Every finding on record at Regency Harmony House Rehab & Nursing

Based on record review and interview, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protected and promoted resident rights under federal and state law and regulations) of discharges and/or transfers, as required for 1 of 3 sampled residents (Resident 53), reviewed for hospitalization and discharges. This failure placed residents at risk of not having an advocate during and after discharge.Findings included .Review of admission assessment dated [DATE], documented Resident 53 had diagnoses including a stroke, dementia, and depression. Resident 53 was cognitively intact and able to make their needs known. Review of progress note dated 09/12/2025 at 5:38 PM documented Resident 53 discharged home with their family member. During an interview on 11/23/2025 at 12:49 PM, Staff G, Health Information Director, stated they did not notify the Ombudsman when a resident discharged home, only when they went to the hospital. Staff G stated they were unaware they needed to notify the Ombudsman for all discharges. In an interview on 11/23/2025 at 12:55 PM, Staff B, Director of Nursing, stated it was important to notify the Ombudsman so they could follow up with the residents to ensure they were doing okay. No associated WAC

Based on observation, interview and record review, the facility failed to incorporate recommended behavioral health interventions into the comprehensive care plan timely for 1 of 5 sampled residents (Resident 3) reviewed for PASRR recommendations (Preadmission Screening and Resident Review, a behavioral health evaluation that identified psychosocial needs of residents). This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of quarterly assessment dated [DATE], documented Resident 3 had diagnoses including anxiety, depression and a paranoid personality disorder (a pattern of distrust and suspicion of others). The assessment further showed the resident had moderate cognitive impairments.Review of Level II PASRR (a more in-depth assessment conducted after a Level I screening suggested an individual may have a serious mental illness) evaluation dated 11/06//2025 recommended the following: -bed rails to enhance Resident 3's safety-bed in low position -bedside mats or positional supports based on facility policy and risk assessment-adequate lighting at night and visual cues -clear orientation cues such as a large print clock -calendar and signage in the room to include the facility name, date, and names of staff members -regular opportunities to play cards in groups or one-on-one, activities involving flowers, participation in reading sessions, particularly those focusing on historical topics or World War II, view World War II documentaries or attend history talks followed by group discussions to stimulate their interests and memory-an eye exam was recommended-It was stated Resident 3 might misinterpret care actions or perceive staff behavior as punitive. Clear, calm communication was important during any disagreement or misunderstanding, avoiding escalation and validating t heir emotional experiences, even when their interpretation of events appeared distorted. Review of Resident 3's electronic health record after 11/06//2025, showed no eye examination scheduled for Resident 3. Review of Resident 3's care plan showed no Level II PASRR recommendations.In an observation on 11/22/2025 at 9:13 AM, Resident 3 was lying in bed. There were no bed rails, bed was not in low position, no fall mat was on the floor, no large clock on the wall, and there was no signage in the room with the facility name, date or which staff was working. In an interview on 11/23/2025 at 11:33 AM, Staff C, Nursing Assistant, stated they knew what care to provide the residents by looking at their Kardex (nursing assistant instructions for resident care that came from the comprehensive care plan) which was a part of their care plan. In an interview on 11/23/2025 at 1:15 AM, Staff B, Director of Nursing, stated the Level II PASRR recommendations were sent on 11/06/2025 and should have been on the care plan. Staff B stated it was important to have the recommendations on the care plan, so they were utilized by staff, and it benefited the residents. Reference: WAC 388-97-1020(5)(b)

Based on observation, interview and record review, the facility failed to follow provider orders for 1 of 5 sampled residents (Resident 4) reviewed for nutrition. Specifically, Resident 4 had orders for a fluid restriction, and their oral fluid intake was not fully monitored. This failure placed the resident at risk for health consequences. Findings included . The 09/25/2025 quarterly assessment documented Resident 4 had diagnoses including heart failure (heart not strong enough to pump blood well enough to meet the body's needs), atrial fibrillation (irregular and abnormal heartbeat) and high blood pressure. Resident 4 had moderate cognitive impairment and was able to verbalize their needs.A 01/09/2025 provider order documented Resident 4 was on a 2000 milliliter (ml) fluid restriction. Nursing staff was to include the total amount of fluids consumed for each shift including nursing administered medications, meals and free fluid if provided.Review of the 03/07/2025 dehydration care plan documented Resident 4 was on a fluid restriction related to heart failure. The care plan documented the kitchen provided 840 mls with all meals, nursing was to provide 120 mls with each medication pass for a total of 360 mls and the resident had 800 mls of free fluid intake. The resident, family and caregivers were to be educated on the importance of fluid intake. A review of the electronic health records showed fluids consumed were documented in medication administrator records and the nursing assistant task monitor.During observation on 11/20/2025 at 3:19 PM, Resident 4 was lying in bed and had a water pitcher on their tray table. During an observation on 11/21/2025 at 9:52 AM, Resident 4 was sitting on their bed and had a water pitcher on their tray table and stated the staff filled it for them. The water pitcher was picked up and was full.In an observation on 11/22/2025 at 10:59 AM, Resident 4 was sitting on their bed and stated as long as there was water in their pitcher they were going to drink it. In an interview on 11/22/2025 at 9:34 AM, Staff E, Housekeeper, asked a staff member and stated the water pitchers held 30 ounces of water which converted to 887 mls. During an interview on 11/23/2025 at 9:06 AM, Staff C, Nursing Assistant, stated the water pitchers were filled in the mornings and changed every shift. Staff C stated they knew if a resident was on a fluid restriction by looking at their Kardex (nursing assistant care instructions) which was a part of their care plan. Staff C stated all residents were able to have a water pitcher in their room and when asked who was on a fluid restriction, Resident 4 was not mentioned. In an interview on 11/23/2025 at 9:12 AM, Staff D, Registered Nurse, stated the medication administration record (MAR) showed how many fluids the resident was to receive. Staff D stated the nursing assistants charted the amount of fluids the residents consumed on the computer, and they were able to see this. Staff D stated residents on fluid restrictions did not typically have a water pitcher in their room. Staff D confirmed that Resident 4 was on a fluid restriction. In an interview on 11/23/2025 at 9:16 AM, Staff B, Director of Nursing, stated the nurses documented fluid intake in the MAR and the nursing assistants in the tasks and at the end of the shift the total amount of fluids were calculated. When asked how nursing staff accounted for the fluids that were given in the water pitchers, Staff B stated they did not think that was monitored. Staff B stated it was important to follow the fluid restrictions to prevent fluid overload (fluid retention that can exacerbate heart failure). Staff B acknowledged the fluid restriction was not consistently followed. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 1 of 5 sampled residents (Resident 3) reviewed for medication management. This failure placed residents at risk of medical complications.Findings included . The 11/15/2025 quarterly assessment documented Resident 3 had diagnoses including depression, anxiety and heart failure. The assessment further showed the resident had moderate cognitive impairments. The 08/11/2025 care plan instructed nursing to give Resident 3 their medications as ordered.A review of the November 2025 Medication Administration Record (MAR), showed:-Acetaminophen 500 milligrams (mg) two tablets three times a day related to chronic pain. The entry on 11/01/2025 was blank and 10/07/2025 and 11/02/2025 had a code 9 entered, which indicated there was a progress note. The progress notes on both of those days stated the resident was asleep.-Amiodarone 200 mg twice daily related to atrial fibrillation (an irregular heartbeat). The entry on 11/01/2025 was blank and 10/07/2025 and 11/02/2025 also had a code 9 entered. The progress notes on both of those days stated the resident was asleep.-Apixaban 5 mg twice daily related to atrial fibrillation. The entry on 11/01/2025 was blank and 10/07/2025 and 11/02/2025 also had a code 9 entered, which documented the resident was asleep. -Ascorbic Acid 500 mg daily for a supplement. The entry on 11/01/2025 was blank and 10/07/2025 and 11/02/2025 had a code 9 which documented the resident was asleep. -Atorvastatin 40 mg daily for high cholesterol. The entry on 10/07/2025 had a code 9 and a progress note stated the resident was asleep. -Clonazepam 0.5 mg three times a day related to anxiety. The entry on 11/01/2025 was blank and 10/07/2025, 10/08/2025 and 11/02/2025 had a code 9 which documented the resident was asleep.-Melatonin 10 mg daily related to insomnia. The entry on 11/01/2025 was blank and 11/02/2025 had a code 9 which documented the resident was asleep.-Methenamine Hippuate 1 gram twice daily related to history of urinary tract infections. The entry on 11/01/2025 was blank and 10/07/2025, 10/08/2025 and 11/02/2025 had a code 9 which documented the resident was asleep. -Metoprolol 25 mg twice daily for heart failure. The entry on 11/01/2025 was blank and 10/07/2025, 10/08/2025 and 11/02/2025 had a code 9 which documented the resident was asleep. -Mirtazapine 30 mg daily for depression. The entry on 11/01/2025 was blank and 10/07/2025, 10/08/2025 and 11/02/2025 had a code 9 which documented the resident was asleep. -Nystatin powder 100000 unit/gram to left breast and groin every shift for yeast. The entry on 11/01/2025 was blank and 11/02/2025 had a code 9 which documented the resident was asleep. On the night shift of 10/01/2025 and 10/21/2025 the MAR was blank, 10/07/2025 had a code 9 and a progress note stated the resident was asleep, and on the dayshift of 10/21/2025 and 10/25/2025 there was a 13 which meant the medication was not required. -Oxycontin Extended Release 10 mg every 12 hours for pain. The entry on 11/01/2025 was blank and 10/07/2025, 10/08/2025 and 11/02/2025 had a code 9 which documented the resident was asleep.-Clotrimazole 1% cream to right armpit twice daily for yeast. On the night shift of 10/01/2025 it was blank. On 10/07/2025 there was a code 9 and a progress note stated the resident was asleep. The progress notes did not contain any entries on what efforts the staff made to wake the resident, what other arrangements they attempted to get the resident their medications, or what attempts were made to notify the provider. In an interview on 11/23/2025 at 12:33 PM, Staff B, Director of Nursing, acknowledged the medications were not given. Staff B stated the nurse wrote a note on 11/03/2025 that stated Resident 3 was checked on several times and they were asleep. Staff B stated their expectation was for the nurse to wake Resident 3 and attempt to give their medications and if it was unsafe to do so, the provider needed notified. At 1:13 PM Staff B stated it was important to give the medications as ordered to keep the resident healthy and stable. Reference: WAC 388-97-1060(3)(k)(iii)

.Based on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 1 of 1 wound care observations. Additionally, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves when providing high contact types of care for residents with drains, tubes, or wounds) were implemented and followed when indicated for 2 of 3 sampled residents (Residents 1 and 23), reviewed for infection control. This failure placed residents at risk for potential unintended health consequences, the potential spread of infectious diseases or organisms resistant to antibiotics, and diminished quality of life.Findings included.According to The Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE- gloves, disposable gowns, eye protection or masks) Use in Nursing Homes to prevent Spread of Multidrug-Resistant Organisms updated July 12, 2022, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended use of EBP as an infection control intervention that employed targeted gown and glove use during high contact resident care activities when Contact Precautions do not apply for residents with wounds or indwelling medical devices such as feeding tubes (inserted tube that provides liquid nutrition) or catheters (flexible tube inserted into bladder to drain urine). EBP directs staff to put on gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting.ENHANCED BARRIER PRECAUTIONS<Resident 1>The 10/22/2025 quarterly assessment documented Resident 1 had diagnoses including heart failure, malnutrition, and depression. The resident was cognitively intact and made their needs known. In an observation and interview on 11/21/2025 at 2:58 PM, Resident 1 was sitting in their recliner wearing tennis shoes. Resident 1 stated they had a sore on their right ankle and that it was an ongoing struggle. Resident 1 stated nursing applied a dressing on the sore daily. There was no EBP sign on the door, and no PPE was seen by the door or in the resident's room. The 07/18/2025 admission assessment documented Resident 1 admitted with a pressure ulcer (damage to the skin and soft tissue caused by prolonged pressure) to their right ankle. The 07/18/2025 care plan documented Resident 1 had a pressure ulcer to their right ankle and instructed nursing staff to administer treatments as ordered. The goal was for Resident 1 to remain free of infection. The care plan did not instruct staff to wear PPE for wound care. During an observation of Resident 1's dressing change on 11/21/2025 at 1:44 PM, Staff F, Registered Nurse, was wearing gloves but did not put on a gown as required. Staff F removed the dressing from Resident 1's ankle and there was yellow drainage on it. There was no EBP sign on the door and no PPE in the room or outside of the room. <Resident 23>The 09/15/2025 admission assessment documented Resident 23 had diagnoses including heart failure, stroke and depression. The resident had severe cognitive impairments. A 10/08/2025 facility incident report documented Resident 23 had a pressure ulcer to their left heel. An 11/22/2025 provider order instructed nursing staff to wash the wound bed, apply a thin layer of ointment and cover the wound with a dressing every three days and as needed. In an observation on 11/21/2025 at 2:42 PM, Resident 23 was not in their room. There was no EBP sign in place and no PPE inside or outside of the resident's room. In an observation on 11/22/2025 at 3:40 PM, Resident 23 was lying in bed wearing a pressure relieving foam boot on their left heel. There was an EBP sign on the door with PPE outside of the room near the door. In an interview on 11/21/2025 at 2:06 PM, Staff F, when asked about PPE, stated they should have worn a gown to do Resident 1's dressing change. Staff F stated it was important to wear gowns to protect the residents from infection and to protect themselves as well. Staff F stated they knew who was on EBP by the signs on the doors. At 2:13 PM Staff F stated they checked with Staff B, Director of Nursing, and EBP was only for chronic wounds or Stage III (a full thickness skin loss that extended into the subcutaneous fat tissue) or higher-pressure ulcers. In an interview on 11/21/2025, Staff B stated EBP was for feeding tubes, intravenous lines (IV's) or chronic wounds or Stage III or higher-pressure ulcers. Staff B stated they considered Resident 1's wound to be chronic and were placing them on EBP. Staff B stated it was important to use EBP to protect the wound from introduction of bacteria and to prevent infection. Staff B was given information on Centers for Disease Control guidance for EBP. Staff B was unaware that a gown and gloves needed to be worn for wound care. HAND HYGIENEIn an observation on 11/21/2025 at 1:52 PM, Staff F washed their hands and put on a pair of gloves. Staff F reached down with their gloved hands and moved the garbage can under Resident 1's leg. Wearing the same gloves, Staff F touched clean gauze, then removed the soiled dressing from Resident 1's right ankle. Staff F removed their soiled gloves and put on clean gloves without performing hand hygiene.In an interview on 11/21/2025 at 2:06 PM, Staff F stated they should have changed their gloves after touching the garbage can prior to touching anything else. Staff F added it was important for infection control and their supplies were clean prior to them moving the garbage can and touching the gauze. In an interview on 11/21/2025 at 2:29 PM, Staff B stated it was important to change gloves after touching unclean surfaces because of the increased risk of bacteria entering the resident's wound. Reference: WAC 388-97-1320 (1)(c)(2)(b)

Based on interview and record review, the facility failed to protect 1 of 3 residents (Resident 2) reviewed for drug diversion (transfer of medication from the resident it was prescribed for to another person for unlawful use), from misappropriation of controlled medications (a drug or chemical that is regulated due to its potential for abuse or dependence). This failure placed residents at risk for unmet care needs, on-going misappropriation of medication, and a diminished quality of life.Review of a facility incident report dated 07/11/2025 showed that on 07/11/2025 Staff C, RN, reported to Staff A, Administrator, that on 06/14/2025 during shift exchange, Staff D, RN, and Staff C, RN were counting controlled medications when Staff C noticed a clear, 30 milliliter (about two tablespoons), medication cup containing some liquid in the top medication cart drawer. Staff C reported they picked up the medication cup to dispose of it when Staff D, took the medication cup, with the liquid, from them, stating No. That's mine. Just leave it alone. Staff D then continued to draw the small amount up into an orange oral syringe and placed it in a medication crush sleeve (a small envelope made of clear plastic used to crush solid medications). [They] then opened up the narcotics drawer, dropped it in and said something to the effect of, 'that's for later. That's for that one,' as [they]nodded towards the resident in room [ROOM NUMBER] (Resident 3). [They] then continued to say, 'don't worry, all your numbers are right. I made sure of it.'Further record review of the facility investigation found that when Staff A, Administrator and RN, and Staff B, Director of Nursing, examined the controlled medications they found one open bottle of liquid lorazepam (a controlled medication prescribed for temporary relief of symptoms of anxiety), prescribed for Resident 2, with a pink tinged liquid in the bottle. Both RN's knew liquid lorazepam was colorless, they then removed the bottle from circulation and took photos of the bottle. They then confirmed with Staff E, Pharmacy Quality Assurance RN, that liquid lorazepam was indeed colorless and that the bottle had been tampered with. Review of Resident 2's medical record showed that they were nearing the end of their life and were on comfort care (a medical approach that focuses on relieving symptoms and improving quality of life for residents with serious illnesses, rather than treating the underlying conditions). Review of their medication administration record (MAR) showed that they had a physician order for liquid lorazepam to be administered, as needed, every four hours, for generalized anxiety disorder. Review of the Resident's MAR for June and July of 2025 showed that they were administered the liquid lorazepam six times between 06/14/2025 and 07/11/2025, in addition to other comfort focused medications. No indication was found in record review or interview that the resident did not experience relief from symptoms associated with the order for the liquid lorazepam.During an interview on 07/30/2025 at 3:10 PM, Staff A confirmed that they had found the bottle of pink tinged liquid lorazepam, prescribed for Resident 2, on 07/11/2025 when they had begun their investigation into Staff C's report. They further stated that they had immediately removed the bottle from circulation and confirmed with the facility pharmacy that the bottle had been tampered with. Reference: WAC 388-97-0640(2)(a), (3)(c)(d)See F 605 dated 07/30/2025.

Based on observation, interview and record review, the facility failed to ensure residents were free of chemical restraints for 2 of 3 residents (Resident 1 and 3) reviewed for unnecessary medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life.Review of a facility incident report dated 07/11/2025 showed that on 07/11/2025 Staff C, Registered Nurse (RN), reported to Staff A, Administrator, that on 06/14/2025 while counting controlled medications (a drug or chemical that is regulated due to its potential for abuse or dependence) and making sure everything was in order in the nurse medication cart, Staff C had found a clear, plastic, medication cup in the top drawer of the nurse medication cart with a small amount of clear liquid in the cup. Staff C then went to dispose of the unmarked medication cup when Staff D, RN, intervened, took the medication cup from them, drew up the clear liquid into an orange oral syringe, placed the oral syringe in a small clear plastic sleeve (used for crushing and then holding solid medications for residents who cannot swallow medication in pill form) and then placed the oral syringe in the locked narcotic box of the medication cart, stating, that's for later. That's for that one,' as [they]nodded towards the resident in room [ROOM NUMBER] (Resident 3).The same facility incident report stated that Staff C was unsure of what to do but thought the medication in the clear, plastic cup was lorazepam (a controlled medication prescribed for temporary relief of symptoms of anxiety) prescribed for Resident 2. The incident report went on to detail that on 06/29/2025, Staff C had asked Staff D did you secretly Ativan (a brand name for generic lorazepam) any residents last night to survive? Staff D then replied that they had given the controlled medication to Resident 1 and 3 and told them the dose that was given.During an interview on 07/30/2025 at 1:10 PM, Staff C reiterated their statement from the facility incident report dated 07/11/2025 and added that they thought that Staff D had given several residents, including Resident 1 and 3, the liquid lorazepam prescribed for Resident 2, on several occasions related to those residents' evening/nighttime wandering and behaviors. They further stated that they could not remember if they had noticed any side effects from the sedating medication allegedly given by Staff D to Resident 1 and 3 but that they would have charted it if they had noticed anything.<Resident1>Record review for Resident 1 showed that they were admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder which slowly destroys memory, thinking skills and eventually the ability to carry out even simple tasks) and dementia with severe mood disturbance (a collection of symptoms affecting memory, language and cognitive function with behaviors manifesting as agitation, anxiety and mood changes).Review of nursing progress notes found that on 06/14/2025 at 2:27 AM Staff D, wrote, Resident was verbally aggressive during shift and hard to keep calm. Resident was exit seeking most of the shift, looking for dog/car.Review of Resident 1's sleep chart (a visual representation of sleep patterns over a specific period of time) for June 2024 showed that on 06/14/2025 Staff C charted Resident 1 slept for 10 hours on day shift (7:00 AM to 7:00 PM). Review of the resident's sleep chart showed this was unusual behavior and that they generally napped for one to two hours during the day.Further review of nursing progress notes found that Staff C had written on 06/14/2025 at 2:27 PM that the Resident had a difficult time getting out of bed this AM and spent most of the morning laying down.Observation and interview of Resident 1, on 07/30/2025 between 2 to 3 PM, showed a cognitively impaired individual who was self-propelling their wheelchair throughout the facility while interacting in a positive manner with staff, other residents and their visitors. They were very active during the observation, attempted to exit out the front door and were easily redirected by facility staff. <Resident 3>Record review of Resident 3's medical record showed they were not cognitively intact and had been discharged home on [DATE]. Further record review did not find a sleep chart for this resident or other supporting evidence to show side effects of the alleged administration of liquid lorazepam were identified. The facility investigation, dated 07/11/2025, showed that the residents' representative did not report any concerns for changes in this resident's behavior related to the possible use of a chemical restraint.During an interview with Staff A, on 07/30/2025 at 3:10 PM, they stated that on 07/11/2025, at the beginning of their investigation into the report from Staff C, they had found an opened bottle of liquid lorazepam, prescribed for Resident 2, with the lorazepam in the bottle tinged a pink color. They stated that liquid lorazepam is clear, and that they had then confirmed with Staff E, Pharmacy RN, that the bottle had been tampered with and it was removed from circulation and later destroyed. They further stated that during their investigation they did not find evidence to support that either Resident 1 or 3 had been chemically restrained. When the sleep chart and progress notes for Resident 1 were reviewed, Staff A stated that the amount of sleep and difficulty getting around on 06/14/2025 were not at all typical for Resident 1, who was generally very busy, and they thought this did support that Resident 1 was probably chemically restrained on 06/14/2025.Reference: WAC 388-97-0620 (1)(a)See F 602 dated 07/30/2025.

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for choices, was afforded the right to choose their own attending physician. This failure placed the resident at risk for a diminished quality of care. Findings included Review of Resident 1's electronic medical record showed they admitted to the facility on [DATE] from a hospital with diagnoses including repair of right upper leg fracture with revision of a total hip replacement after a fall. The resident had a large surgical incision (about 16 inches long) related to the fracture repair. In a telephone interview on 02/18/2025 at 12:16 PM with Collateral Contact 1 (CC1), they stated that they had requested the facility to contact Resident 1's Primary Care Physician (PCP) for orders and a history of the resident as they were familiar with the resident and their history, and were told by a facility nurse that they had to use the facility Physician, Staff D. CC 1 stated that they were not happy with this decision as they did not feel the facility Physician understood Resident 1's complex medical history. Record review showed a progress note dated 01/25/2025 at 7:30 PM where Staff C, Registered Nurse wrote that Collateral Contact 1 had requested Resident 1's PCP be called to get orders and resident history, it was explained that [their] PCP within this facility upon admission to this facility was Staff D, Physician. During an interview on 12/18/2025 at 1:57 PM, with Staff B, Director of Nursing, they stated that residents could only use the three physicians that were approved by the facility, as their physican while they were admitted to the facility for treatment. During an interview on 12/18/2025 at 3:43 PM with Staff A, Administrator, they stated that they had trouble finding physicians to see residents in the facility in the past related to their rural location. They further stated that they had not had a resident request to use their own PCP and would work on the process. Reference: WAC 388-97-0200 (1)

Based on observation, interview and record review, the facility failed to adequately date food items and ensure expired food items were disposed of when indicated during 1 of 1 inspections in the main kitchen. This failure placed the residents at risk for food-borne illnesses. Findings included . Review of the undated facility guideline titled Dry, Refrigerated and Freezer Storage Chart documented proper storage times for opened and unopened dry, refrigerated and frozen food items. The guideline instructed the staff to follow manufacturer's directions and expiration dates and those expiration dates superseded the guidelines. The guideline instructed that once a food item was opened it was not to be stored longer than the total unopened time. An observation and interview in the facility's kitchen on [DATE] at 11:15 AM was completed with Staff C, Dietary Services Manager with the following findings: <REFRIGERATED GOODS> 1. A bag of Caesar salad was dated ,d+[DATE] but had no clear indication if that was the date the food item was received by the facility, or the discard or expiration date. 2. 16 to 20 margarine blocks were undated. 3. Four bags of romaine lettuce had no discard by or expiration date. Staff C stated the staff repackaged the romaine lettuce and did not usually date them. Staff C stated they would find out when the lettuce was to be discarded. 4. One opened bag of celery heads had no discard by or expiration date. The storage chart recommended celery had a storage time of one week. <DRY STORAGE> 1. Five unopened and undated loaves of sliced bread and one opened and undated loaf of bread with about ,d+[DATE] of the loaf inside the bag were in the storage area. Staff C stated they did not date the bread; it was used up quickly. The storage chart documented unopened bread was to be stored for four to five days. Opened and unrefrigerated bread was to be stored for 1 day. 2. A jar of basil leaves had no opened or expiration date. The storage chart documented herbs were to be stored for six months, whether opened or unopened. 3. A jar of bay leaves had a handwritten opened date of [DATE]. Staff C acknowledged the food item expired six years ago and disposed of it. The storage chart recommended a storage time for whole spices of one to two years. 4. A plastic tub with the word cocoa, ,d+[DATE], and ,d+[DATE] handwritten on it had no actual manufacturer label. Staff C confirmed the tub contained cocoa powder, but stated they did not know how long it had been sitting there. 5. Two large cans of chunky light tuna had no discard by or expiration date. The storage chart recommended unopened canned foods, specifically fish and seafood, were to be discarded within one year of receipt by the facility. 6. A gallon bag of opened dry cereal had no opened or expiration date on it. 7. A bottle of [NAME] cooking wine had two dates written on it, ,d+[DATE] as the date received, and ,d+[DATE] as the date opened. No year was identified for either date. The storage chart recommended opened [NAME] wine was to be discarded within six to nine months. 8. A bottle of olive oil had an opened date of ,d+[DATE] and no expiration date. The storage chart provided no guidance for the recommended storage time. 9. Eight large bins contained different dry pastas that included spaghetti, macaroni, penne, and lasagna. The pastas were not labeled with an opened date or discard by date. When interviewed on [DATE] at 11:26 AM, Staff C acknowledged that adequate dates had not been documented on the foods identified. Staff C agreed that dating foods allowed staff to know when food items needed to be discarded and how long foods could be stored. Reference: WAC [DATE](3), -2980

Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures when they failed to report an allegation of abuse to the State Agency (SA) within the required timeframe and failed to complete a thorough investigation for 1 of 2 sampled residents (Resident 23) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse. Findings included . The 10/2022 revised facility policy titled Abuse/Neglect/Misappropriation/Exploitation documented the facility protected residents from abuse and neglect by implementing procedures designed to prevent, identify, report, and investigate allegations of abuse and neglect. The policy instructed staff to report immediately to the Abuse Hotline (a SA), but no later than 2 hours after an allegation of abuse or neglect was made if the events that caused the allegation resulted in serious bodily injury, and no later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury. The policy documented that all alleged incidents of abuse or neglect were thoroughly investigated to determine what occurred and to make necessary changes to the provision of care and services to prevent recurrence. The policy documented a thorough investigation included but was not limited to an interview with the alleged resident victim, the assigned caregiver and caregivers in the immediate area, and a physical examination of the resident. This policy defined sexual abuse as any form of non-consensual contact including but not limited to unwanted or inappropriate touching. The policy instructed staff to evaluate whether the resident had the capacity to consent to sexual activity when determining if the incident met the definition for an allegation of sexual abuse. Appendix D of the October 2015 Nursing Home Guidelines The Purple Book, instructed a facility to report sexual abuse/assault to the SA, log the incident in the facility's Incident Log within 5 days of discovery and notify the police. <Resident 23> A review of the 08/01/2024 significant change assessment documented Resident 23 had medically complex conditions, was cognitively intact, used a wheelchair and was independent with mobility throughout the facility. A 01/19/2024 Social Services progress note documented Resident 23 and an unnamed resident were witnessed by staff kissing on the lips while in the dining room. The unnamed resident had severe cognitive impairment and was unable to give consent. The note further documented staff met with Resident 23, who stated they were not aware the unnamed resident was cognitively impaired. Resident 23 stated they understood that any further physical contact would not be appropriate. Resident 23 was assigned to a different table in the dining room, and the unnamed resident was moved to a room closer to the nurse's station to allow closer supervision. Staff A, Administrator, and Staff B, Director of Nursing, were notified of the incident. The January 2024 Incident Log was reviewed and there was no entry on the log that documented the 01/19/2024 observation of a potential sexual abuse incident, that the incident was reported to the SA, investigated, or reported to law enforcement as instructed by The Purple Book. During an interview on 09/09/24 at 8:39 AM, Staff A confirmed the resident observed kissing with Resident 23 currently resided in the facility on the same hall as Resident 23. Staff A acknowledged the 01/19/2024 allegation of sexual abuse had not been logged on the incident log, reported to the SA, and investigated as required and should have been. Staff A agreed an investigation would have allowed the facility to determine the extent of any nonconsensual contact between Resident 23 and other residents, if any. Staff A also confirmed the incident had not been reported to law enforcement. Reference: WAC 388-97-0640(2)

Based on interview and record review, the facility failed to assess, identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 2 sampled residents (Resident 7) reviewed for trauma informed care. This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life. Findings included . The 10/2022 revised facility policy titled Trauma Informed Care described a traumatic event as either a single or enduring repeated or multiple experiences that completely overwhelmed a resident's ability to cope or integrate ideas and emotions involved in that experience. Trauma-Informed Care promoted an environment of healing and recovery rather than practices that might inadvertently re-traumatize a resident. Staff were instructed to screen residents for trauma-informed care needs upon admission and identify the triggers and history of trauma in residents, with the help of family/friends/responsible parties. A care plan was to be developed that aimed to reduce re-traumatization, provide interventions for de-escalation, and provide a safe and secure environment. <Resident 7> A review of the 08/14/2024 annual assessment documented Resident 7 had diagnoses including post-traumatic stress disorder (PTSD, a disorder that developed when a person experienced or witnessed a scary, shocking, terrifying, or dangerous event that usually included a threat to life or a severe injury.) The assessment documented Resident 7 had severe cognitive impairment, was mildly depression, experienced delusions (a false belief or judgment about external reality, held despite undeniable evidence to the contrary), and occasionally rejected care and wandered. Their behavior had worsened compared to the prior assessment. Review of the 09/18/2020 Psychosocial History and Discharge Plan confirmed Resident 7 had a history of traumatic events that might include abuse/neglect, war, assault, PTSD, or natural disasters, for example. The resident also had sleep disturbances and adjustment/mood/behavior problems. A Trauma-informed Care Plan was initiated in this section of the electronic medical record that carried over to the electronic version of the care plan. It documented Resident 7 had a potential alteration in psychosocial well-being related to survivor of traumatic event. The goal was that the resident verbalized feeling safe and secure in their living environment through the next review period. There was no documentation to show what type of traumatic event Resident 7 had experienced, any triggers that could re-traumatize the resident, and what measures the staff needed to take to prevent or de-escalate re-traumatization. A 09/03/2024 revised care plan documented Resident 7's PTSD was related to having served in the military during war time. The goal developed was that triggers of the traumatic event would be minimized. The care plan did not include what the triggers for re-traumatization were. Additionally, there were no interventions to instruct the staff how to minimize or prevent the triggers or de-escalate episodes of re-traumatization. During an interview on 09/09/24 at 8:20 AM, Staff D, Social Services Director, stated Resident 7 had a diagnosis of PTSD because of the war. They stated Resident 7's diagnosis was there, but the resident had never displayed any behaviors related to it. Staff D was unable to state what Resident 7's triggers were because the resident had not had any episodes of PTSD, it was just a diagnosis. Staff D acknowledged Resident 7's plan of care lacked clarity and guidance on how the diagnosis of PTSD impacted the resident, what triggers might re-traumatize the resident, what signs or symptoms the resident could exhibit, and what staff were to do to prevent or de-escalate re-traumatization. Staff D stated they needed to do more research to determine what events might trigger Resident 7. During an interview on 09/09/24 at 8:29 AM, Staff E, Nursing Assistant-Registered, stated PTSD was a behavior that came about from previous situations. Staff E stated they were familiar with Resident 7, but they were unsure if Resident 7 had PTSD. During an interview on 09/09/2024 after breakfast hours, Staff F, Nursing Assistant (NAC), described PTSD as people being really stressed and frustrated. Staff F stated they were familiar with Resident 7, but they were unsure if Resident 7 had PTSD. During an interview on 09/09/24 at 1:19 PM, Staff G, NAC, stated that they had heard of PTSD, it stood for post-traumatic stress disorder, but they did not know what that meant. Staff G thought they had received training about PTSD. Staff G was unsure if Resident 7 had PTSD. No Associated WAC

Based on observation, interview, and record review, the facility failed to consistently maintain dish machine temperatures which placed all residents at increased risk for foodborne illness. Findings included . During an observation of the kitchen on 10/17/2023 at 12:21, Staff E, Dietary Manager, stated the dishwasher was a low temperature dishwasher, which must sanitize the dishes at 120 degrees or above. The temperature logs for October 2023 showed the temperatures were below 120 degrees on 16 different occasions. Staff E stated that maintenance was informed each time the dishwasher was below 120 degrees, and the temperature was fixed. Staff E was unable to provide documentation showing the temperature had been fixed and what the new temperature was afterward. During an interview on 10/17/2023 at 1:35 PM, Staff F, Maintenance Assistant, stated they are notified when the temperature of the dishwasher was low. When Staff F looked at the temperature log for October 2023, they stated they were unaware that the temperature had dropped below 120 degrees that often. Staff F stated that the dishwasher is connected to the laundry and when the temperature of the dishwasher goes below 120 degrees, they shut down a washer and the temperature of the dishwasher increases. When Staff F was asked for documentation showing the temperatures were rechecked after the dishwasher was fixed, they stated they did not have any because they did not know they needed the documentation. During an interview on 10/18/2023 at 8:56 AM, Staff A, Administrator, stated the dishwasher had to be ran a few times before the temperature would rise to the appropriate temperature. Staff A added the temperature of the dishwasher should have been 120 degrees or above and there had not been any foodborne illnesses. Reference: WAC 388-97-1100 (3) and 388-97-2980

Based on observation, interview, and record review the facility failed to appropriately label, and store refrigerated controlled substances in a permanently affixed compartment as required in 1 of 1 medication rooms observed for medication storage. In addition, the facility failed to maintain records to reconcile refrigerated emergency kit controlled medications in 1 of 1 medication rooms. This failure placed the facility at risk of controlled drug diversion. Findings included . Review of pharmacy policy titled, Inventory Control of Controlled Substances, dated 01/2022, showed the facility should maintain a written record of all controlled substance medications transferred from the pharmacy to the facility's emergency medication kit. The policy further showed facility staff should count all medications with risk for abuse or diversion at each change of shift or at least once daily and document on a controlled substance count sheet. During observation of the medication room refrigerator on 10/13/2023 at 10:42 AM with Staff C, Resident Care Manager (RCM), a locked black metal box was removed from the refrigerator and opened by Staff C. The contents of the black metal box consisted of three resident specific containers of Ativan (a controlled medication used to treat anxiety or seizures), a brown semitransparent unlabeled prescription bottle that contained a sealed vial of injectable Ativan, and a prescription bottle labeled as the facility's emergency medication kit that contained a sealed vial of injectable Ativan. In an interview on 10/13/2023 at 10:54 AM, Staff D, Registered Nurse (RN), stated the brown unlabeled prescription bottle that contained a vial of injectable Ativan was part of the facility's emergency kit. Staff D further stated the emergency kit Ativan was counted in the electronic medication dispensing machine and not in a controlled substance medication book. Staff D attempted to log into the medication dispensing machine to verify the controlled medication count but was unsuccessful. In an interview on 10/13/2023 at 10:55 AM, Staff C, RCM, stated the emergency kit Ativan was not counted in a controlled substance medication book but was counted in the electronic medication dispensing machine by pharmacy staff once a month. Staff C attempted to log into the medication dispensing machine to verify the controlled medication count but was also unsuccessful. Staff C acknowledged the emergency kit Ativan should be counted in a controlled substance medication book by facility staff. In an interview on 10/13/2023 at 11:58 AM, Staff A, Administrator, acknowledged the Ativan in the facility's emergency kit was not being counted and there was no system in place to track it. Staff A also acknowledged the Ativan should be stored in an affixed compartment. In an interview on 10/13/2023 at 12:25 PM, Staff B, Director of Nursing, stated the facility followed the pharmacy's policy for controlled substances. Staff B acknowledged Ativan from the facility's emergency medication kit was only counted by the pharmacy technician once a month and not routinely counted or tracked by facility staff. Staff B also acknowledged the Ativan was not stored in a permanently affixed compartment. Reference WAC: 388-97-1300 (2)

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was appropriately maintained and changed regularly, according to professional standards of practice for 1 of 2 sampled residents (Resident 38) These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress. Findings included . Per the 12/09/2022 admission assessment, Resident 38 admitted to the facility with heart failure and chronic obstructive pulmonary disease (a group of lung diseases that block airflow, making it difficult to breathe) and required oxygen due to those conditions. Review of the physician orders showed on 12/09/2022, the resident had been prescribed oxygen to be used continuously due to the diagnoses listed. The most recent physician order dated 06/20/2023 directed nursing staff to change the oxygen tubing weekly and as needed. On 10/11/2023 at 11:48 AM, Resident 38's oxygen tubing on their walker was dated 08/02/2023. On 10/12/2023 at 8:58 AM, Resident 38 was observed lying in bed, wearing oxygen that was connected to their concentrator. The tubing attached to their walker was dated 08/02/2023. On 10/12/2023 at 11:50 AM, Resident 38's oxygen tubing that was connected to their concentrator was dated 08/02/2023. Subsequent observations of the oxygen tubing being dated 08/02/2023 were on 10/12/2023 at 2:29 PM, 10/13/2023 at 8:01 AM, 10/13/2023 at 10:04 AM and 10/13/2023 at 12:17 PM. During an observation on 10/16/2023 at 8:51 AM, Resident 38 stated their oxygen tubing was changed that morning (1 month and 2 weeks since the last time the oxygen had been changed). During an interview on 10/16/2023 at 11:57 AM, Staff B, Director of Nursing (DNS) stated oxygen tubing is to be changed weekly and needed to be dated. Staff B stated if the oxygen tubing is not changed timely, it could cause an infection. Staff B, DNS, approached surveyor on 10/16/2023 at 1:57 PM and stated the oxygen tubing had not been changed on 10/14/2023, although the treatment administration record was signed saying it had been. Staff B stated the oxygen was changed two days later on 10/16/2023. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review the facility failed to consistently and comprehensively assess and monitor 1 of 3 residents (Resident 1) with an inserted catheter (flexible tubing inserted into the body to remove fluid) or surgical drain (tubing used to remove excess fluids from the body). Failure to consistently assess and monitor Resident 1's surgical drain placed the resident at risk for infection and possible medical complications. Findings included . Resident 1 was admitted to the facility on [DATE] after having a surgical drain placed in their right lower back to drain an abscess (collection of pus that has built up within the tissue of the body) near their right kidney. Review of Resident 1's hospital discharge summary dated 08/04/2023 and titled What to do Next, Instructions From Your Doctor, stated to measure drain output daily, track it and bring when you see [Urologist] (a doctor who specializes in treatment of the function of the urinary system). Record review of Resident 1's care plan showed a focus for alteration in skin integrity related to a drain to right flank with direction to administer treatments as ordered and monitor for effectiveness. The same care plan also had a focus for risk/presence of infection related to right flank drain with a goal that Resident 1 would no show signs or symptoms of infection. The interventions specific to this focus did not detail an assessment or monitoring of the drain tubing insertion site for said signs or symptoms of infection. Record review of Resident 1's medication administration record (MAR) and treatment administration record (TAR) for August of 2023 showed an order on 08/16/2023 to wash Resident 1's drain site with normal saline (a solution of salt and water used for wound care to wash away irritants, bacteria and dried blood), dry with sterile gauze (gauze that is packaged to prevent exposure to dirt or surfaces and resist bacteria) and cover the drain site with Tegaderm (a clear dressing used to cover and protect wounds and catheter sites) every three days. The order also included the direction to monitor for signs or symptoms of infection or drainage at the drain site every three days. This order was placed nine days after the resident admitted to the facility. No order was found to monitor or record any drainage from the surgical drain. On 09/07/2023 at 2:50 PM during an interview with Staff B, Registered Nurse, they stated that they had cared for Resident 1, but did not remember any orders to check the output from their drain. They further stated it had been more than a year since they had cared for a resident with a surgical drain within the facility. During an interview on 09/07/2023 at 3:09 PM with Staff A, Director of Nursing, they stated that it had been more than a year since nursing staff had cared for a resident with a surgical drain. They further stated that nursing staff had received training on how to manage and be aware of tubing inserted into a resident's body but not on nursing specific topics such as monitoring and recording surgical drain output. They further stated that they were not sure if Resident 1's discharge instructions contained a physician order to monitor and record the output from Resident 1's drain because it was written in paragraph form, but that nursing staff had not communicated with the discharging hospital to see if monitoring and recording Resident 1's drain discharge was necessary. Staff A could not say why there was not a dressing order in place to monitor or cover the drain insertion site until nine days after the resident admitted . Reference: WAC 388-97-1060 (1)(2)(3)(ii)

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines. This failure placed residents and staff at risk for contracting COVID-19. Findings included According to the Center for Disease Control document, How to use Your N95 Respirator, dated 03/16/2022, showed N95 masks must form a seal to the face to work properly. The N95 should be placed under the chin, with the nose piece bar at the top. The top strap should be pulled over the head and placed near the crown, and the bottom strap should be placed at the back of the neck, below the ears. The straps should lay flat, untwisted and not be crisscrossed. On 05/23/2022 at 11:33 AM, Staff B, Director of Nursing, was observed in the lobby area of the facility wearing an N95 with both mask straps placed behind the neck. At 1:02 PM Staff H, Activity Director, was also observed wearing an N95 with both mask straps placed behind the neck. Additional observations of Staff B wearing the mask straps behind the neck were made at 1:57 PM and 4:24 PM that same day. On 05/25/2022 at 10:10 AM, Staff H was observed on the East Unit speaking with a resident to inquire if they wanted to attend the activity. Staff H's N95 mask had both straps behind the neck and under the ears. At 11:59 AM on the same day, Staff J, Staffing Coordinator, was observed to have both the N95 mask straps placed behind the neck. At 11:25 AM on 05/27/2022, Staff I, Charge Nurse, was observed walking down the East Unit hallway with both N95 straps placed behind the neck. During an interview at 11:28 AM, when asked how the N95 mask straps should be positioned, Staff I readjusted the top strap to place it on the top of the head and stated the strap probably fell down earlier when they had adjusted their earpiece. In an interview on 05/27/22 at 11:38 AM with Staff A, Administrator and Staff B, when asked about the positioning of the straps for the N95, Staff B confirmed the bottom strap should be around the base of the neck and the top strap should be above the ears. Reference (WAC): 388-97-1320 (1)(a)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sample residents (33), reviewed for range of motion/mobility, received appropriate monitoring and consistent treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Review of the resident's record showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the record, the resident required two people to extensively assist with bed mobility, transfers, toileting, dressing, and personal hygiene. Contracture assessments (a contracture is an abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching, which could cause a permanent decrease in range of motion), completed on 01/17/2022 and 04/18/2022, showed the resident did not have a contracture in their left hand. The resident's care plan, dated 08/21/2019, addressed a deficit with the resident's ability to perform activities of daily living. The care plan included an intervention for a positioning splint (a medical device to hold a joint in a neutral position, to prevent loss in range of motion) as needed for the resident's left hand, with direction to be placed on in the morning when the resident was dressing, and to be removed when the resident was ready for bed. In an observation on 05/24/2022 at 9:08 AM, Resident 33 was observed lying in bed with their left arm dependent at their side, and their left fingers and thumb curled into their palm. At that time, the resident reported they recognized it was getting harder to completely straighten their left fingers and thumb. Review of the facility's restorative program showed the resident was to participate in an active range of motion program (resident participation with movement), five to six times weekly, starting in January of 2022. There was no specific direction found in the resident's record related to maintaining range of motion in the resident's left hand, arm or shoulder, or assistance with placement of the left-hand positioning splint. On 05/25/2022 at 2:01 PM Staff E, Restorative Aide, confirmed that Resident 33 had a range of motion program in place. Staff E explained that the range of motion program did not include working with the left-hand positioning splint, as the resident had to ask for the splint to be put on their left hand. Staff E added the resident did not always participate in range of motion, and they worked with the resident when they were out of bed and willing to participate. In an observation of Resident 33 on 05/24/2022 at 11:46 AM, they had the left-hand positioning splint on with their left fingers and thumb curled into their palm, and not positioned correctly. The resident tried to move their hand in the splint, and was unable to place their left fingers flat in the splint. During the above observation Staff F, Nursing Assistant, entered the room and was asked how the splint worked. Staff F stated that they worked as a restorative assistant part-time, and would occasionally help the resident put on the brace if the resident requested. Staff F was able to place the resident's thumb in the correct position, but was not able to straighten the 1st, 2nd and 3rd fingers to fit fully straightened into the positioning splint. On 05/25/2022 at 11:28 AM Staff C, Physical Therapist, was asked how the facility monitored the resident's range of motion to ensure it was not declining. Staff C stated that physical therapy would receive a communication from restorative or nursing staff if a resident's range of motion was declining. Staff C stated that they had not received any kind of communication from nursing or restorative that Resident 33's left-hand positioning splint was not fitting properly, or a report from the resident or staff of worsening of a left-hand contracture. Staff C reported not having worked with the resident for more than six months, and stated that occupational therapy had last worked with the resident in January 2022. On 05/25/2022 at 2:10 PM, Resident 33 was observed in the hallway outside the dining room with their left fingers held fully extended in the splint with a velcro strap, and their left thumb held fully extended with another velcro strap. In an interview on 05/25/2022 at 1:26 PM, Staff C stated that the resident's hand was flaccid today, and Staff E was able to place the resident's hand in the splint with their fingers extended. Staff C also stated they had worked with the resident for several years, and the resident was not always able to focus on one task, and it may not be fair to rely on the resident to ask to have the splint put on as they may lose focus and forget to ask staff to put the splint on. Reference: (WAC) 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to serve food at palatable temperatures for 1 of 6 sample residents (33), reviewed for in-room dining. This failure placed the resident at risk for inadequate nutritional intake, and a reduced quality of life. Findings included . In an interview on 05/23/2022 at 3:05 PM, Resident 33 stated that when food was delivered to their room it was cold. In an interview on 05/25/2022 at 8:42 AM, Resident 33 was observed sitting at the edge of their bed eating breakfast. When asked how breakfast tasted the resident replied, the eggs are cold. Staff F, Nursing Assistant, was in the room when the resident made the comment, and did not offer to warm the eggs up, or get warm ones. An observation of the lunch service was completed on 05/26/2022 at 11:36 AM. At 12:02 PM Staff G, Cook, was asked to take the temperature of the hot food as it was placed in Styrofoam clamshell containers, to be delivered to isolation residents eating in their rooms. The lasagna was 184 degrees Fahrenheit (F) at that time. The resident hall trays were then placed into a thin aluminum sided cart with the door left open, and were transported from the kitchen area to the hallway outside of room two. At 12:40 PM, staff prepared to deliver the last tray on the cart to a resident in room fifteen. The temperature of the lasagna was taken, and was 128.7 degrees F. According to the Washington State Retail Food Code (page 44, section ), holding temperature for hot foods was to be 135 degrees F. Per the document, food not at that temperature must be re-heated to an internal temperature of 165 F or above for 15 seconds, in order to limit the possible growth of organisms harmful to humans. In an interview on 05/26/2022 at 2:14 PM Staff D, Kitchen Manager, acknowledged a temperature of 128.7 degrees Fahrenheit was not a proper holding temperature for hot food. They further stated the Styrofoam containers had been used for the last three days for residents under isolation precautions (precautions that create barriers between people and germs to prevent spread), and were not designed to hold heat. Staff D stated they were not aware it was taking an extended period to deliver trays to those residents. In an interview on 05/26/2022 at 2:17 PM Staff A, Administrator, and Staff B, Director of Nursing, stated that they did not recognize there was a problem with isolation trays being delivered with food below palatable and safe holding temperatures. Reference: (WAC) 388-97-1100 (1), (2)

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity during dining for one of one sample residents (6), reviewed for dignity. This failure placed the resident at risk for embarrassment and a decreased quality of life. Findings included . Per the quarterly assessment dated [DATE], Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A dietary note dated 02/18/2022 showed the resident was on a modified liquid diet. In an observation on 05/24/2022 at 12:50 PM, the resident was in their room in a wheelchair, with lunch on a tray table in front of them. Staff M, Nursing Assistant, stood over the resident while feeding them. Staff M quickly spooned the liquified food into the resident's mouth, without telling them which food they were being fed, or asking the resident for their preference. During the same observation on 05/24/2022 at 12:54 PM, Staff K, Nursing Assistant, came into the room and took over feeding the resident from Staff M. Staff K also stood over the resident to feed them for the rest of the meal. Again, staff didn't let the resident know which food they were being fed, prior to spooning food into the resident's mouth. In a follow-up interview on 05/27/2022 at 12:22 PM, Staff K stated it was facility policy for staff to sit with residents who required assistance with eating, and acknowledged they had not done that. Staff M was not available for an interview. Reference: WAC 388-97- 0180 (1-4)

Based on interview and record review, the facility failed to follow up on the recommendations of the resident council, and notify the council of their response, for one of six resident council meeting minutes reviewed. This failure disallowed residents a meaningful opportunity for input into their own care, and placed residents at risk for a diminished quality of life. Findings included . Review of the resident council minutes for 04/01/19 showed members of the resident council reported concerns related to late medication administration times, and rude staff treatment of [REDACTED]. Review of the resident council minutes for the following resident council meetings, dated 05/05/19 and 06/03/19, showed no documented response to the resident council's concerns. Interviews on 06/12/19 at 2:31 PM with Resident #21, 06/13/19 at 12:54 PM with Resident #30, and 06/14/19 at 9:21 AM with Resident #41's representative, showed concerns related to rude treatment from staff were ongoing. On 06/17/19 at 2:45 PM a resident council meeting was held with 13 residents in attendance (Residents #3, 35, 27, 17, 30, 23, 11, 5, 15, 244, 2, 26, 13). When asked about the facility's response to their concerns, several residents present agreed concerns were not always followed up on. Per the resident council, late medications, especially on evening shift, was a current problem. In an interview on 06/18/19 at 3:51 PM, Staff G stated she had received training on customer service/communication with residents when she first started working with them, and annually afterwards. Staff G stated it had been nearly a year since the most recent in-service (training), related to staff and resident communication. In an interview on 06/19/19 at 3:29 PM, Staff A, Administrator, stated resident council concerns were brought up in the facility's quality assurance committee, and were addressed individually with the resident who voiced the concern. Per Staff A, the (MONTH) 2019 resident council concerns had not yet been brought up to the quality assurance committee, but nursing staff would have been notified of the concerns regardless. During interviews on 06/19/19 at 3:45 PM, 3:58 PM, and 4:14 PM, Staff B, Director of Nursing, stated she was notified of a concern related to late medication administration times, and an in-service for nurses on the topic was completed on 05/06/19. Staff B also stated she was notified of the concern related to rude staff, but was told both complaints were brought up by Resident #35 only. Per Staff B, Resident #35 denied both resident council concerns were an issue when asked individually, so nothing further was done, including follow up with the resident council to ensure they were satisfied with the facility response. Reference: WAC 388-97-0920

Based on observation, interview, and record review, the facility failed to provide timely monitoring for 1 of 3 residents (#1), reviewed for diabetic management, in a sample of 5. This resulted in harm for Resident #1, who experienced an unrecognized episode of [DIAGNOSES REDACTED], requiring intervention by emergency medical personnel, and transfer to the hospital emergency room for evaluation and treatment. Findings include: According to the record, Resident #1 was admitted to the facility from the hospital on [DATE], after experiencing confusion and a fall at home. The resident had short-term memory problems, and required extensive assistance of one staff for most activities of daily living. Additional record review revealed the resident had [DIAGNOSES REDACTED]. The physician ordered the resident's blood sugar level to be checked once daily (in the morning). Additional physician orders [REDACTED]. -Check the resident's blood sugar as needed for signs/symptoms of low or high blood sugar(altered level of consciousness is a sign of possible low blood sugar). -Notify the physician for blood sugars less than 70, or greater than 300. -If the blood sugar was less than 70 and the resident was able to swallow, licensed nurses were directed to give protein/carbohydrate snacks, and recheck the blood sugar in 10-15 minutes. -If the resident had an altered level of consciousness, licensed nurses were directed to administer either instant glucose gel orally, or glucose by subcutaneous injection, and repeat blood glucose testing in 10-15 minutes. Record review revealed on 12/12/15, the resident's morning blood sugar was 119. The resident ate 30% at breakfast, 100% at lunch, and 60% at dinner. The resident received the diabetic medications, including insulin, as prescribed. On 12/12/15 at 8:45 p.m., Staff A (a nurse) documented the resident exhibited an altered mental state. She notified the on-call physician, family, and called emergency medical staff to transport the resident to the hospital emergency room for evaluation. Review of the facility investigation revealed when emergency medical staff arrived, they asked if the resident was diabetic. Staff A initially responded no. However, emergency medical staff recognized the resident's name, and knew the resident's medical diagnoses. Emergency medical staff checked the resident's blood glucose, which was 30, administered glucose, and the resident's level of consciousness began to return to baseline. According to hospital emergency room records dated 12/12/15, the resident was alert and cooperative when evaluated. The resident was monitored, and was able to return to the facility, with physician orders [REDACTED]. During interview on 01/12/16, the resident had just finished participating in an activity. She stated yes, when asked if she was receiving her medications correctly, and had no concerns about her care and services. During interview on 01/12/16 at 10:00 a.m., Staff C confirmed Staff A did not identify Resident #1 exhibiting signs of [DIAGNOSES REDACTED] (low blood sugar), review the physician orders [REDACTED]. Failure to check the blood sugar when the resident exhibited a change in level of consciousness, resulted in a delay in identifying and treating the low blood sugar. The resident required transfer to the hospital emergency room , and suffered harm as a result.