Willapa Harbor Care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a thorough investigation was conducted for 1 of 2 sampled residents (Resident 1) reviewed for accident and incident investigations. This failure placed residents at risk for abuse and neglect, inappropriate corrective actions, and a diminished quality of life.Findings included . Record review of the facility policy, titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, dated 08/2022, documented, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review and investigate all allegations of abuse, neglect, exploitation, mistreatment, injuries of an unknown source, and misappropriations of resident property using the Risk Management electronic incident report in Point Click Care [electronic medical record system] and components of a thorough investigation to include resident interview, resident observation, staff interviews, other resident interviews etc. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's 5-day Minimum Data Set, an assessment tool, dated 07/16/2025, documented Resident 1 was cognitively intact. Record review of a reported complaint received on 07/29/2025 at 6:36 PM, showed it was alleged Resident 1 threatened staff and another resident (Resident 2) with a butterknife. Record review of the facility's Accident and Injury log failed to document the encounter. A review of Resident 1's progress note, dated 07/28/2025, documented, [Resident 1] was having some heightened behaviors. Refusing Meds, throwing things, trying to pull the fire alarm, verbal threats to everyone around him and some physical contact with Aides. This writer came to the facility and sat with him until about 2230 [10:30 PM]. We just talked until he got tired. He agreed to take his meds and went to sleep. When this writer arrived at the building 23-2 [Resident 1] had calmed down. 23-1 [Resident 2] had been moved to room [ROOM NUMBER] to keep him out of the activity. No harm to 23-1. The following day I asked 23-1 (now 11) if he had any issues from the night before. He wasn't able to recall anything and was in a very good mood. In an interview on 08/21/2025 at 10:27 AM, Staff A, Administrator, said there was an incident with Resident 1 late 07/28/2025 going in to 07/29/2025 where he was watching news about wildfires and believed he was going to burn. Resident 1 started pulling fire alarms and was going after the staff and his roommate, Resident 2. Staff A said Resident 2 was separated from Resident 1 at this time. Staff A said Resident 1 had a butterknife he took from his meal tray and hit the window with the butterknife. Staff A said Resident 1 had made threats about cutting people and Resident 2 was there when the threats were made. Staff A said an incident report was not filed regarding this incident. Staff A said verbal abuse would be considered a reportable incident, but did not believe Resident 2 had been verbally abused. In an interview on 08/21/2025 at 11:25 AM, Staff A said she had asked staff members to write witness statements regarding the 07/28/2025 incident. Staff A said she did not ask any residents to write witness statements. Staff A said monitoring Resident 2 for possible harm did not occur. Staff A said while she talked to Resident 2 the next day, a documented evaluation to determine if Resident 2 felt safe in the facility did not occur. Staff A said she did not do what she would consider to be a full investigation. Reference WAC 388-97 -0640 (6)(a)(b).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete an accurate comprehensive dental/oral assessment for 1 of 1 resident (Resident 8) reviewed for dental status. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included .Resident 8 was admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 02/17/2025, documented the resident was alert and oriented.Record review of Resident 8's oral/dental status MDS assessment, dated 02/17/2025, documented Resident 8 did not have broken or loose natural teeth. In an observation on 08/04/2025 at 10:48 AM, Resident 8 was observed to have broken and loose teeth.In a joint observation on 08/06/2025 at 10:44 AM, Staff G, Licensed Practical Nurse, assessed Resident 8's mouth and stated, his teeth are loose, and he has broken teeth. Resident 8 was observed to be able to push his front teeth back and forth using his tongue. In an interview on 08/07/2025 at 9:37 AM, Staff C, Infection Preventionist/Registered Nurse reviewed the oral/dental status MDS assessment dated [DATE]. Staff C said Resident 8 did have broken teeth therefore the MDS assessment was incorrect. Staff C said it was the expectation that an accurate physical assessment was completed and documented in the MDS assessment. Reference WAC 388-97-1000 (1)(b)(2)(K)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a resident care plan for 1 of 3 sampled residents (Resident 37) reviewed for activities of daily living (ADL). This failure placed residents at risk for unmet needs and inappropriate plans of care.Findings included.Record review of the facility's policy titled, Care Planning Process, revised date 05/19/2023, stated the care plan must be reviewed and revised according to the RAI (resident assessment instrument) process at a minimum upon admission, quarterly and with significant change in condition and services provided or arranged must be consistent with each resident's written Care Plan.Resident 37 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 06/25/2025, documented Resident 37 was dependent with oral care, and needed substantial/maximal assistance with personal hygiene. Resident 37 was moderately cognitively impaired.Review of Resident 37's ADL self-care performance deficit care plan, revised date 08/23/2022, documented, Personal Hygiene/Oral Care: The resident requires set up assist of (1) staff for personal hygiene and oral care.During an interview on 08/06/2025 at 2:17 PM, Staff I, Certified Nursing Assistant (CNA), said dependent meant the staff provided the full care doing everything for the resident with personal care and teeth. Staff I said personal care was head to toe, brush hair, teeth, dress and wash face and hands. Staff I said partial/moderate assistance was setting up and helping residents with something the residents could not do themselves. During an interview on 08/06/2025 at 2:55 PM, Staff C, Infection Preventionist/Registered Nurse, said partial assistance meant staff should encourage residents to do as much of their own care as possible. Staff C said if the MDS documented a resident was dependent with ADLs the care plan should be updated to reflect the change. During an interview on 08/06/2025 at 3:02 PM, Staff B, Director of Nursing/Registered Nurse, said if the resident's care needs changed the MDS should reflect the change, and the care plan should be updated. During an interview on 08/06/2025 at 3:10 PM, Staff B said she spoke with the CNA and was told Resident 37 did have a change with her care needs. Reference WAC 388-97-1020(2)(c)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide resident centered activities that incorporated the resident's preferences for 1 of 3 residents (Resident 37) reviewed for activities. This failure placed residents at risk for a diminished quality of life.Findings included .Resident 37 was admitted to the facility on [DATE]. The Annual Minimum Data Set, an assessment tool, dated 06/25/2025, documented it was very important for Resident 37 to listen to music she liked. Resident 37 was moderately cognitively impaired. Review of The Life Enrichment quarterly progress notes dated 02/15/2025 and 03/21/2025, documented music became more important to her. Review of Resident 37's care plan, revised date 02/12/2025, showed Resident 37 prefers the following TV channels: news, sports, drama, etc. Resident 37 sometimes joins in a JW (Jehovah's Witness) meeting on Zoom [a platform that provides video and audio conferencing and online meetings]. Review of Resident 37's Planned Activities task, dated 07/08/2025 to 08/05/2025, documented Resident 37 had five of 27 days of one-on-one visits. No other activities were documented. In an observation on 08/05/2025 at 9:27 AM, Resident 37 was lying in bed, eyes closed head slightly turn to left shoulder. The TV was on. In an observation on 08/05/2025 at 10:08 AM, Resident 37's eyes were closed, her head slightly turned to her left. Resident 37 did not respond to knocks on the door or calling out to her. In an interview on 08/06/2025 at 11:10 AM, Resident 37 said she loved country music. When asked if she listened to music here, she stated no! Resident 37 said if they had music television she would listen to it, but she preferred a radio. In an interview on 08/06/2025 at 2:25 PM, Staff J, Life Enrichment Director, said if a resident had a preferred activity, they would do what they could to meet that resident's preferences. Staff J said they had two cd (compact disc) players and a variety of music to include country. Staff J said they did not have any radios. Staff J said he had offered Resident 37 the opportunity to use the cd player a few times, but she declined. Staff J said they don't document how often residents decline or refuse. In an interview on 08/06/2025 at 3:12 PM, Staff A, Administrator, said if a resident refused a program staff should document. Reference WAC 388-97-0940 (1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to initiate bowel interventions for 3 of 6 residents (Resident 1, 3 & 30) reviewed for quality of care. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included .
Record review of the facility policy, titled, “Management of constipation,” revision date, November 2023, documented, “when a resident is identified with no/small BM (bowel movement) documented for 64 hrs (hours), the LN (licensed nurse) will assess the resident and determine if the bowel protocol will be initiated.” The facility policy outlined standard bowel protocol based on providers’ orders which included:
“Milk of magnesia 30 ml (milliliters) PO (by mouth) HS (at hour of sleep) after eight shifts of no BM.
Bisacodyl Suppository rectally if no results from the milk of magnesia.
Fleets Enama rectally if no results from the Bisacodyl Suppository.”
Resident 1
Resident 1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 07/30/2025, documented the resident was alert and oriented.
Review of Resident 1's the Bowel Movement (BM) task sheet, undated, showed documentation of Resident 1’s BM activity on 07/13/2025 at 2:48 PM. Resident 1’s next BM was documented on 07/18/2025 at 06:42 AM, approximately 118 hours since the last BM.
Record review of Resident 1’s physician’s order, dated 06/22/2025, documented, “Milk of Magnesia [MOM- medication for constipation] Suspension 400 MG [Milligrams]/5ML [Milliliters] (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for Constipation Give at bedtime or at resident preferred time if no BM on 3rd day.”
Review of Resident 1’s physician’s order, dated 06/22/2025, documented, “Dulcolax Suppository (Bisacodyl) [medication for constipation] Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from MOM after 12 hours.”
Review of Resident 1's Electronic Medication Administration Record (EMAR), dated July 2025, did not show documentation of medication intervention for no BM after 64 hours from 07/13/2025 to 07/18/2025.
Review of Resident 1’s physician’s order, dated 06/22/2025, documented, “Fleet Enema Enema 7-19 GM [Grams]/118ML (Sodium Phosphates) Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify MD [Doctor].”
Resident 3
Resident 3 was admitted to the facility on [DATE]. The Medicare 5-day MDS, an assessment tool, dated 06/27/2025, documented the resident was alert and oriented.
Record review of the Bowel Movement task sheet, undated, showed documentation of Resident 3’s BM activity on 07/22/2025 at 12:08 PM. Resident 3’s next BM was documented on 07/27/2025 at 01:55 PM, approximately 121hours since the last BM.
Record review of Resident 3’s physician’s order, dated 06/23/2025, documented, “Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for Constipation Give at bedtime or at resident preferred time if no BM on 3rd day.”
Record review of Resident 3’s physician’s order, dated 06/23/2025, documented, “Dulcolax Suppository (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from MOM after 12 hours.”
Record review of Resident 3’s physician’s order, dated 06/23/2025, documented, “Fleet Enema Enema 7-19 GM(grams)/118ML (Sodium Phosphates) Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify MD.”
Record review of Resident 3’s Electronic Medication Administration Record (EMAR), dated July 2025, did not show documentation of medication intervention for no BM after 64 hours from 07/25/2025 to 07/26/2025
In an interview on 08/06/2025 at 1:39 PM, Staff B, Director of Nursing Services/Registered Nurse (RN), said the bowel protocol should be initiated 64 hours after the last BM. Staff B said after reviewing the medical records the bowel protocol for Resident 3 had not been initiated 64 hours after the last BM on 07/22/2025.
Resident 30
Resident 30 was admitted to the facility on [DATE]. The Medicare 5- Day MDS, dated [DATE], documented the resident was alert and oriented.
Review of Resident 30's Bowel Movement task sheet, undated, showed documentation of Resident 30’s BM activity on 07/23/2025 at 5:21 AM. Resident 30’s next BM was documented on 07/28/2025 at 03:21 PM, approximately 130 hours since the last BM.
Record review of Resident 30’s physician’s order, dated 07/22/2025, documented, “Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for Constipation Give at bedtime or at resident preferred time if no BM on 3rd day.”
Review of Resident 30’s physician’s order, dated 07/22/2025, documented, “Dulcolax Suppository (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from MOM after 12 hours.”
Review of Resident 30’s physician’s order, dated 07/22/2025, documented, “Fleet Enema Enema 7-19 GM(grams)/118ML (Sodium Phosphates) Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify MD.”
Review of Resident 30’s EMAR, dated July 2025, did not show documentation of medication intervention for no BM after 64 hours from 07/23/2025 to 07/28/2025.
In an interview on 08/07/2025 at 10:03 AM, Staff N, Licensed Practical Nurse stated, “There should be something in the records from that stretch of time. There are no BM interventions for both.”
In an interview on 08/07/2025 at 10:26 AM, Staff B, said it was her expectation to follow the bowel protocol. Staff B stated, “we have a problem with documentation. That is unacceptable to not have started the bowel protocol.”
Reference WAC 388-97-1060 (1)(3)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an order was in place prior to the administration of oxygen, for 1 of 2 sampled residents (Resident 30) reviewed for respiratory services. This failure placed residents at risk for complications in respiratory health and a diminished quality of life. Findings included . Record review of the Facility's Oxygen Management Policy, revised on 12/2022, documented, The center requires that a physician's order be obtained prior to the administration of oxygen. Resident 30 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease making it difficult to breathe) and pulmonary fibrosis (condition in which scare tissue builds up in the lungs, making it difficult to breathe). The Medicare 5- Day Minimum Data Set, an assessment tool, dated 07/22/2025, documented Resident 30 was alert and oriented. In an observation on 08/04/2025 at 1:06 PM, and at 3:23 PM Resident 30 was observed in bed with continuous oxygen on. Record review of Resident 30's physician order, dated, 08/05/2025, documented, 2lpm [liters per minute] n/c [nasal canula] oxygen continuously. Review of Resident 30's Electronic Health Records (EHR) did not contain any documentation of physician's order for oxygen prior to 08/05/2025. In an interview on 08/07/2025 at 12:21 PM, Staff C, Infection Preventionist/Registered Nurse, said Resident 30 had been using oxygen since her admission on [DATE]. Staff C stated, she has been on it ever since she has been here. In an interview on 08/07/2025 at 12:36 PM, Staff C stated, Yes, she admitted with oxygen. We checked and there was no order in until the 5th. In an interview on 08/07/2025 at 2:08 PM, Staff B, Director of Nursing Services, said that oxygen must be ordered by a physician. Staff B said she would expect oxygen to be administered per facility policy. Reference WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to ensure nursing hours were accurately posted and updated daily for 30 of 31 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.Findings included.Record review of the Daily Nursing Staffing Report postings, prior to being edited, from 07/05/2025 to 08/04/2025 were not provided for review. Review of the Daily Nursing Staffing Report postings provided by the facility, from 07/05/2025 to 08/04/2025, showed changes for every day, except for 07/21/2025, to columns titled Hours Scheduled, Staffing Total, and Actual Hours Worked daily.In an interview on 08/05/2025 at 11:05 AM, Staff H, Staffing Coordinator, said she had only done staffing since May and was still learning. Staff H said she had not been updating the staffing numbers for each shift on the posted Daily Nursing Staffing Report. Staff H said yesterday's updated staffing did not get added to the daily posting during the day and that happened a lot.In an interview on 08/07/2025 at 9:49 AM, Staff B, Director of Nursing/Registered Nurse, said staffing was a new role for Staff H and she was still learning the process. Staff B said Staff H would only post the daily staffing numbers that were scheduled. Staff B said Staff H did not know she had to update the postings with changes each shift, and Staff H did not have a process to update them. Staff B said they would need a process to figure out who would be updating them. Staff B said the Daily Nursing Staffing Report needed to be updated with changes throughout the day.In an interview on 08/07/2025 at 10:42 AM, while looking at the Daily Nursing Staffing Reports provided by the facility with Staff H, Staff H said the postings provided to the surveyors had changes to them because she reviewed and corrected the postings the next day after they were taken down. Staff H said she would take the previous posted day down, review and correct it, and post a new one for the current day. Staff H said she did not know it needed to be updated to reflect current staffing throughout the day.No WAC Reference

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to distribute resident meal trays in a sanitary manner in 1 of 2 hallways reviewed for infection control. This failure placed residents at risk of infection transmission and a diminished quality of life.Findings included .In an observation on 08/04/2025 at 12:46 PM, Staff F, Certified Nurse Assistant, was observed carrying a meal tray from the food cart into room [ROOM NUMBER] and placed it on a bedside table. room [ROOM NUMBER] had an orange-colored sign at the room entrance indicating the resident in room [ROOM NUMBER] was on enhanced barrier precautions (infection control precautions). Resident in room [ROOM NUMBER] declined the meal tray. Staff F proceeded to pick up the tray from the bedside table and returned it into the meal cart in the hallway which had other meals trays due to be served. In an interview on 08/04/2025 at 1:01 PM, Staff F was asked where she would keep residents meal trays if the resident refused it. Staff F stated, we typically put them back in the meal cart. In an interview on 08/07/2025 at 9:36 PM, Staff C, Infection Preventionist/Registered Nurse, said it was the expectation when a resident declined their meal tray, staff were expected to leave the meal tray in the room and not return the tray into the meal cart thus preventing contamination of the other trays in the cart. Reference WAC 388-97-1320 (1)

Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 2 kitchen refrigerators, reviewed for food storage. This failure placed residents at risk for food borne illness, and a diminished quality of life.Findings included .During an observation on 08/04/2025 at 10:03 AM, the kitchen refrigerator on the left, was observed with the following expired, opened items: 1. Metal Tupperware Jar of Butter Pasta- labeled with use by date of 08/03/20252. Metal Tupperware Jar of Meatballs - labeled with use by date of 08/02/20253. Metal Tupperware Jar of Diced Carrots - labeled with use by date of 08/03/20254. Plastic Ziplock bag of Bulk Ham- labeled with use by date of 07/25/20255. Plastic Ziplock bag of Deli Ham- labeled with use by date of 07/29/20256. Plastic Ziplock bag of Parmesan Cheese- labeled with use by date of 08/02/2025In an interview on 08/04/2025 at 10:05 AM, Staff M, Dietary Manager, said the items in the refrigerators should be kept until the use by date, and then disposed of. Staff M stated, they should be tossed out, and proceeded to throw away the expired items. In an interview on 08/07/2025 at 10:26 AM with Staff B, Director of Nursing, said she expected food items in the refrigerators and freezers to be discarded by the use by date. Reference WAC 388-97-1100 (3) & 2980

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and/or behaviors) for 1 of 5 sampled residents (Resident 14) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.Findings Included . Review of the facility's policy titled, Psychoactive [a drug affecting the mind] Medication Management, revised 08/2024, documented, .10. Complete the Psychopharmacologic [drugs used to treat mental health conditions] Medication Information Evaluation with the resident/resident representative. a. Review the Psychopharmacologic Medication Information Evaluation with the resident/resident representative when psychoactive medication is prescribed. Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including depression and dementia. The End of PPS (Prospective Payment System) Minimum Data Set, an assessment tool, dated 06/20/2025, documented Resident 14 was severely cognitively impaired, taking antidepressant (used to treat depression) medication, and an antipsychotic (a class of psychotropic medications used to treat symptoms of various mental disorders) medication. Record review of Resident 14's physician orders, dated 05/12/2025, documented Resident 14 was prescribed Sertraline (a medication used to treat depression) 50 mg (milligrams) daily. The August 2025 Electronic Medication Administration Record (EMAR) showed Resident 14 was receiving Sertraline 50 mg daily. Review of Resident 14's Electronic Health Record (EHR) Psychopharmacologic Medication Informed Consent, dated 05/30/2025, showed Resident 14's representative gave consent for Sertraline on 05/30/2025, 18 days after the medication was started. Record review of Resident 14's physician orders, dated 05/12/2025, documented Resident 14 was prescribed Bupropion (a medication used to treat depression) 150 mg two times a day. Further review of Resident 14's EHR, showed the Bupropion dose ordered and administered was decreased to 100 mg two times a day starting 06/12/2025, decreased to 50 mg two times a day on 07/12/2025, and decreased to 25 mg two times a day on 08/02/2025. Review of Resident 14's EHR Psychopharmacologic Medication Informed Consent, dated 05/12/2025, showed Resident 14 gave consent for Bupropion on 05/12/2025. Review of Resident 14's EHR did not show documentation of consent or notification of change in dose from the resident or resident's representative for dose changes of the Bupropion on 07/12/2025 and 08/02/2025. In an interview on 08/07/2025 at 8:48 AM, Staff C, Infection Preventionist/Registered Nurse (RN) said they got consent from the resident and/or the resident's representative prior to administering psychotropic medications. Staff C said if there was a dosage change to psychotropic medications; they would notify the resident and/or the resident representative. When asked about Resident 14's Sertraline consent signed on 05/30/2025, Staff C said it was signed late, it should have been signed before Resident 14 started the medication. Staff C said she did not see a consent signed prior to starting Sertraline. When asked about Resident 14's Bupropion consent, Staff C said the original consent should not have been signed by Resident 14, it should have been signed by a representative or power of attorney (POA), stating, Her BIMS [Brief Interview for Mental Status, a screening tool used to assess cognitive function) is so low. Staff C said she did not find documentation Resident 14's representative was notified for the start of Bupropion and the dose changes on 07/12/2025 and 08/02/2025. In an interview on 08/07/2025 at 9:39 AM, Staff B, Director of Nursing/RN, said it was her expectation consents were signed by the resident or POA prior to the start of psychotropic medications. Staff B said the resident and/or the POA needed to be notified, and it documented in the EHR, if there was a change in dose for psychotropic medication. Staff B said if a resident had a low BIMS score, they needed to get consent from the POA for psychotropic medications. Reference WAC 388-97-0260 (1)-(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 5 residents (Resident 20) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life.Findings Included. Review of the facility's policy titled, Medication Administration, revised 12/2024, documented, .15. Remain with the resident until all medication is taken. Resident 20 was admitted to the facility on [DATE]. The End of PPS (Prospective Payment System) Part A Stay Minimum Data Set, an assessment tool, dated 07/08/2025, documented Resident 20 was cognitively intact. In an observation and interview on 08/04/2025 at 10:47 AM, Resident 20 was observed lying in bed with no staff present in the room. A medication cup with 9 pills in the cup was observed in front of Resident 20 sitting on the bedside table. When Resident 20 was asked about the pills in the cup, she said she wasn't ready to take them when the nurse brought them in. Resident 20 said she was still sleepy, so the nurse left them there for her to take. Resident 20 said she did not know what they all were for. Resident 20 said some were for nausea, dizziness, and some for high blood pressure. Record review of Resident 20's electronic health record did not show a self-medication administration evaluation had been completed. In an interview on 08/04/2025 at 10:51 AM, Staff B, Director of Nursing/Registered Nurse, said she did not think there were any residents on a self-medication program. Staff B said medications should not be left at the bedside if a resident was not on a self-medication program. In an observation and interview on 08/04/2025 at 10:55 AM, Staff B went to Resident 20's room to observe the medication cup at bedside. Resident 20 was observed to be swallowing and then set the empty medication cup down on bedside table. Resident 20 said she just swallowed her medications. When asked if the nurse left the medications there for her, Resident 20 stated, Yes. In an interview on 08/04/2025 at 11:01 AM, Staff B said Resident 20 was not on a self-medication program. Staff B said she talked to Resident 20's nurse. Staff B said Resident 20's nurse said she handed Resident 20 her pills and thought Resident 20 would take them, so she left the room. Staff B said the nurse should have stayed and watched Resident 20 take her medications. Reference WAC 388-97-1300 (1)(b)(i), (3)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to obtain an evaluation assessment, consent, and physician order for full length bolsters on both sides of the bed for 1 of 2 sampled residents (7) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.
Findings included .
Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 05/16/2024, documented Resident 7 was moderately cognitively impaired.
On 07/21/2024 at 3:28 PM, Resident 7 was observed lying in bed on an air mattress with bolsters on the upper and lower full length left and right side of the bed.
On 07/22/2024 at 12:54 PM, Resident 7's bed was observed with an air mattress with bolsters on the upper and lower full length left and right side of the bed.
At 1:47 PM, Resident 7 was observed lying in bed on an air mattress with bolsters on the upper and lower full length left and right side of the bed.
Record review of Resident 7's Electronic Health Record did not show an evaluation assessment, consent, or physician's order related to a bolstered air mattress.
On 07/23/2024 at 9:12 AM, Resident 7 was observed lying in bed on an air mattress with bolsters on the upper and lower full length left and right side of the bed.
At 2:26 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said an assessment, physician's order, and consent, signed by the resident or family member, was needed for use of a bolstered mattress. Staff E said she could not find an assessment, physician order, or consent for Resident 7's bolsters on the mattress and it should have been done.
At 3:22 PM, Staff B, Director of Nursing Services and Registered Nurse, said she expected evaluation assessments, consents, and physician orders were completed for use of safety devices such as bolsters on mattresses.
Reference WAC 388-97-0620 (1)(a)(b)(4)(a)(b)
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Based on observation and interview, the facility failed to provide a safe dining environment by ensuring the floorboard heater was not hot to the touch in 1 of 1 dining room reviewed for environment. This failure had the potential to place residents at risk of burns and a diminished quality of life.
Findings included .
On 07/21/2024 at 12:45 PM, the dining room floorboard heater was observed radiating heat. The floorboard heater was hot to the touch and made this observer's hand move quickly away when touched.
At 12:47 PM, Staff D, Maintenance Director, said the floorboard heater had to be manually turned on. Staff D touched the floorboard heater, removed his hand quickly and stated, It's pretty hot.
At 12:51 PM, Staff D was observed using a thermometer which read 100 degrees. Staff D said it was hot and would be turned down.
Reference WAC 388-97-0880 (1)
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan addressing wounds for 1 of 5 sampled residents (20) reviewed for comprehensive care plans. This failure placed residents at risk for continued decline and decreased quality of life.
Findings included .
Resident 20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 04/17/2024, documented Resident 20 was cognitively intact and was at risk of developing skin breakdown.
On 07/21/2024 at 3:08 PM, Resident 20 was observed lying in bed and had a darkened skin impairment to his left great toe.
Resident 20's comprehensive care plan did not address the skin impairment on his left great toe.
On 07/24/2024 at 10:17 AM, Staff E, Infection Preventionist and Licensed Practical Nurse, said Resident 20's electronic health record did not have a specific care plan for the left great toe skin impairment.
At 2:07 PM, Staff B, Director of Nursing Services and Registered Nurse, said it was the expectation that if a new skin impairment developed, a care plan would be implemented to address the skin impairment's care. Staff B said there was not a care plan for the left great toe skin impairment in Resident 20's comprehensive care plan.
Reference WAC 388-97-1020 (1)(2)(a)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure grooming assistance was provided for 1 of 2 sampled residents (12) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, poor hygiene, and a diminished quality of life.
Findings included .
Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 07/22/2024, showed Resident 12 was cognitively intact and had an impairment on one side (left) of the upper extremity.
Resident 12's care plan, dated 06/19/2023, showed Resident 12 required extensive assistance with personal hygiene and did not have specific interventions for nail care.
On 07/22/2024 at 11:31 AM, Resident 12 was observed to have long unkept fingernails on both hands. Resident 12 said it was her preference for her fingernails to be shorter.
The electronic medical record did not reflect any nail care was offered and/or refused from 06/30/2024-07/22/2024.
On 07/23/2024 at 10:30 AM, Staff F, Nursing Assistant, said nail care was completed on shower days. Staff F said shower days were two times weekly, and nail care refusal should be documented.
At 12:20 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said nail care was offered with shower or skin assessment. Staff E said nail care refusals would be documented just like a shower refusal in the electronic medical record or on a paper shower sheet.
At 3:50 PM, Staff B, Director of Nursing Services and Registered Nurse, said nail care should be completed on shower days and any refusal should be documented. Staff B observed Resident 12's nails and indicated they were long and unkept.
Reference WAC 388-97-1020 (2)(a)(i)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to provide resident centered activities incorporating the resident's preferences for 1 of 1 sampled resident (285) reviewed for activities. This failure placed residents at risk for a diminished quality of life.
Findings included .
Resident 285 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 05/06/2024, showed Resident 285 was moderately cognitively impaired and had an activity preference of going outside to get fresh air when the weather was good.
The May 2024, June 2024 and July 2024 Activity Participation reports did not have documentation Resident 285 had been offered, refused, or had gone outside while at the facility.
On 07/22/2024 at 8:52 AM, Resident 285 said it would be nice to go outside.
On 07/24/2024 at 9:25 AM, Staff C, Life Enrichment Director, said she did an initial assessment to learn Resident 285's choices. Staff C said she invited residents outside if the weather permitted. Staff C said they had invited Resident 285 to go outside but was not sure if the resident had been outside.
At 1:44 PM, Staff B, Director of Nursing Services and Registered Nurse, said resident preferences should be offered.
At 2:24 PM, Staff A, Administrator, said he expected activities staff to document what they were doing and how long. Staff A said documenting refusals was weak.
Reference WAC 388-97-0940 (1)(2)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 2 sampled residents (12) reviewed for range of motion (ROM) and mobility. This failure placed residents at risk for avoidable decline and diminished quality of life.
Findings included .
Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 07/22/2024, showed Resident 12 was cognitively intact, had impairment on one side of the body, and did not show the resident was on a restorative therapy program.
The care plan, dated 06/19/2023, showed Resident 12 had limited physical mobility related to stroke and weakness. There were no interventions for maintaining ROM or function in the care plan. The care plan showed Resident 12 required extensive assistance x2 (two person) for bed mobility, and repositioning, and transfers with 2 staff members with a mechanical lift.
On 07/21/2024 at 11:31 AM, Resident 12 said her hand did not open, and the resident demonstrated the limited mobility of her hand. Resident 12 indicated she did not recall staff ever performing range of motion to the left hand.
On 07/23/2024 at 12:20 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, stated, We do not have any patients with contractures. When asked what they would do if they had a resident with a contracture, Staff E said they would have a diagnosis and a care plan. Staff E said they were in the process of getting a restorative program back up and running.
At 3:45 PM, Staff B, Director of Nursing Services and Registered Nurse, stated, I would have to check with the MDS nurse to see if any patients had contractures. When asked about Resident 12, Staff B observed Resident 12's left hand and stated, Well, it looks like it is contracted. Staff B said no restorative program was in place.
Reference WAC 388-97-1060 (3)(d)
.

.
Based on interview and record review, the facility failed to ensure Registered Nurse (RN) supervision was provided at least eight hours daily for 3 of 30 days reviewed. This failure placed residents at risk for not receiving needed care and supervision of care.
Findings included .
The Aging and Long-Term Support Administration (ALTSA) Staffing Pattern, and the facility's Daily Nurse Staffing Forms, showed the facility did not have an RN on duty for any of their three shifts (day, evening & night) on 06/30/2024, 07/07/2024 and 07/14/2024.
On 07/24/2024 at 2:24 PM, Staff A, Administrator, said they were trying to hire nurses from using a hiring software; however, they mostly got Licensed Practical Nurse applicants. Staff A said if they were short on RNs they would pull from their management team and use staff from another facility whenever they could.
Reference WAC 388-97-1080 (3)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure hand sanitization was being performed to prevent the transmission of a multi-drug resistant organism (MDRO), Extended Spectrum Beta-Lactamase (ESBL, an enzyme resistant to antibiotics and is spread through contaminated hands and surfaces), for 1 of 2 sampled residents (2) reviewed for infection prevention and control related to Transmission Based Precautions (TBP). This failure placed residents at risk of transmission of a MDRO and a diminished quality of life.
Findings included .
The Center for Disease Control website, https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, noted EBP included the need for everyone to clean hands before entering a resident's room and when leaving the room.
Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 07/27/2023, documented Resident 2 was severely cognitively impaired.
Resident 2's electronic medical record (EMR), reviewed on 08/07/2023 at 3:16 PM, showed Resident 2 had tested positive for ESBL and was placed on Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of resistant organisms).
On 08/07/2023 at 10:00 AM to 11:30 AM, three facility staff members were observed entering Resident 2's room and did not use hand sanitizer prior to entry nor on exit.
At 1:00 PM to 1:40 PM, two facility staff members were observed entering Resident 2's room and did not use hand sanitizer prior to entry nor on exit.
On 08/08/2023 at 9:20 AM to 11:46 AM, two facility staff members were observed entering Resident 2's room and did not use hand sanitizer prior to entry nor on exit.
On 08/09/2023 at 3:12 PM to 4:02 PM, one facility staff member was observed entering Resident 2's room and did not use hand sanitizer prior to entry nor on exit.
At 4:15 PM, Staff D, Certified Nursing Assistant (CNA), said hand hygiene should be completed before entering a resident room and after leaving a resident room, between passing food trays, and after resident care.
At 4:25 PM, Staff L, CNA, said hand hygiene should be completed when entering a resident's room, leaving their room, before contact with each resident, after breaks and after going to the restroom.
At 7:12 PM to 8:46 PM, three facility staff members were observed entering Resident 2's room and did not use hand sanitizer prior to entry nor on exit.
At 7:40 PM, Staff B, Director of Nursing Services and Registered Nurse, said the expectation of staff was to perform hand hygiene after bathroom use, eating, breaks, between residents, depending on the care provided it may need to be done in the middle of care, and entering and leaving a resident room. Staff B said all staff should be using hand hygiene before they enter the room of Resident 2.
Reference WAC 388-97-1320 (1)(c)

.
Based on interview and record review, the facility failed to ensure staff received dementia training and/or abuse/neglect training for 3 of 5 sampled staff (F, G & H) reviewed for nurse aids in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff.
Findings included .
Staff F, Certified Nursing Assistant, was hired on 06/18/2023. No training records or in-services provided showed Dementia or Abuse/Neglect training was completed since hire.
Staff G, Certified Nursing Assistant, was hired on 12/02/2022. No training records or in-services provided showed Dementia or Abuse/Neglect training was completed since hire.
Staff H, Certified Nursing Assistant, was hired on 11/07/2022. No training records or in-services provided showed Abuse/Neglect training was completed since hire.
On 08/08/2023 at 3:15 PM, Staff A, Administrator, said staff should have at least one Dementia training per year.
Reference WAC 388-97-1680 (2)(b)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 30 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident had severe cognitive impairment, the resident's pneumococcal vaccination was not up to date, and the pneumococcal vaccine was not offered.
Resident 30's medical record did not show documentation of the resident's pneumococcal vaccine status. The medical record did not document if the resident was offered or received a pneumococcal vaccine.
Reference WAC 388-97-1340 (1)(2)(3)
Based on interview and record review, the facility failed to offer the pneumococcal vaccine to 3 of 5 sampled residents (16, 31 & 30) reviewed for immunizations. This failure placed residents at risk for developing pneumonia with potential negative outcomes.
Findings included .
1) Resident 16 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2023, documented the resident was moderately cognitively impaired, the resident's pneumococcal vaccination was not up to date, and the pneumococcal vaccine was not offered.
Resident 16's medical record did not show documentation of the resident's pneumococcal vaccine status. The medical record did not document if the resident was offered or received a pneumococcal vaccine.
On 08/08/2023 at 1:25 PM, Staff B, Director of Nursing Services and Registered Nurse, said residents were educated on the risks/benefits of a vaccination via the consent form. Staff B said a floor nurse would educate residents on the risks and benefits, obtained consent or declination, and documented in the evaluations tab of the electronic medical record. Staff B said there was not a consent or declination in place for Resident 16. Staff B said Resident 16 should have a pneumococcal consent or declination in place at this time.
2) Resident 31 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident had moderate cognitive impairment, the resident's pneumococcal vaccination was not up to date, and the pneumococcal vaccine was not offered.
Review of Resident 31's medical record did not show documentation of the resident's pneumococcal vaccine status. The medical record did not document if the resident was offered or received a pneumococcal vaccine.
On 08/09/2023 at 11:00 AM, Staff B said there was not a pneumococcal immunization consent or declination in Resident 31's electronic medical record, and there should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure informed consents were obtained prior to administration of psychotropic medications (medications affecting the mind) for 2 of 5 sampled residents (16 & 31) reviewed for rights to be informed about care and treatment related to unnecessary medications. This failure placed residents at risk of not knowing the effects of medications, medication side effects, and a decreased quality of life.
Findings included .
1) Resident 16 was admitted to the facility on [DATE] with diagnoses including depression. Resident 16's admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2023, documented the resident was moderately cognitively impaired.
A physician's order, dated 06/19/2023, documented Resident 16 was ordered Trazodone, an anti-depressant medication.
A physician's order, dated 06/20/2023, documented Resident 16 was ordered Venlafaxine, an anti-depressant medication.
A physician's order, dated 06/20/2023, documented Resident 16 was ordered Diazepam, an anti-anxiety medication.
Resident 16's August 2023 Medication Administration Record documented the resident received Trazodone, Venlafaxine, and Diazepam on a routine basis.
Resident 16's electronic medical record (EMR) did not show informed consents were completed explaining the risk and benefits of the psychotropic medications.
On 08/08/2023 at 1:18 PM, Staff B, Director of Nursing Services and Registered Nurse, said psychotropic medications included medications such as antidepressants and anxiolytics (anti-anxiety medications). Staff B said residents were educated on the risks and benefits to psychotropic medications by informed consent forms containing information on the prescribed medications. Staff B said floor nurses were responsible for obtaining informed consents for psychotropic medications. Staff B said she could not find the consents for Resident 16's Trazodone, Venlafaxine, and Diazepam medications, and there should be consents in place for the medications.
2) Resident 31 was admitted to the facility on [DATE] with diagnoses including depression. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired.
A physician's order, dated 06/28/2023, documented Resident 31 was prescribed Sertraline, an antidepressant medication.
A physician's order, dated 06/28/2023, documented Resident 31 was prescribed Mirtazapine, an antidepressant medication.
Resident 31's EMR did not show informed consents were completed explaining the risk and benefits of the psychotropic medications.
On 08/09/2023 at 10:57 AM, Staff B said there were no informed consents in Resident 31's medical record for the psychotropic medications and there should have been.
Reference WAC 388-97-0180 (1-4)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 6 sampled residents (2) reviewed for participating in care planning. This failure placed residents at risk of not belong allowed to be involved in care decisions and a diminished quality of life.
Findings included .
Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/17/2023, showed the resident was moderately cognitively impaired.
The electronic health records (EHR) showed the facility's last Care Conference for Resident 2 was on 03/07/2023.
On 08/08/2023 at 2:27 PM, Staff E, Social Services Director, said care conferences should be completed quarterly. After reviewing the EHR, Staff E said Resident 2's last care conference was in March 2023.
At 2:44 PM, Staff A, Administrator, said care conferences should be completed quarterly for long-term residents. Staff A said if Staff E was not able to find the Care Conference notes then it probably was not completed.
Reference WAC 388-97-1020 (5)(f)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure resident preferences were honored regarding a later wake-up time in the morning for 1 of 1 sampled residents (20) reviewed for self determination. This failure placed residents at risk of depression, fatigue, and a decreased quality of life.
Findings included .
Resident 20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/31/2023, documented the resident was cognitively intact.
On 08/07/2023 at 11:11 AM, Resident 20 said her breakfast came at a time when the resident would rather be sleeping. Resident 20 said this would happen every day. A breakfast tray, uneaten, was observed on the residents bedside table positioned in front of the resident.
On 08/08/2023 at 8:33 AM, Resident 20 said the facility staff woke her up for breakfast like they do every morning.
On 08/09/2023 at 9:11 AM, Resident 20 said facility staff woke her up for breakfast, which she did not like. Resident 20 said she would be taking a nap after breakfast.
Review of Resident 20's medical record did not show a preference for waking up later in the day.
On 08/09/2023 at 10:23 AM, Staff D, Certified Nursing Assistant, said residents would tell her their preference for wake-up time. Staff D said if a resident informed her of a different preference, she would inform her nurse so the nurse could update the resident's care plan. Staff D said Resident 20 did not want to be bugged until after breakfast. Staff D said Resident 20 liked to get up and eat breakfast about 10:30 AM.
At 11:11 AM, Staff B, Director of Nursing Services and Registered Nurse, said resident preferences such as when they choose to wake up and eat breakfast were assessed upon admission, quarterly, and anytime in between, as residents could voice their preferences at any time. Staff B said if a resident requested a later wake up time, she would inform the kitchen and update the care plan. Staff B said Resident 20 received her morning medications at noon per her preference for later wake up time. Staff B said she would look into getting Resident 20's dietary preferences assessed.
Reference WAC 388-97-0900 (1)-(4)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and homelike environment for 2 of 5 sampled residents (Residents 15 & 28) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life.
Findings included .
1) Resident 28 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 07/18/2023, documented Resident 28 was severely cognitively impaired.
On 08/07/2023 at 2:45 PM, Resident 28's room was observed to only contain a bed, a TV, and one very small picture on the wall. No other personal items were present in the room.
2) Resident 15 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 15 was moderately cognitively impaired.
On 08/07/2023 at 2:24 PM, Resident 15's room was observed to only contain a bed, a TV, one very small picture on the wall, and a pair of shoes next to the bed. No other personal items were present in the room.
On 08/08/2023 at 10:03 AM, Staff B, Director of Nursing Services and Registered Nurse, said she was not sure why the rooms of Residents 15 and Resident 28 did not have any personalization. Staff B said it would be best if their rooms were personalized so they felt as comfortable as they can.
Reference WAC 388-97-0880 (1)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure comprehensive care plans addressed dental and end of life for 2 of 2 sampled residents (16 & 32) reviewed for development and implementation of comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.
Findings included .
1) Resident 16 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated [DATE], documented the resident was moderately cognitively impaired and had no natural teeth.
Resident 16's comprehensive care plan did not address a dental care plan.
On [DATE] at 2:14 PM, Resident 16's family member (FM) said the facility was trying to get the resident to a dentist. The FM said it was hard to communicate with the resident due to her not having any teeth.
On [DATE] at 10:20 AM, Staff D, Certified Nursing Assistant (CNA), said she used the [NAME] (a reference used to guide resident care) to understand the care needs of her assigned residents.
At 10:48 AM, Staff B, Director of Nursing Services and Registered Nurse, said care plans were initiated with information gathered from hospital admission packets and admission assessments. Staff B said when a resident's care plan was updated, the [NAME] used by CNAs, would automatically update. Staff B said an issue had been identified when the company changed ownership where the Care Assessment Areas would not automatically generate a care plan like the previous company's medical record would. Staff B said Care Assessment Areas would have to be manually entered to generate a care plan. After reviewing Resident 16's care plan, Staff B said a dental care plan was added on [DATE], but a dental care plan should have been in place prior.
2) Resident 32 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented the resident had short-term and long-term memory problems and had moderately impaired decision-making.
A progress note, dated [DATE], documented, Significant change from baseline noted. Resident transitioned to EOL [End of Life] care.
Resident 32's comprehensive care plan did not address an EOL care plan.
Resident 32's medical record documented the resident expired on [DATE].
On [DATE] at 3:02 PM, Staff B said when a resident was determined to be EOL, the resident's care plan should be updated to reflect EOL care such as turning and repositioning. Staff B said usually herself, the MDS nurse, or the Social Services Director would update a resident's care plan when new orders were placed in the electronic medical record. Staff B said she could not locate an EOL care plan in Resident 32's medical record and someone on EOL care should have an EOL care plan.
Reference WAC 388-97-1020 (1)(2)(a)(b)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 1 of 1 sampled residents (7) reviewed for care plan timing and revisions related to hospitalization. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.
Findings included .
Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 07/13/2023, documented the resident was moderately cognitively impaired.
Resident 7's electronic medical record (EMR) documented the resident was admitted to the hospital on [DATE] and re-admitted to the facility on [DATE]. The EMR showed Resident 7 was diagnosed with a non-ST-elevated myocardial infarction (NSTEMI, a type of heart attack), respiratory failure (a serious condition making it difficult to breathe on your own), sepsis (a life-threatening bodily response to infection) and urinary tract infection (UTI) while admitted at the hospital.
Resident 7's EMR documented the resident was re-admitted to the hospital on [DATE] and re-admitted to the facility on [DATE]. Resident 7 was diagnosed with clostridium difficile colitis (c-diff, inflammation of the colon caused by bacteria) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) while admitted at the hospital.
Resident 7's comprehensive care plan, dated 05/22/2023, showed no revisions had been made to Resident 7's care plan to include the new diagnoses of NSTEMI, respiratory failure, sepsis, COPD and UTI after the 06/02/2023 to 06/12/2023 and 06/27/2023 to 07/06/2023 admissions at the hospital.
On 08/09/2023 at 7:40 PM, Staff B, Director of Nursing Serves and Registered Nurse (RN), said she completed care plan revisions and Staff J, MDS Nurse and RN, created the initial care plans. Staff B said care plans were revised when a resident had a change or a new diagnosis. Staff B said Resident 7's new diagnoses should have been addressed on the care plan when she returned from the hospital. Staff J said Resident 7's diagnoses of NSTEMI, respiratory failure, sepsis, COPD and UTI should have been addressed on the care plan.
Reference WAC 388-97-1020 (2)(c)(d)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure that provider orders were followed and/or completed for 1 of 5 sampled residents (12) reviewed for services meet professional standards related to unnecessary medications. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of care.
Findings included .
Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/09/2023, documented Resident 12 was cognitively intact.
Resident 12's July 2023 Medication Administration Record (MAR) documented instances where the provider orders were not administered and/or completed over the previous 30 days. On 07/18/2023 and 07/26/2023 monitoring was not followed/completed for symptoms of depression/anxiety and monitoring pain, medication side effects, and edema. The incentive spirometer (a device to exercise/expand lungs) order was not completed on 07/14/2023.
Resident 12's Electronic Medical Record (EMR) showed Resident 12 was not out of the facility on the dates the provider orders were not administered and/or completed on 07/14/2023, 07/18/2023 and 07/26/2023.
At 3:15 PM, Staff K, Licensed Practical Nurse, said all orders on the MAR should be completed and the nurse should initial each item on the MAR to indicate that each order was followed and/or completed. Staff K said if there was a reason why orders could not be followed or completed, it should be documented in the EMR and the Director of Nursing Services (DNS) and provider should be alerted.
At 7:40 PM, Staff B, DNS and Registered Nurse, said the nurses should be completing all orders on the MAR and if they could not complete them, they needed to document on the EMR and let the provider and DNS know. The DNS said she was surprised and disappointed about the nurses not having completed the orders on the MAR for Resident 12. Staff B said it may be related to having agency nurses working or may be due to the resident having been out of the facility.
Reference WAC 388-97-1620 (2)(b)(i)(ii)(6)(b)(i)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure ongoing neurological assessments (assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) were performed for a resident after an unwitnessed fall for 1 of 3 sampled residents (30) reviewed for quality of care related to accidents. This failure placed residents at risk of having unidentified injuries, a delay in treatment, worsening conditions, health complications and a diminished quality of life.
Findings included .
Resident 30 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated [DATE], showed the resident was severely cognitively impaired.
The incident report investigation, dated 03/06/2023 documented, resident was found lying with her head against table leg.
The Neurological Observation sheet, dated 03/06/2023, was blank for q (each) 15 minutes 8:00 PM, q ½ hour 8:30 PM, q ½ hour 9:00 PM and q hour 10:00 PM. Blanks were also noted at 19th HR (hour)/q 4 hour 1:00 PM and 24 HR/q 4 hour 5:00 PM.
On 08/09/2023 at 8:52 AM, Staff B, Director of Nursing Services/Registered Nurse, said she expected staff to perform the neurological assessment for unwitnessed falls. Staff B said if the resident resisted or refused, nursing should document it on the form.
Reference WAC 388-97-1060 (1)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and adverse behaviors for 1 of 5 sampled residents (31) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.
Findings included .
Resident 31 was admitted to the facility on [DATE] with diagnoses including depression. The admission Minimum Data Set, an assessment tool, dated 07/05/2023, documented the resident was moderately cognitively impaired.
A physician's order, dated 06/28/2023, documented the resident was prescribed Sertraline, an antidepressant medication and Mirtazapine, an antidepressant medication.
Resident 31's depression care plan, initiated 06/28/2023, documented an intervention to Monitor/document side effects and effectiveness. COMMON ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations [thoughts of harming self].
Resident 31's electronic medical record did not show psychotropic medication side effect monitoring or adverse behavior monitoring.
On 08/09/2023 at 10:30 AM, Staff C, Registered Nurse (RN), said residents were monitored for medication side effects and adverse behaviors through staff observation throughout the day. Staff C said potential side effects of an antidepressant medication include agitation, lethargy, or lack of appetite. Staff C said side effect and behavior monitoring was captured on the resident's Treatment Administration Record (TAR). After reviewing Resident 31's TAR, Staff C said Resident 31 only had pain monitoring in place. Staff C said side effect monitoring and behavior monitoring should be in place for residents taking an antidepressant.
At 10:57 AM, Staff B, Director of Nursing Services and RN, said nurses on the floor should monitor for medication side effects and adverse behaviors every shift. Staff B said staff looked for signs such as increased tearfulness, not sleeping, not eating, increased lethargy, agitation, and increased anxiety. Staff B said there were side effect monitoring orders in place for Resident 31 (placed on 08/08/2023, 42 days after admission to the facility). Staff B said there should be side effect and behavior monitoring in place for residents on antidepressants.
Reference WAC 388-97-1060 (3)(k)(i)
.

.
Based on interview and record review, the facility failed to provide oxygen (O2) treatment per professional standards for 1 of 1 residents (Resident 1) reviewed for respiratory care. This failure placed residents at risk of not receiving care according to physician's orders, possible medical complications, and a diminished quality of life.
Findings included .
Record review of Resident 1's admission Minimum Data Set, an assessment tool, dated 07/04/2023, showed the resident had a diagnosis of respiratory failure, heart failure and received O2 therapy.
Resident 1's plan of care, initiated December 2022, showed the resident received O2 therapy related to diagnosis of his heart failure.
Record review of July 2023 nurse progress notes showed on 07/01/2023 nursing services initiated O2 therapy and the resident continued with the use of O2 until passing away on 07/08/2023.
Resident 1's July 2023 physician's orders showed no orders for O2 services were obtained by nursing services for the use of the O2.
On 07/31/2023 at 3:20 PM, Staff B, Licensed Nurse, said residents with O2 would have physician's order specifying flow rates, parameters and instructions for weaning off the O2. Staff B said the nursing assistants charted O2 saturation checks every 8 hours in the vital sign records and nursing charted daily in progress notes.
At 4:15 PM, Staff A, Nursing Services, said residents with O2 would have physician's order specifying the required instructions to provide O2 services. Staff A said Resident 1 did not have orders for O2 services, and this did not meet expectation of nursing services.
Reference WAC 388-97-1060 (3)(j)(vi)
.