated 08/09/18 showed the resident was at high risk for falls related to Gait/balance problems and had a history of [REDACTED]. The care plan directed the facility staff to: A. Follow facility fall protocol. B. Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Further review of the resident's care plan (ADL's/self-care performance deficit) showed the resident required one person assist with dressing and grooming, will transfer self to toilet without asking for help/fall risk, and Watch her closely, will often try to transfer self. Review of the incident investigation report dated 12/13/18, showed that on 12/13/18 at 1:40 PM, the resident was heard and found crying out for help in her room. The incident report documented, Resident claimed that she was trying to get out of bed into wheelchair when she fell , however Staff D, Nursing Assistant, (NA), claimed that 2-3 minutes prior to fall she had passed by room and noted that resident was sitting up in wheelchair. Review of the witness statements completed by three different staff members, showed that on 12/13/18 at 1:30 PM, the resident had just finished lunch and was taken back to her room by Staff D, NA and was left unattended/unsupervised in the room. The resident had known history of falls and unsafe transfers, was assessed to be at high risk for falls due to impaired cognition and had known history of not using call lights to call and alert staff for help was left unattended/unsupervised in the room by the facility staff. The investigation summary report documented, Resident able to tell staff she was transferring unassisted when she fell . Nurse Assistant able to fill in blanks and had only observed her 2-4 minutes prior to fall. Resident continues to attempt complete independence when she need extensive assist with transfers. The investigation was missing information on why the resident, with known risk for fall, was left unattended/unsupervised in the room. The resident's clinical records also showed the resident had several falls in the past as follows: A. 11/20/18, the resident had a non-witnessed fall in her room at 4:15 PM. The investigation summary report documented, Resident able to tell staff what happened. Stated she was attempting to put her shoes on when she slid from the wheelchair as it rolled out from under her because it was not locked . The resident reported she hit her head on the wall and sustained a head injury 1.5cm x 1.5cm redness to the right forehead. Review of the witness statements, completed by five different staff members, showed that on 11/20/18 at 4:10 PM, the resident was left unattended/unsupervised in the room and the NAC on duty was on break. The question specific for the resident's footwear was not filled out and the investigation did not address why the resident was left unattended/unsupervised in the room. B. 10/07/18: The resident had a non-witnessed fall in her room at 10:37 AM. Similar findings were applicable to which the resident was left unattended/unsupervised in her room. The investigation summary report documented, Resident attempted to go back to bed unassisted . She stood and half turned, lost balance/weight bearing ability resulting in falling to the floor. The investigation did not address why the resident was left unattended/unsupervised in the room. The facility failed to conduct a thorough investigation, failed to rule out and address the root cause of the incident and failed to rule out abuse/neglect. (Refer to F610 - Investigate/Prevent/Correct Alleged Violation for more information.) Review of the resident's clinical records, showed no referral or therapy order obtain to review and address the resident's increase risk/high risk for fall as directed by the facility policy and plan of care. During a meeting and joint record review on 12/15/19 at 4:40 PM with the Administrator and the DNS, the resident's incident reports and clinical records were reviewed. Both the staff members were not able to answer why the facility staff left the resident unattended/unsupervised having the knowledge that the resident had impaired memory/cognition with known history of unsafe transfers and inability/not using call lights to call for staff assistance for the incidents on 12/13/18, 11/20/17 and 10/07/18. Both the Administrator and the DNS stated, the facility had no documented records that the staff had provided adequate supervision to the resident as directed by the resident's plan of care watch her closely and that the incident on 12/13/18 should have been reported to the state agency as required. Both the Administrator and the DNS, when asked why the facility investigations were not thorough and missing information about the root cause of each incident, stated, I think we had tunnel vision on the falls. Both the Administrator and the DNS stated they didn't look at the resident's fall history and the circumstances of the incident, rather they were more focused on minimizing the resident's injury. (Refer to F609 - Reporting of Alleged Violations and F610 - Investigate/Prevent/Correct Alleged Violation for more information.) A review of the X-ray report dated 12/13/18, showed the resident suffered a non-displaced left obturator ring fracture (pelvic ring/pelvis) after a fall. HOT BEVERAGES/BURN A review of the facility policy titled, Policy on Serving Hot Beverages, dated, 07/2014, showed Palatability and Risk for scalding are two factors that the facility will take in consideration when serving hot beverages . Beverages including most coffee and tea need to be brewed at a temperatures near 200 degrees F (Fahrenheit) to extract the full flavor. The policy directed the facility staff to: A. Plan with the resident how to safely drink hot beverages at their preferred temperatures. B. Resident assessed to be at risk for handling hot beverages may be referred to Occupational Therapy if appropriate. RESIDENT 3 Resident 3 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS dated [DATE] showed the resident needed one person assistance with ADLs including eating. Review of the facility incident reporting log from 08/2018 to 02/15/19 showed the resident suffered a substantial injury (burn) on 02/02/19. Review of the incident investigation report dated 02/02/19 showed that on 02/02/19 at 8:45 AM, Resident spilled coffee in lap during breakfast, stated fell asleep holding cup. Noted redness right anterior thigh 8cmx1cm applied cold washcloth. Resident stated burning pain at site at time of incident . Ways to prevent reoccurrence: Will use lids on coffee cup, will have coffee ½ (half) full. Review of the incident investigation summary report dated 02/02/19 documented, Resident spilled hot coffee during breakfast in lap, sustained minimal burn right anterior thigh. Care Plan updated for her to use a lid for all hot beverages . The facility failed to conduct a thorough investigation, failed to rule out and address the root cause of the incident and failed to rule out abuse/neglect. (Refer to F610 - Investigate/Prevent/Correct Alleged Violation for more information.) During a meeting and joint record review on 12/15/19 at 4:45 PM with the Administrator and the DNS, the resident's incident reports and clinical records were reviewed. Both the Administrator and the DNS stated the resident was not seen or assessed by nursing staff and/or therapy staff on how to safely drink hot beverages or assessed the resident's risk for injury from burn/scalding. The resident's clinical records showed no evidence the facility had comprehensively assess the resident's safety with hot beverages as directed by the facility policy. The resident was at high risk for injury from handling hot beverages related to her current medical conditions and the facility failed to identify and develop a person centered plan of care to minimize this risks. Additionally, the incident investigation was missing information about the accurate description of the injury sustained by the resident and had failed to address the root cause of the resident falling asleep while holding a coffee cup. This placed the resident at significant risk for serious harm and the likelihood of serious injury from hot beverages/burn. See also: F610 - Investigate/Prevent/Correct Alleged Violations and F609 - Reporting of Alleged Violations for more information. This is a repeat citation from 07/02/18 survey. Reference: (WAC) 388-97-1060 (3)(g)