Bethany At Silver Lake

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident grievances were filed and addressed for 1 of 5 residents (Resident 29) reviewed for grievances. This failure to address and resolve resident grievances placed residents at risk for diminished dignity, unresolved missing property and diminished quality of life.Findings included .Review of the facility's policy titled Grievance Policy and Procedure for Residents, revision date 10/2022, documented any employee that is informed of a grievance by a resident will immediately initiate the procedures for resolution of a grievance. Upon learning of grievance, prompt action will be taken to resolve and provide timely response of concern.Resident 29 was admitted on [DATE]. According to the quarterly Minimum Data Set (an assessment tool) assessment dated [DATE], the resident was cognitively intact.In an interview on 03/16/2026 at 10:02 AM, Resident 29 stated they had a Samsung tablet that's been missing for two to three months. They added that the staff were aware of this but had not heard of any follow-up regarding the missing tablet. In a review of the grievances since April of 2025, Resident 29's missing tablet was not found listed.In an interview on 03/17/2026 at 2:42 PM, Resident 29 stated they reported the missing tablet to Staff K in Social Services. In an interview on 03/17/2026 at 2:57 PM, Staff K, Social Services Assistant, stated they were aware of Resident 29's missing tablet. Staff K was unable to remember when the resident reported the missing tablet. Staff K stated that they had been trying to reach resident's family members to verify if they took the tablet but had not received any call back from relatives at this time. Staff K stated when a resident reports a personal item missing, they fill out a grievance form. Requested a copy of the grievance form and investigation regarding the missing tablet. In an interview on 03/19/2026 at 9:54 AM, Staff K, stated they could not find the grievance form related to the missing tablet. They will fill out a grievance form today and investigate the missing tablet.Refer to WAC 388-97-0460(1)(2).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set, (MDS, an assessment tool that was used to develop the resident centered care plan) for 1 of 2 residents (Resident 2) reviewed for communication and 2 of 3 residents (Resident 22 and 86) reviewed for insulin (a hormone that body secretes to regulate the amount of sugar in the blood) use. Failure to accurately complete the MDS placed residents at risk for inappropriate medical care and decreased quality of life.Findings included.

Resident 2 was admitted to the facility on [DATE]. According to the 12/26/2025 MDS, the resident's primary language was not English.
On 03/16/2025 at 9:53 AM, Staff U, Licensed Practical Nurse (LPN), reported Resident 2 had dementia (disease affecting cognitive function and memory). Staff U reported the staff communicated with Resident 2 by family translating for resident or used staff that spoke the same language.
On 03/16/2026 at 12:57 PM, during an interview with Resident 2 and the use of an interpreter, resident was noted to have difficulty communicating. The interpreter stated that Resident 2 was having difficulty understanding the questions even if the interpreter repeated the question. The answers Resident 2 provided were not always related to the question asked. Resident 2 could not elaborate on their concerns regarding food or missing clothing.
During an observation and interview on 03/18/2026 at 10:47 AM, Staff V, Nursing Assistant Certified, reported they used gestures and simple English phrases to communicate with Resident 2. During an observation of care, Staff V used gestures to cue Resident 2 to turn in bed and held up choices of clothing for Resident 2 to point at what they wanted to wear.
Review of Resident 2's Care plan showed a Focus statement that documented resident had a communication problem related to a language barrier and their primary language was not English, dated 11/07/2024. There was another Focus statement that documented resident had moderately impaired cognition, dated 04/21/2025.
Review of the MDS, dated [DATE], showed Resident 2 was understood and understands in Section B and they were rarely or never understood in Section C.
On 03/18/2026 at 3:13 PM, Staff D, Social Service Assistant, stated they had coded Rarely Understood under section C as Resident 2's family had reported the resident was not making sense in their language. Staff D reported Resident 2 can understand gestures and can make simple needs known.
On 03/19/2026 at 8:30 AM, Staff G, MDS coordinator/LPN, stated Resident 2 can make basic needs known by gestures or using family to translate. Staff G did report Resident 2 had some confusion. Staff G reported that the coding between Section 2 and Section 3 was conflicting.
On 03/19/2026 at 8:45 AM, Staff B, Director of Nursing Services (DNS), reported Resident 2's ability to communicate was hit and miss depending on their mood. Staff B reviewed sections B and C of the MDS and reported there appeared to be a discrepancy for Resident 2's communication and cognition.

Review of Resident 22's MDS, dated [DATE], documented the resident had received one insulin injection in the prior seven days.
Review of Resident 22's February 2026 Medication Administration Records (MAR) showed no documentation of the resident receiving an insulin injection.

Review of Resident 86's MDS, dated [DATE], documented the resident had received one insulin injection in the prior seven days.
Review of Resident 86s February 2026 Medication Administration Records (MAR) showed no documentation of the resident receiving an insulin injection
During an interview on 03/19/2026 at 8:37 AM, Staff G reported they had coded the MDS for insulin injections as resident had received an injection of tirzepatide (GLP-1 medication, a medication that enhances the body's ability to secrete insulin). Staff G reported they were aware the medication was used for diabetes (disease where body cannot adequately control the sugar in the blood), but was not aware it was not an insulin product.
During an interview on 03/19/2026 at 8:45 AM, Staff B stated they expected the MDS to be coded for insulin if the resident received insulin injections and not for receiving a GLP medication.
Refer to WAC 388-97-1000 (1)(d), (4)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 11) reviewed for activities had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the individual resident's physical and mental needs. Based on the reasonable person concept, not having adequate recreation and/or sensory stimulation placed the resident at risk for social isolation, lack of stimulation and diminished quality of life.Findings included .Resident 11 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (an assessment tool) assessment dated [DATE], the resident had severely impaired cognition.In a telephone interview on 03/16/2026 at 1:29 PM, Resident 11's Collateral Contact 1 stated that the resident was being left on their own for many hours without any stimulation or activities.During observations on 03/18/2026 at 8:12 AM, 10:10 AM and 2:00 PM, Resident 11 was in bed with no lights on and TV was off. During observations on 03/19/2026 at 8:21 AM and 9:07 AM, Resident 11 was in bed, TV was off and roommate's light was on.In an interview on 03/19/2026 at 8:32 AM, Staff N, Certified Nursing Assistant (CNA) stated that Resident 11 does not get out of bed. Staff N did not know what activities the resident did or attended but they sometimes turned the TV on for them.In an interview on 03/19/2026 at 9:40 AM, Staff L, Activity Director, stated they review residents' activities quarterly and update their preferences if there were any changes. For residents that don't get out of bed they provide room visits, talk to them, and offer daily reading if they request that. Staff L stated Resident 11 used to attend activities but has not attended any lately and has been in bed most of the time. They visit Resident 11 in their room, but they were asleep most of the time, so they don't provide activities for them. Staff L was made aware of multiple observations of the resident in bed with no lights on, no TV on, and no other stimulation. The resident was able to respond when talking to them. Staff L stated they can go and check on the resident and can play light music for them to listen to.In an interview on 03/20/2026 at 10:15 AM, Staff L, Activity Director stated that they usually spend 15 minutes on average with each resident they visit. Staff L did not think that 15 minutes a day was enough time to provide activity and stimulation for a resident in a 24-hour period. Staff L stated they will work on offering more activities and stimulations for Resident 11.Refer to 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 that 1 of 2 residents (Resident 24) reviewed for limited Range of Motion (ROM) received necessary care and services. The facility failed to ensure residents received appropriate services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff). This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life.Findings included. Review of the facility policy titled, Restorative Nursing Documentation, reviewed 01/12/2026 stated the facility maintains documentation of treatments and responses to those treatments.if an unusual event occurs during a treatment (i.e. pain, swelling, skin breakdown) document in the narrative note and report to the charge nurse.evaluation will be documented quarterly and as needed if a change to the program or new service was started. care plan will be updated on routine intervals and as indicated. Resident 24 readmitted to the facility on [DATE] with diagnosis that included history of stroke, generalized osteoarthritis (joint condition, can cause pain, and stiffness) and rheumatoid arthritis (autoimmune disease that affects joints causing pain and swelling). The Annual Minimum Data Set Assessment (MDS - assessment tool) dated 06/09/2025 documented the resident had severe impaired cognition. Review of Resident 24's care plan focus dated 07/22/2023, documented the resident had limited physical mobility related to chronic pain, and advanced dementia with cognitive and physical decline. The goal of care was to tolerate restorative passive exercises without pain or discomfort, maintain current level of function, and remain free of complications such as contractures. Interventions included passive range of motion (PROM) to upper and lower extremities five to six days a week, and therapy referrals as needed. Review of Resident 24's therapy restorative nursing program (RNP) referral form dated 10/04/2023 documented the resident was to receive PROM to upper and lower extremities to maintain range of motion, and strength, six times a week as tolerated. Review of Resident 24's provider notes 03/18/2025 - 03/19/2026, documented on 12/16/2025 and 01/30/2026 the resident had severe extremity contractures. No documentation of contractures was found prior to 12/16/2025. Review of Resident 24's MDS progress notes dated 05/28/2025, 08/26/2025, 11/20/2025, and 02/12/2026 showed no changes to the current RNP were required, as Resident 24 remained a high risk for contractures. In observations on 03/16/2026 at 8:01 AM, 10:25 AM, 1:01 PM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In observations on 03/17/2026 at 9:05 AM, and 11:58 AM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In an observation on 03/18/2026 at 8:20 AM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In a review of Resident 24's care plan and physician orders on 03/18/2026, no documentation was found related to Resident 24's contracted hands, or that they required washcloths to both hands. In an interview on 03/18/2026 at 1:30 PM, Staff N, Nursing Assistant Certified (NAC) stated Resident 24 was dependent on staff for all activities of daily living. Staff N stated they thought the resident had to have washcloths to prevent their nails from digging into the palm of their hands due to their clenched fingers. Staff N stated they thought the restorative aids (RA) were responsible for maintaining the washcloths, but they would assist if needed. In an interview on 03/18/2026 at 3:07 PM, Staff O, NAC/RA stated they perform PROM on Resident 24 to upper and lower extremities. Staff O stated they remembered the washcloths were started awhile ago. Staff O stated the resident was able to partially open their hands and would try to scratch their nose, but we (facility) noticed they were having more swelling and pain to their hands, so the washcloths were started to assist the resident. Staff O was asked who was responsible for implementing the washcloths daily and stated it was mostly the floor staff, but they would assist as needed. In an interview on 03/18/2026 at 3:50 PM, Staff C, Director of Clinical Services (DCS) stated they were unable to locate any occupational therapy evaluations or notes for Resident 24, and the resident had not been seen by skilled therapy services since 2023. In an observation on 03/19/2026 at 8:56 AM and 12:46 PM, Resident 24 was observed to have rolled washcloths to both hands, fingers were clenched around the washcloths. In an interview on 03/19/2026 at 9:10 AM, Staff P, NAC/RA stated they could not recall how long they have been placing washcloths to Resident 24's hands, stated sometime in the last year. Staff P stated their hands are tight, and their fingernails will poke into their skin. In an interview on 03/19/2026 at 9:16 AM, Staff T, NAC stated they were the assigned staff for Resident 24 on that day. Staff T stated they were not familiar with Resident 24's routine care and stated they noticed the washcloths on both of their hands but were unaware they needed to do anything with them. In an interview on 03/19/2026 at 11:03 AM, Staff Q, NAC stated they Resident 24 used to be able to open and close their hands, until recently their hands had been tight and their nails were poking into their skin. Staff Q stated that was why they used the washcloths. Staff Q stated within the last year the facility was placing the washcloths in Resident 24's hands. In an interview on 03/19/2026 at 11:30 AM, Staff R, Registered Nurse (RN) stated Resident 24's hands were very contracted, and their fingernails will dig into their skin, so they apply the washcloths for that prevention. Staff R stated the floor staff, and RAs are usually the ones that applied them. Staff R stated they have worked with Resident 24 since they started in September/2025, and their hands had been that way. Staff R was asked what the process was when a resident presented with a decline or had shown signs of a contracture. Staff R stated they would assess them, notify the provider and then go from there. Staff R was asked if the provider or therapy were notified of Resident 24's contractures, and Staff R stated they were not aware. In an interview on 03/19/2026 at 1:14 PM, Staff G, Licensed Practical Nurse (LPN)/MDS stated they were the licensed nurse who was responsible for overseeing the restorative nursing program at the facility. Staff G stated Resident 24 had been on a PROM RA program for some time. Staff G stated the washcloths were implemented by nursing not through the Restorative program. Staff G was asked if there was a referral or conversation about Resident 24's contracted hands, Staff G stated they did not remember or know of any right now. In an interview on 03/19/2026 at 1:30 PM, Staff S, LPN/Resident Care Manager (RCM) stated they recently took over the RCM role about two weeks ago, however, have known Resident 24 for about two years. Staff S stated Resident 24's hands have been contracted for a while, and the use of the washcloths was to prevent more contracture and prevent their nails from poking into their skin. Staff S was not aware of any assessment, referral for occupational therapy related to Resident 24's contracted hands. In a joint interview on 03/19/2026 at 2:48 PM, Staff B, Director of Nursing Services, and Staff C, DCS. Staff B stated they were not aware Resident 24 had washcloths on both hands until this week. Staff B stated they were unclear on the rationale and documentation to support why it was started. Staff C stated they were reviewing the medical record to determine when the decline occurred. Staff C stated again there had been no skilled therapy services provided to Resident 24 since 2023. Staff B and Staff C were unable to provide any further information. Refer to WAC 388-97-1060(3)(d)

Based on interview and record review the facility failed to ensure one of five staff reviewed, (Staff H) received timely annual performance evaluations. Failure to complete timely evaluations of nursing staff performance, conduct education and in-services based on those evaluations had the potential to result in decreased quality of resident care. Findings included .Staff H was hired 02/18/2020 and was a certified nursing assistant. Review of requested employee evaluations on 03/18/2026 showed the most recent employee evaluation provided for Staff H was dated 08/13/2024. In an interview on 03/18/2026 at 3:00 PM, Staff I, Administrative Assistant, stated there were no more recent evaluations found for Staff H. In an interview on 03/20/2026 at 09:20 AM, Staff B, Director of Nursing Services, acknowledged late evaluation for Staff H and stated the expectation was that evaluations were done yearly. Refer to WAC 388-97-1680(1)(2)(a)-(c)

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Two medication errors were identified for 2 of 4 residents (Resident 97 and 39) observed during 25 medication opportunities which resulted in an error rate of 8%. Failure to provide medications on an empty stomach as ordered and failure to prime the needle prior to administration of insulin (synthetic hormone that allows sugar to enter cells and regulates the amount of sugar in the blood) placed residents at risk of decreased medication efficacy.Findings included.Review of a facility policy titled, Medication Administration, dated 06/18/2020, documented medications were to be administered 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician.
Review of a facility policy titled, Procedure for Insulin Pen Administration, dated 08/2018, documented the insulin flow was to be checked prior to each injection. Dial two to three units and slowly depress the button to check that a drop of insulin appeared at the end of the needle.

Review of Resident 97's Order Summary Report documented a physician order for lispro (fast acting) insulin 5 units three times a day since 01/08/2026.
During an observation on 03/17/2026 at 7:45 AM, Staff E, Registered Nurse (RN), attached a disposable needle onto the lispro pen (multidose container of insulin in shape of a pen). Staff E set the dial of the pen to 5 units. Staff E injected the insulin into Resident 97. Staff E did not prime the needle prior to injection.
During an interview on 03/17/2026 at 7:46 AM, Staff E stated that they were not aware of how to prime the insulin needle prior to use.
During an interview on 03/18/2026 at 12:08 PM, Staff B, Director of Nursing Services (DNS), reported they were aware of Staff E not priming the needle prior to insulin administration and that it was their expectation nurses primed the needle prior to each insulin administration.

Review of Resident 39's Order Summary Report documented a physician order for omeprazole (medication to decrease stomach acid) one time a day before breakfast since 10/29/2024.
Review of Resident 39's March 2026 Medication Administration record revealed omeprazole was scheduled to be given at 7:30 AM.
During an observation on 03/17/2026 at 8:20 AM, Staff F, RN, provided omeprazole to Resident 39. Resident 39 had already had breakfast.
During an interview on 03/17/2026 at 8:35 AM, Staff F stated it was always an issue getting the medications scheduled before breakfast, done before breakfast.
During an interview on 03/18/2026 at 12:08 PM, Staff B stated if a medication order documented the medication was to be administered before breakfast, they expected the nurse to provide the medication before breakfast arrived.
Refer to WAC 388-97-1060 (3)(k)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure skilled rehab services were delivered in accordance with resident evaluations and treatment plans for 3 of 4 residents (8,91,119) reviewed for rehab and restorative services. This failure placed residents at risk for delay in recovery and/or discharge and decreased quality of life. Findings included .In an interview on 03/19/2026 at 10:52 AM, Staff J, Director of Rehabilitation Services, stated the new therapy company started on 03/01/2026. Staff J stated they were provided transitional evaluations from the outgoing therapy company. Staff J stated the transitional evaluations provided a baseline for them to work from and then updated goals as they began treating residents. Staff J stated residents were all set up to be seen at the maximum frequency and at least 5 times per week. Resident 119 admitted [DATE] with diagnoses which included gait impairment and a fractured right arm which did not require surgery. The resident was transferred to the facility for skilled therapy to return to their prior level of function. In an interview and observation on 03/16/2026 at 12:19 PM, Resident 119 was in bed with a sling on the right arm. Resident 119 stated they were here because of their arm. Resident 119 stated they did not think they were getting as much therapy as they were supposed to be getting, stating they didn't know exactly, but just felt like they weren't getting very much. Review of Resident 119's transitional therapy evaluation dated 02/26/2026 showed therapy frequency: Physical Therapy (PT) 3-5 times per week. Occupational Therapy (OT) 3-5 times per week. Review of the therapy service logs for the month of March 1-18, 2026 showed:March 1-18, 2026 the resident received skilled PT a total of 5 visits and OT a total of 7 visits. The week of 3/11-3/17, the resident received OT only twice. The week of 3/11-3/17, the resident received PT only twice. Resident 8 admitted [DATE] with diagnoses which included a left upper leg fracture from a fall. In an interview on 03/16/2026 at 8:24 AM, Resident 8 stated they thought some of the therapists were inexperienced, and stated they saw a lot of the OT people, but not much of the PT and stated they thought they needed to do more strength training. In an observation on 03/18/2026 at 9:06 AM, Resident 8 was observed in the therapy gym with OT staff using a resistance band while seated in the wheelchair. Review of a therapy evaluation dated 02/17/2026 showed recommendations for: Physical Therapy 3-5 times per week. Occupational Therapy 3-5 times per week Review of the therapy service logs for the month of March 1-18,2026 showedNo PT the first 5 days of the month. A total of 4 PT visits. The week of 03/04-03/10, the resident received PT only twice The week of 03/11-03/17, the resident received PT only twice with 03/13/2026 marked as OTH which was listed as a missed therapy code, not further defined. Resident 91 re-admitted on [DATE] with diagnoses which included toe amputations due to infection. In an interview on 03/16/2026 at 9:32 AM, Resident 91 stated it had been at least 4 days since they had therapy. Resident 91 stated they knew it was a new therapy company, but wanted more therapy and didn't understand why there were big gaps in receiving treatments. Review of a transitional therapy evaluation dated 02/05/2026 showed recommendations for: Physical Therapy 3-5 times per week. Occupational Therapy 3-5 times per week Review of the therapy service logs for the month of March 1-18, 2026 showed:A total of 5 PT visits. No PT visits from 03/11- 03/18/2026 (print date/time of report was 03/18/2026 at 3:12PM.) In a follow-up interview with Staff J on 03/19/2026 2:16 PM, Staff J confirmed the therapy week was defined as Sunday-Saturday and after review of Resident 119, 8 and 91 therapy logs, Staff J stated there had been a physical therapist assistant out and confirmed there had been missed PT visits for residents related to lack of PT staff. Staff J stated they had been utilizing OT to attempt to fill in gaps in the PT staffing. Staff J stated they were attempting to utilize on call or per diem staff. In an interview on 03/20/2026 at 09:20 AM, Staff C, Director of Clinical Operations, and Staff B, Director of Nursing Services, stated the new therapy company had taken over on 03/01/2026 and they had not been aware of any therapy staffing issues or aware that residents had concerns about not receiving their ordered therapy. Refer to WAC 388-97-1280 (1)(a)(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 40) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life.
Findings included .
Review of the facility policy titled, Oxygen Administration, undated, showed oxygen would be administered to resident's who needed it, consistent with professional standards of practice, the comprehensive care plan and the resident's goals and preferences. The explanation and guidelines outlined in the policy showed oxygen was administered under orders of a physician.
Resident 40 admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease (COPD-progressive lung disease that limits airflow and makes it difficult to breath).
On 12/16/2024 at 1:51 PM, Resident 40 was observed lying in their bed. Resident 40 was wearing a nasal cannula (a thin flexible tube that goes around the head and into the nose that administers oxygen) which was attached to the oxygen concentrator. The concentrator was set to administer 4 liters per minute of oxygen (lpm).
On 12/17/2024 at 2:38 PM, Resident 40 was observed lying in their bed on their back, the head of the bed slightly elevated. Observed the oxygen concentrator setting at 4 lpm.
Review of Resident 40's Medication Administration Record (MAR) for December 2024, showed they had a physician order to apply oxygen, per nasal cannula, at 2 lpm to keep oxygen saturations (a measurement of the amount of oxygen in the blood) greater than or equal to 88-92 percent as needed.
Review of Resident 40's care plan revised on 08/11/2023, showed oxygen settings included O2 by use of nasal prongs at 2 lpm as needed to keep O2 saturations above 88-92 percent.
In an interview on 12/17/ 2024 at 3:15 PM, Staff D, Licensed Practical Nurse (LPN) stated the process for residents on O2 included checking their O2 saturations and changing the tubing every Monday. When asked how the settings on the concentrator are determined, Staff D stated they follow the physician orders. Staff D stated the concentrator settings are checked every time they go into the room. Staff D stated Resident 40 had a physician order for O2 as needed at 2 lpm. Staff D stated Resident 40 always wore their oxygen, they always wanted to use it and it was usuaslly set at 2 lpm. Staff D stated they could not find an order for Resident 40's oxygen use.
On 12/17/2024 at 3:20 PM, Staff D entered Resident 40's room and checked the setting on the concentrato, stated the concentrator was set at 4 lpm. Staff D adjusted the concentrator settings from 4 lpm to 2 lpm .
In an interview on 12/17/2024 at 3:24 PM Staff C, Registered Nurse/Nurse Manager, stated O2 settings should be checked each time a nurse enters a resident's room, but at minimum each shift. Staff C stated Resident 40 has a physician order for O2 use at 2 lpm as needed, but the resident wanted to use it all the time.
Refer to WAC 388-97-1060(3)(j)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Resident 92 was admitted to the facility on [DATE].
In an interview on 12/16/2024 at 10:33 AM, Resident 92 stated scheduled showers are once a week. Resident 92 stated when they refuse to shower, they are not given a choice to have a shower at another time or with assistance from a female aide during the week.
During an interview on 12/19/2024 at 2:15 PM, Staff H, RN/Nurse Manager, stated when residents are admitted , they are given a sheet of paper about their choices, and are able to document their preferences. If a resident refused to shower, the shower aid should ask why and tell the nurse manager and social worker.
Record review of documentation on the 'Documented Survey Report V2 (documentation of care provided by staff), dated November 2024, showed that Resident 92 received one shower in November.
Refer to WAC 388-97-0900(1)
Based on observation, interview and record review the facility failed to accommodate resident preferences for 3 of 5 sampled residents (Resident 508, 35, and 92) regarding important daily routines and health care. The failure of the facility to honor resident choice placed residents at risk for a diminished quality of life.
Findings included .

Resident 508 admitted to the facility on [DATE].
In an interview on 12/16/2024 at 10:26 AM, Resident 508 stated they preferred not to be awakened at 6:00 AM. Resident 508 stated they had told the nurses not to come in and they did not want breakfast, but the staff kept coming in and waking them up.
Review of Resident 508's choice assessment, dated 12/14/2024, showed Resident 508 preferred to get up at 8:00 AM.
Review a progress note dated 12/16/2024 at 1:45 PM, showed Resident 508 was angry for being woken up in the morning, and they refused vitals (blood pressure and heart rate) checked, breakfast, blood sugar check (checks sugar level in blood) and weight.
Review of a progress note dated 12/17/2024 at 12:06 PM showed Resident 508 refused blood sugar check at 7:00 AM and refused their breakfast.
Review of a progress note dated 12/18/2024 at 7:22 AM, showed Resident 508 refused having their blood sugar checked.
In an interview on 12/18/2024 at 10:56 AM, Staff J, Licensed Practical Nurse (LPN), stated Resident 508 had refused their blood sugar check and insulin at 7:00 AM on 12/16/2024-12/18/2024 because they did not want to be woke up before 8:00 AM. Staff J stated they reported this to the nurse practitioner on 12/17/2024.
Review of a facility form, titled, Nurse Practitioner non urgent communication log, showed the provider had been notified of Resident 508's preference to not be woke up before 8:00 AM and had morning medications scheduled at 7:00 AM. The form showed the provider had responded on 12/16/2024 to change AM (morning) medications to be administered after 8 AM.
Review of Resident 508's Medication Administration Record (MAR), dated December 2024, showed the morning medications were still ordered to be administered at 7:00 AM.
In an interview on 12/18/2024 at 1:55 PM, Staff H, Registered Nurse (RN)/Nurse Manger, stated that they were not aware of Resident 508's preference because they had not done a care conference yet. Staff H stated the responses on the nurse practitioner non urgent communication log were supposed to be implemented within 24 hours. Staff H stated Resident 508's orders had not yet changed since the provider's 12/16/2024 response.

Resident 35 admitted to the facility on [DATE]. According to the Minimum Data Set (MDS-assessment tool) assessment, dated 12/06/2024, the resident was cognitively intact.
In an interview on 12/16/2024 at 2:32PM, Resident 35 stated they preferred more frequent showers or bed baths. Resident 35 stated they did not have a shower last week because they preferred female aides. There were only two young male aides working on their scheduled shower day.
Review of Resident 35's shower task record, print date 12/17/2024, showed during the last 30 days the resident had received one shower on 12/14/2024. Staff documented not applicable for shower tasks on 11/19/2024, 12/05/2024 and 12/12/2024.
Review of a facility form titled, Central Shower Schedule, copied on 12/18/2024, showed Resident 35 was scheduled for showers once a week on Thursday evenings.
Review of a progress note dated 12/12/2024 at 03:44 PM, showed Resident 35 refused to take a shower with a male caregiver they preferred to shower with a female aide and the resident was scheduled to have a shower the next day. There was no documentation that Resident 35 was offered a shower with female caregivers on the following day.
Reviewed of Resident 35's care plan, dated 12/16/2024, showed no documentation of Resident 35's preference for female caregiver with showers.
In an interview on 12/18/2024 at 11:23 AM, Staff J, stated residents were assigned for showers once a week based on what room the resident was in, and staff do not ask residents about their shower preferences.
In an interview on 12/18/2024 at 1:11 PM, Staff K, Social Service Director, stated nursing staff oversaw obtaining shower preferences. Social services would not ask for preferences unless the resident brought them up themselves during the care conferences.
In an interview on 12/18/2024 at 1:45 PM, Staff H, stated nurses should chart resident refused instead of not applicable on the documentation of shower task records. Staff H stated nurses should offer the shower the next day if resident refused due to no female caregiver. Staff H stated they were not aware of Resident 35's preference to have more frequent showers. Staff H reviewed the shower documentation for the last 30 days for Resident 35 and agreed it showed Resident 35 had received one shower on 12/14/2024 and did not receive showers as scheduled.
In an interview on 12/18/2024 at 2:09 PM, Staff B, Interim Director of Nursing (DNS), stated staff were to determine the reason why Resident 35 refused their shower and should offer a shower the following day to accommodate the residents shower needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly report and document resident grievances for 1 of 3 sampled residents (Resident 35) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing property and placed residents at risk for frustration and diminished quality of life.
Findings included .
Review of the facility policy, titled, Grievance Policy and Procedure for Residents, revised date of June 2022, showed any employee that is informed of a grievance by a resident will immediately initiate the procedures for resolution of a grievance.
Resident 35 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 12/06/2024, the resident was cognitively intact.
In an interview on 12/16/2024 at 2:34 PM, Resident 35 stated they were missing a left-hand arthritis glove, and it had been missing for one week, and they had told everyone about it. Resident 35 stated the gloves provided comfort for their hands.
Review of the facility grievance logs for 07/16/2024 through 12/16/2024 showed no grievances were logged for Resident 35.
In an interview on 12/17/2024 at 2:00 PM, Staff L, Occupational Therapist, stated Resident 35 had arthritis gloves but one was missing since about one week ago.
In an interview on 12/18/2024 at 1:11 PM, Staff K, Social Service Director, stated they had received the grievance form for Resident 35 on 12/17/2024 and they were not aware the arthritis glove had been missing for one week. Staff K stated everyone in the facility could complete the grievance form when the resident reported their missing items.
In a follow up interview on 12/18/2024 at 2:24 PM, Staff L stated they had not completed a grievance form when Resident 35 reported missing the arthritis glove. Staff L stated Resident 35 had told a lot of people, including aides, they had lost their glove one week ago.
In an interview on 12/18/2024 at 1:45 PM, Staff H, Registered Nurse/Nurse Manager, stated Resident 35 lost their arthritis glove one week ago. Staff H stated the person with knowledge of the missing glove should have completed the grievance form immediately.
Refer to WAC 388-97-0460(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide 4 of 5 residents (Resident 28, 86, 35, 508) with a summary of their baseline care plan. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services and placed them at risk for unmet needs and possible complications.
Findings included .
Review of a facility policy, titled, Baseline Care Plan, dated 02/05/2020, showed the base line care plan:
- Be developed within 48 hours of a resident's admission,
- Admitting nurse shall gather information from hospital information, physician orders and discussion with the resident,
- A written summary of the baseline care plan will be provided to the resident,
- The written summary will be signed by the resident and included in the medical record.

Resident 28 re-admitted to the facility on [DATE].
Review of Resident 28's baseline care plan form showed which staff had completed the base line care plan. There was a signature by Staff N, Social Service Assistant and Staff O, Licensed Practical Nurse, dated 08/30/2024. The section that showed the baseline care plan had been reviewed with the resident and/or representative and the space where a copy had been provided to the resident were both blank.

Resident 86 admitted to the facility on [DATE].
Review of Resident 86's Baseline Care plan form showed which staff had completed the base line care plan. There was a signature by Staff E, Registered Nurse (RN)/nurse manager (NM), on 10/23/2024. There was a signature by Staff N, dated 10/28/2024, five days after admission. The section showed the baseline care plan was reviewed with the resident and/or representative and the space where a copy had been provided to the resident was blank.

Resident 35 admitted to the facility on [DATE].
Review of the Baseline Care plan form showed a section for staff that had completed the base line care plan. There was a signature by Staff N, dated 10/16/2024, no other disciplines had completed the baseline care plan. The section showed the baseline care plan was reviewed with the resident and/or representative and the space where a copy had been provided to the resident was blank.
Review of Resident 35's Electronic Health Record (EHR) showed no documentation that a written summary of the baseline care plan was provided to the resident or their representative.

Resident 508 admitted to the facility on [DATE].
Review of the Baseline Care plan form showed a section for staff that had completed the base line care plan. There was a signature by Staff K, Social Service Director, dated 12/16/2024, no other disciplines had completed the baseline care plan. The section showed the baseline care plan was reviewed with the resident and/or representative and the space where a copy had been provided to the resident was blank.
Review of Resident 508's EHR, showed no documentation that a written summary of the baseline care plan was provided to the resident or their representative.
In an interview on 12/18/2024 at 1:55 PM, Staff H, RN/NM, stated the admission nurse initiated the baseline care plan and the baseline care plan should be done within 48 hours. Staff H stated it was social service's responsibility to set up a meeting with the family which also included nursing and therapy departments.
In an interview on 12/18/2024 at 2:09 PM, Staff B, Interim Director of Nursing, stated whomever the nurse was that completed the admission should be the one to put the baseline care plan information together within 24 hours. The admission nurse should discuss with the resident their basic care, including pain, skin, Activity of daily living (ADL) .as much as possible. Staff B stated the baseline care plan should be printed and provided and have residents or representatives sign. The signed copy of the baseline care plan should be scanned into the EHR. Staff B stated a brief care conference should be held within 24 hours and should include social service, nursing and a therapist. Staff B replied they did not see documentation that Resident 28, 86, 35 or 508 had reviewed their baseline care plan with facility staff.
Refer to WAC 388-97-1020(3)(4)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Resident 40 admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease (COPD-progressive lung disease that limits airflow and makes it difficult to breath).
In an observation and interview on 12/16/2024 at 1:32 PM Resident 40 stated they needed to get their teeth pulled so they could get dentures. Resident 40 was observed to have several missing teeth, two lower teeth and no upper teeth.
In a review of Resident 40's care plan dated 11/28/2022 showed resident did not want to have dentures and did not want their diet changed.
In a review of Resident 40's admission Minimum Data Set, dated [DATE] showed the resident had mouth or facial pain, discomfort or difficulty with chewing.
In a review of Resident 40's Annual MDS dated [DATE] showed resident had no mouth or facial pain, discomfort or difficulty with chewing.
In an interview on 12/19/2024 at 1:19 PM Staff C, RN/NM stated residents are offered dental services at admission and as needed. Staff C stated residents are re-offered services when it was determined they had any dental problems or pain. Staff C stated they did not know the last time dental services were discussed with Resident 40.

Resident 9 admitted to the facility on [DATE] with diagnoses that included stoke, hearing loss, and diabetes mellitus 2 (disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves).
In an interview and observation on 12/16/2024 at 2:37 PM, Resident 9 was in their room laying in their bed. When attempted to speak with Resident 9, they pointed to a white board/dry erase board, sitting on their bed side table and stated the pen did not work. A new dry erase pen was provided from Staff C, RN/Nurse Manager.
Review of Resident 9's progress notes from 12/01/2024 through 12/18/2024 showed they frequently refused use of their hearing aids. No other information was provided about the reason for the refusals.
Review of Resident 9's care plan dated 07/29/2024 showed they had a communication problem related to a hearing deficit and just obtained hearing aids. The goals for Resident 9 included they would be able to make their needs and wants known by verbal communication and tolerate wearing their hearing aids throughout the day. Resident 9 would be assisted daily with placement of their hearing aids in the morning and removal at the night. There was no intervention in Resident 9's care plan regarding the use of a dry erase board for communication.
In an interview on 12/19/2024 at 9:27 AM, Staff P NAC stated they know how to care for a resident by reviewing the care plan, information provided to them from the nurse or other aides.
In an interview on 12/19/24 01:23 PM, Staff C stated Resident 9 was able to communicate if speaking directly in front of them. Staff C stated the resident used the dry erase board infrequently, did not know how the dry erase board was implemented. Staff C stated the resident had hearing aids and heard just fine with them, but often declined to wear them because they heard more than what they wanted.

Resident 83 admitted to the facility on [DATE] with diagnoses that included stroke and heart failure.
Review of Resident 83's care plan dated 12/05/2024 showed the resident had bladder incontinence related to their disease process and was at risk for infections, skin breakdown and was being treated for a urinary tract infection. The goals on Resident 83's care plan included no skin breakdown and resolution of a urinary tract infection. Interventions included changing the resident every two hours and as needed in addition to establishing a voiding pattern.
Review of Resident 83's electronic medical record showed no information about establishing a voiding pattern.
In an interview on 12/19/2024 at 1:25 PM Staff C stated updating care plans was a process that includes the interdisciplinary team. Staff C stated the care plan for Resident 83 needed to be updated as they were beyond finding a pattern to voiding given Resident 83 was incontinent of urine.
In a joint interview on 12/20/2024 at 10:48 AM, Staff A, Administrator and Staff B, Interim DNS both stated they were unaware of the concerns with implementation and revision of resident's comprehensive care plans.
Refer to WAC 388-97-1020(5)(b)
Based on observation, interview, and record review the facility failed to review and revise care plans for 1 of 2 sampled residents (Resident 69) reviewed for activities of daily living (ADLs), 1 of 1 sampled residents (Resident 75) reviewed for discharge planning, 1 of 2 sampled residents (Resident 9) reviewed for communication, 1 of 4 sampled residents (Resident 18) reviewed for dementia care, 1 of 1 sampled residents (Resident 40) reviewed for dental services, and 1 of 1 sampled residents (Resident 83) reviewed for urinary management. These failures placed the residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life.
Findings include .
Review of the facility policy titled, Comprehensive Care Plans, dated February 2023, showed that the facility will develop and implement a comprehensive person centered care plan for all residents, consistent with resident rights, that include measurable objectives and timeframes to meet the needs, comprehensive care plan will be revised and reviewed by the interdisciplinary team after each comprehensive and quarterly assessment, objectives will be used to monitor the residents progress, and alternate interventions will be documented as needed.

Resident 18 admitted to the facility on [DATE] with diagnoses to include Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions). According to the quarterly Minimum Date Set (MDS- an assessment tool) assessment dated [DATE], Resident 18 had severely impaired cognition.
In a record review on 12/17/2024, Resident 18's care plan under focus revised 09/09/2022, showed that Resident 18 and Power of Attorney (POA) wished the resident to remain on the memory care unit at the facility and only be asked about returning to the community on comprehensive assessments. The facility no longer has a memory care unit.
In a record review on 12/17/2024, Resident 18's care plan under focus stated resident was high risk for falls related to history of recurrent falls and unaware of safety needs, revised on 06/05/2024. Under the intervention it showed Resident 18 required a fall mat to the left side of the bed (door side), this was revised 09/05/2023, a four Wheeled [NAME] (4WW) at bedside and in common areas to remind resident to use it, this was revised on 1/01/2023.
In an observation on 12/17/2024 at 1:30 PM, Resident 18 was in bed with eyes closed, no floor mat on the floor and did not see a 4WW in the room.
In an interview on 12/18/2024 at 1:58 PM, Staff F, Nursing Assistant Certified (NAC), stated that Resident 18 was total assist with all their care needs. Staff F stated that resident had not walked since they started working at the facility and had not used floor mat on the floor when resident was in bed.
In an interview on 12/19/2024 at 9:55 AM with Staff G, NAC, stated that Resident 18 required total assist with their care needs. Staff G stated resident no longer walked and does not use 4WW. They also stated that they don't place the floor mat on the floor when resident was in bed.
In an interview on 12/19/2024 at 2:00 PM Staff E, Registered Nurse (RN)/ Nurse Manager (NM) stated that when there were changes or updates on resident's care, they were required to update the care plan as soon as possible. Otherwise, they review care plans quarterly and yearly. They were unsure why Resident 18's care plan was not updated.
In an observation on 12/19/2024 at 2:15 PM, Resident 18 was in bed asleep, no floor mat and did not see a 4WW in the room.

Resident 69 admitted to the facility on [DATE]. According to the quarterly MDS assessment dated [DATE], resident was cognitively intact.
In an interview on 12/16/2024 at 10:12 AM, Resident 69 stated that the staff brings their dinner and place it on their table and leave without waking resident up.
In a record review with a print date 12/17/2024, Resident 69's care plan under intervention for Restorative showed, NAC Restorative Aide (RA) Program: Eating/Swallowing Program; set up, assure upright for meals, remains upright 20-30 minutes after meals, cues/assist to eat/drink slowly, to take small bites/sips, to swallow before taking another bite/sip, to alternate liquids, solids, temps, textures, to take on bite/sip at a time. Monitor for food pocketing and safe swallow. Notify LN if frequently coughs, monitor intake, provide meal replace for poor intake per protocol. Document total # minutes with eating program throughout shift. Date initiated was 08/18/2023.
In an observation on 12/17/2024 at 12:42 PM, Resident 69 was observed lying on their bed with their lunch tray on their table with half drank milk and an empty bowl.
In interview on 12/18/2024 at 10:45 AM, Staff I, Restorative Assistant (RA) stated that they had not assisted Resident 69 with meals and resident was not on Eating/Swallowing Program.
In an interview on 12/18/2024 at 1:30 PM, Staff E stated that Resident 69 was no longer on Restorative Feeding Program and that they would update the care plan.

Resident 75 admitted to the facility on [DATE] with diagnoses to include bilateral (both) below the knee amputation. According to the quarterly MDS assessment dated [DATE], resident was cognitively intact.
In an interview on 12/16/2024 at 2:12 PM, Resident 75 stated their goal was to return to the community. They stated no one at the facility had discussed their discharge plan with them.
In a review of Resident 75's care plan on 12/19/2024 showed no focus area for discharge planning.
In a joint interview on 12/19/2024 at 1:49 PM, Staff N, Social Services Assistant and Staff S, Social Services, Staff S reported they had not discussed discharge planning with Resident 75. Staff N reported they spoke with DSHS (Department of Social and Human Services) case manager in April 2024 when they admitted to the facility and had not followed-up on a plan since then.
During an interview on 12/19/2024 at 2:45 PM, Staff B, Interim Director of Nursing Services (DNS), stated social services were responsible for resident discharge planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 82) reviewed for blood sugar (BS) monitoring received BS checks per standards of practice/care. This failure exposed residents to an increased risk of inaccurate insulin administration and the potential for decreased blood sugar.
Finding Included .
A review of the facility policy, titled Timely Administration of Insulin, dated June 2020, stated that insulin administration will be coordinated with mealtimes and snacks.
Resident 82 admitted to the facility on [DATE] with diagnoses to include diabetes type 2 (a chronic disease that occurs when the sugar level in the blood stream was too high.)
In an observation and interview on 12/19/2024 at 12:56 PM, Staff Q, Licensed Practical Nurse (LPN) assessed Resident 82's BS after they had eaten their lunch. Staff Q then administered sliding-scale (an insulin prescription that adjusts the amount of insulin a person receives based on their blood sugar level) insulin (medication injected into the skin to help regulate blood sugar levels) to the resident. Staff Q stated they needed to administer Resident 82's insulin and nothing more.
Record review of Resident 82's Medication Administration Record (MAR) for December 2024 showed six units (measurement for insulin) of insulin was administered on 12/19/2024, based on their sliding scale BS level of 292.
In an interview on 12/19/2024 at 2:10 PM Staff R, LPN, stated Resident 82's sliding scale insulin needed to be administered even after they had eaten, and the provider would not need to be notified.
In an interview on 12/19/2024 at 2:20 PM, Staff E, Registered Nurse (RN)/Nurse Manager, stated when a resident had their BS taken after they had eaten, the nurse was to notify and obtain guidance from the provider.
In an Interview on 12/19/2024 at 2:45 PM, Staff B, Director of Nursing Services (DNS), stated the provider should be notified and asked for guidance if a BS was checked after a meal.
In an interview on 12/19/2024 at 3:00 PM, Staff C, RN/Nurse Manager, stated when a BS was taken after a resident had eaten, then the sliding scale insulin would be administered, and a note placed in the resident record to show the BS was taken after the meal.
Refer to WAC 388-97-1620(2)(b)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Residents 1 and 2), who resided on a secured Special Care Unit (SCU), were free from sexual abuse. Resident 2 experienced pyshcosocial harm in the form of emotional distress, applying the reasonable person approach, when the facility failed to prevent sexual activity between two residents with cognitive deficits who were unable to consent to sexual relations. This failure placed all residents on the unit at risk of unwanted sexual contact, injury and psychological harm.
Findings included .
Review of an undated facility policy, titled, Special Care Unit, showed the unit provided a safe environment for independent ambulation or wheelchair mobility for residents with poor safety judgement such as a resident who wandered into other resident's rooms.
Review of a facility policy, titled, SCU Admission, Transfer, Discharge, revised date 10/11/2021, showed the unit was intended to provide a structured and secure environment for residents with dementia (a condition with impairment of memory and decision-making ability).
Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 02/03/2023, showed sexual abuse, is defined as non-consensual sexual contact of any type with a resident.
<RESIDENT 1>
Resident 1 admitted to the facility on [DATE] with diagnosis of dementia.
Review of the census tab in the electronic record showed Resident 1 resided in the South unit (SCU) from 04/03/2024-04/17/2024. The resident was moved to the SCU due to wandering/elopement behaviors.
Review of the admission Minimum Data Set, (MDS, assessment of resident's abilities and medical conditions), dated 03/19/2024, showed Resident 1 had a BIMS (cognitive function test) score of four which meant they had severe cognitive impairment and required supervision to propel their wheelchair and walk 10 feet.
Review of Resident 1's current care plan, showed a focus area for altered thought processes initiated on 03/23/2024 with an intervention of cue, reorient and supervise as needed. There was a focus area for Behavior problem of hypersexuality-asking others to have sex with them initiated on 04/29/2024 with an intervention for 1:1 monitoring that was initiated on 04/29/2024.
Review of a progress note, dated 04/17/2024 at 11:20 PM, showed Resident 1 was moved to the North Unit (a non-secure unit) from the South unit (SCU) at 3:00 PM. The nurse documented the resident was forgetful and confused.
During an interview on, 04/22/2024 at 3:57 PM, Resident 1 was observed sitting in their wheelchair in the hallway outside of their room and an interview was attempted. Resident 1 was not able to give any details about an incident with Resident 2 and stated they did not know why they had been moved from the previous unit (SCU).
Review of a progress note, dated 04/22/2024 at 10:30 AM, showed Resident 1 was in another resident's room and told staff that the other resident was their sister.
Review of a progress note, dated 04/25/2024 at 10:30 AM, showed Resident 1 came to the activity office several times, raised their eyebrows, and told the staff member hello gorgeous. When the staff member told Resident 1 that was not appropriate communication, Resident 1 swore at the staff member and left the office.
Review of a progress note, dated 04/29/2024 at 2:39 PM, showed Resident 1 asked staff if they had sex with someone would that get them kicked out of here (facility). This was reported to the administrator and the resident was then placed on 1:1 monitoring.
Review of a behavioral health services note, dated 04/29/2024, showed that Resident 1's immediate recall was impaired (remembered zero of three items,) and that their judgement and insight were limited. The note showed they recommended close monitoring of behaviors.
<RESIDENT 2>
Resident 2 admitted to the facility on [DATE] and resided on the SCU. Resident 2 had a diagnosis of dementia.
Review of the Quarterly MDS assessment, dated 03/22/2204, showed Resident 2 had severe cognitive impairment and was rarely understood.
Review of Resident 2's current care plan showed a focus area of wandering, initiated on 10/11/2023, and impaired cognitive function with impaired decision making, initiated on 09/30/2023. The care plan was updated on 04/17/2024 with the addition of disrobing to the focus area and interventions of redirect, assist with clothing, and provide privacy when behavior occurs was added to the care plan on 04/18/2024.
During an interview on 04/22/2024 at 4:10 PM, Staff F, Licensed Practical Nurse (LPN)/Nurse manager, stated Resident 2 liked to hold hands with others.
During an interview on 04/22/2024 at 4:16 PM, Staff G, LPN, stated that Resident 2 sometimes would hold other peoples' hands.
During an interview on, 04/22/2024 at 4:34 PM, Resident2 was observed lying in bed with no clothes covering their legs and pants were noted on the floor at the bedside. An interview was attempted but Resident 2 was not able to give any details about an incident with Resident 1. Resident 2 shrugged their shoulders to one question and stated I don't know to another.
<SEXUAL ABUSE>
Review of a facility risk management system document, labeled other, dated 04/16/2024, showed Resident 1 was found in Resident 2's bed and both residents were naked.
Review of a witness statement included with the risk management system document showed Staff C, hospitality aide, found both residents in bed together. Staff C had documented that Resident 1 had reported they had the hots for (Resident 2) earlier. The statement showed Staff C observed Resident 1 providing oral sex to Resident 2.
Review of Resident 2's progress note, dated 04/16/2024 at 8:20 PM, showed Resident 2 was in their bed with another resident and they were both naked. The note showed Resident 2 was tearful for a short while after the incident.
During an interview on 4/22/2024 at 4:16 PM, Staff D, Registered Nurse (RN), stated they entered Resident 2's room after Staff C reported the two residents were naked in bed together. Staff D stated Resident 1 was putting on their clothes and reported it was all their (Resident 1's) fault. Staff D stated Resident 2 was capable of disrobing and getting into bed without assistance. Staff D stated they were in the hallway near Resident 2's room when the incident occurred but had their back to that room, so they did not see Resident 1 enter the room.
During an interview on 04/29/2024 at 3:47 PM, Staff C stated they had gone to check on Resident 1 and they were not in their room. Staff C stated they looked for the resident and found them in Resident 2's room. Staff C stated they observed both residents were naked. Resident 2 was lying in bed and Resident 1 was hunched over Resident 2, providing oral sex.
During an interview on 04/29/2024 at 4:22 PM, Staff E, Assistant Director of Nursing Services/ RN, stated both Resident 1 and Resident 2 were cognitively impaired and not able to consent to sexual activity. Staff E stated that Resident 1 had been seen by a behavioral health professional and they reported Resident 1 did not have the cognitive ability to not attempt sexual behavior with other residents, so Resident 1 was placed on 1:1 monitoring.
Refer to WAC 388-97-0640 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 1 of 2 residents (Resident 48) reviewed for hospitalizations. This failed practice placed residents at risk for lack of knowledge regarding the right to hold their beds while they were at the hospital.
Findings included .
A review of Resident 48's nursing progress notes and admission/discharge history notes, showed the resident discharged from facility to the hospital on [DATE] and returned to the facility on [DATE].
Review of Resident 48's medical records revealed no documentation the resident or the resident's representative had been provided with a written bed hold notification at time of discharge or within 24 hours of discharge.
In an interview on 10/31/2023 at 9:12 AM, Staff L, Registered Nurse/Resident Care Manager, stated the nurse sending a resident to the hospital was responsible to notify the resident and/or the resident's representative and complete a bed hold policy agreement assessment at the time of discharge. Staff L stated social service was to follow up the next day with the resident or their representative. Staff L stated Resident 48 was sent to the hospital on [DATE] and no bed hold had been completed.
In an interview on 10/31/2023 at 9:40 AM, Staff F, Social Service Assistant, stated a social service staff member usually followed up with the resident's representative the day after discharge, if the resident has not returned from the hospital. Staff F stated there was no documentation a bed hold was completed for Resident 48.
Refer to WAC 388-97-0120 (4)(a-c)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an updated Pre-admission Screening and Resident Review (PASRR - a screening tool used to determine if a person has an intellectual disability or has indicators for serious mental illness) for 1 of 5 residents (Resident 73) reviewed for PASRR accuracy who required a Level II evaluation (Level II evaluation - more in depth mental health evaluation than the screening PASRR) due to a new mental health diagnosis. This failed practice placed the resident at risk of not receiving specialized mental health services, for unidentified needs, and for a decrease in their quality of life.
Findings included .
Review of the facility policy titled Resident Assessment - Coordinator with PASRR Program, undated, showed that any resident that shows newly evident or a possible mental health disorder would be referred promptly to the state mental health authority for a Level II resident review.
Resident 73 was admitted to the facility on [DATE] with diagnoses to include a major depression disorder.
Review of Resident 73's admission Minimum Data Set (MDS) (MDS - an assessment tool) assessment, dated 04/19/2021, showed Resident 73 had severe cognitive impairment and an active diagnosis of depression.
Review of Resident 73's clinical record showed the resident had a diagnosis of vascular dementia (vascular dementia - changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels) since 10/01/2022, and they had a diagnosis of psychosis (psychosis - when a person perceives or interprets reality in a very different way from the people around them) since 10/17/2022.
Review of Resident 73's medical records showed a PASRR form, dated 04/06/2021, for a Level I (Level I - initial PASRR screening form/tool). The resident was determined to not qualify for a Level II at that time, due to no indicators or diagnosis of psychosis. The medical records showed no update was sent to the mental health authority for a Level II when the resident had a change in behavior and when they were given a diagnosis of psychosis.
In an interview on 10/31/2023 at 10:28 AM, Staff F, Social Service Assistant, stated when a resident was admitted to the facility, they reviewed the PASRR for accuracy. Staff F stated if a resident was to obtain a new mental health diagnosis, have new behaviors, or start on a new psychotropic medication (medications administered to treat mental health disorders) they would resubmit the PASRR for review. Staff F was unable to offer any information as to why Resident 73's PASRR was not reviewed or resubmitted to the mental health authority for additional review.
In an interview on 10/31/2023 at 12:56 PM, Staff A, Administrator, stated they were unaware that Resident 73 had not had their PASRR reviewed or resubmitted. Staff A stated they met monthly to review psychotropic medications, and the PASRR was not an item that had been discussed for the residents.
Refer to WAC 388-97-1975(9)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs of 2 of 4 residents (Resident 86 and 32) reviewed for care planning. This failure placed residents at risk for weight loss, inadequate tube feeding (a flexible tube placed into the stomach to help get nutrition when a person was unable to eat) management, unmanaged pain, not honoring resident's preferences, not receiving necessary care and services, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Comprehensive Care Plans, dated February 2023, showed the care planning process is to develop and implement a comprehensive person-centered care plan (a means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives) for each resident within 21 days of admission. All Care Assessment Areas (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned) triggered by the Minimum Data Set assessment (MDS - an assessment tool), will be considered in developing the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.

Resident 86 admitted on [DATE] with diagnoses to include stroke with dysphagia (difficulty swallowing). According to the 10/02/2023 admission MDS assessment, the resident received 25% or less nutrition through a feeding tube and was on a mechanically altered diet (foods are mechanically altered by whipping, blending, grinding, chopping, or mashing so that they are easy to chew and swallow.) The resident had moderate pain and received pain medications as needed along with non-medication interventions for pain.
Review of the 10/02/2023 pain CAA's, showed Resident 86 stated they had chronic right hip pain. The feeding tube CAA showed the resident was able to tolerate oral nutrition with a mechanically altered minced and moist diet.
In an interview on 10/24/2023 at 2:05 PM, Resident 86 stated to help relieve their pain they used topical pain medication and Tylenol, but it was not going to be enough. The resident stated they wanted to talk to the social service again as they had wanted the tube feeding only temporarily and they didn't want to live like this.
Review of a social service progress note, dated 10/24/2023 at 2:52 PM, showed Resident 86 reported they would like to go on hospice services. The resident did not want to continue receiving nourishment and wanted to be comfortable and felt it was time to start on hospice.
Review of Resident 86's care plan, print date 10/25/2023, showed the resident had a G-tube (type of feeding tube). The interventions directed nurses to check for tube placement and gastric contents/residual volume (residual volume - volume of gastric contents in the stomach) per facility protocol. Hold tube feeding if greater than (SPECIFY) cubic centimeter (cc) aspirate (drawn up contents). There was no volume specified. The care plan showed the resident prefers care (FREQ/TIME) and did not specify the frequency or time. The care plan did not include the resident's goals and desires to be off the tube feeding. The pain care plan did not specify where the pain was located or include the resident's goals for pain relief.
In a joint interview on 10/30/2023 at 2:45 PM, Staff E, Registered Nurse (RN), said the nurses on the floor did not revise the care plans. Staff A, Administrator, said the Director of Nursing Services (DNS), Assistant DNS and unit managers were responsible for the care planning.

Resident 32 admitted to the facility on [DATE] with diagnoses including depression, diabetes, and low nutritional levels (had low potassium and magnesium levels in their blood).
Review of Resident 32's admission nutritional assessment, dated 09/15/2023, showed the resident's admission weight to be 100.2 pounds (lbs.), had a moderate decrease in food intake, and had a weight loss of greater than 6.6 lbs. in the last three months. The assessment determined the resident was malnourished.
Review of the admission MDS assessment, dated 09/23/2023, showed Resident 32 had moderate cognitive impairment and had no refusals of care.
Review of Resident 32's care plan, dated 09/25/2023, showed the resident had a nutritional problem. Interventions were diet as ordered and for the registered dietician to follow. The care plan was not resident-centered and individualized.
In an interview on 10/30/2023 at 9:58 AM, Staff K, RN, stated the nurse manager would usually be the one to update the care plan. Staff K stated if there was an issue in the moment that it needed to be added immediately, they notify the nurse manager right away to add it on.
In an interview on 10/30/2023 at 12:50 PM, Staff L, RN/Nurse Manager, stated when a resident first admitted to the facility, the MDS nurse would start the care plan, and then they would check the care plan quarterly to ensure accuracy. Staff L stated Resident 32 had been refusing meals when they first admitted due to the admission diet order, they made some changes and completed a risk and benefits assessment with the resident and their power of attorney. Staff L stated the resident preferred chicken noodle soup with every meal. Staff L was asked to review the resident's nutritional care plan and they stated it was not resident-centered or individualized for Resident 32.
In an interview on 10/31/2023 at 12:56 PM, Staff A said the expectation was the care plans were resident-centered and updated.
Refer to 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 review and revise care plans for 2 of 5 residents (Resident 53 and 57) reviewed for care planning. These failures placed the residents at risk for unmet care needs, adverse health effects and a diminished quality of life.
Findings included .
Review of the facility policy titled Comprehensive Care Plans, dated February 2023, showed the care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS - an assessment tool) assessment. The policy did not include care plan revisions for changes in the residents' conditions.

Resident 53 admitted on [DATE] with diagnoses to include a stroke resulting in left side weakness and paralysis.
Review of Resident 53's admission MDS assessment, dated 10/16/2023, showed the resident had an indwelling catheter (a tube inserted into the urinary bladder to drain urine).
Review of Resident 53's treatment administration records (TAR) for October 2023, showed the catheter was removed on 10/25/2023 and the staff were to measure post void residual (PVR - amount of urine remaining in the bladder after a person urinates) every shift for three days and notify the provider if the amount was greater than 350 cubic centimeters (CC).
Review of Resident 53's care plan, dated 10/27/2023, showed the resident had an indwelling catheter related to skin breakdown. The care plan was not revised to include the discontinuation of the catheter or the new orders to measure for PVR.
In an interview on 10/27/2023 at 12:00 PM, Resident 53 stated they were thankful their catheter had been removed.
In an interview on 10/30/2023 at 1:00 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated anyone could revise the care plans.
In a joint interview on 10/30/2023 at 2:45 PM, Staff E, Registered Nurse (RN), said the nurses on the floor did not revise the care plans. Staff A, Administrator, said the Director of Nursing Services (DNS), the Assistant DNS and unit managers were responsible for the care planning.
In an interview on 10/31/2023 at 12:56 PM, Staff A said the expectation was that care plans were revised when there were changes.

Resident 57 admitted to the facility on [DATE], and most recently had readmitted on [DATE] with diagnoses to include Alzheimer's Disease (progressive disease that destroys memory and other important mental functions) and peripheral vascular disease (a disease of the blood vessels).
Review of Resident 57's progress notes, dated 03/22/2023, showed they were seen by a wound care specialist and the plan of care was updated for them to wear a Skil-Care Heel Boot (a type of heel protector boot that relieved pressure) on their right lower extremity when in bed.
Review of Resident 57's TAR for June 2023 showed they had an order for a Skil-Care Heel Lift Boot that directed the nursing staff to assure that Resident 57 had the boot on while in bed every shift for protection. The order was started on 03/22/2023 and discontinued 06/26/2023.
Review of Resident 57's care plan, dated 07/05/2023, showed they had ulcers of the right anterior, posterior, and lateral lower leg. One of the interventions included the resident wearing a Skil-Care Heel Boot on their right foot while in bed for protection.
Review of Resident 57's wound care progress note, dated 08/30/2023, showed there was no order or recommendation for them to use a Skil-Care Heel Boot to their right foot.
Review of Resident 57's Kardex (a resident-specific guide for nursing assistants to provide care) showed that nursing assistants were to assure the resident had a Skil-Care Heel Lift Boot on their right foot while in bed for protection.
In observations on 10/26/2023 at 9:02 AM, 10/26/2023 at 4:05 PM, and 10/27/2023 at 9:06 AM, Resident 57's was observed to be in bed with only a yellow non-skid sock on their right foot. There was no Skil-Care Heel Lift Boot on their right foot.
In an interview on 10/31/2023 at 12:05 PM, Staff Y, RN, stated Resident 57 had wound care to their right lower leg three times a week. Staff Y stated the resident was no longer being seen by the wound healing specialists due to the resident being on hospice services. Staff Y stated the interventions to address their wound on their right lower extremity were offloading, repositioning, and ongoing wound care three times a week. Staff Y stated that the Skil-Care Heel Lift Boot was discontinued a long time ago and should have been removed from the resident's care plan. Staff Y stated they would be updating the care plan right then.
Refer to WAC 388-97-1020 (2)(a)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oral hygiene was performed for 1 of 1 resident (Resident 33) reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor oral hygiene, dental complications, decreased self-esteem, and diminished quality of life.
Findings included .
Resident 33 admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (progressive disease that destroys memory and other important mental functions).
Review of Resident 33's care plan, dated 07/11/2023, showed the resident had their own teeth and required total assistance with oral care.
Review of Resident 33's Documentation Survey Report v2 (a comprehensive report that detailed cares provided for a resident) for October 2023, showed Resident 33's oral hygiene was not completed on 10/11/2023 day and evening shift. On 10/15/2023 Resident 33 was noted to be independent with their oral hygiene.
In an interview on 10/24/2023 at 11:23 AM, Collateral Contact 5 (CC5), (Resident 33's Power of Attorney), stated they did not know if staff were brushing Resident 33's teeth. CC5 stated when Resident 33 was residing at home, they were unaware of what a toothbrush was or how to use it.
Observation on 10/26/2023 at 8:57 AM, observed Resident 33 in their bed with the head of the bed elevated and they were observed with discolored front teeth with white debris in between them. There was no toothbrush at either sink within the room or in Resident 33's closet.
In an interview on 10/30/2023 at 10:07 AM Staff Y, Registered Nurse (RN), stated the resident's teeth were to be brushed daily, every morning before breakfast. Staff Y stated Resident 33 was fully dependent on staff to meet all their needs.
In a joint interview and observation on 10/31/2023 at 9:09 AM, Staff DD, Nursing Assistant Certified (NAC), stated the resident was dependent on staff to meet their needs. When asked about the location of Resident 33's toothbrush, Staff DD looked throughout Resident 33's closet, bathroom, and eventually uncovered a toothbrush in the drawer of the bedside table under several pieces of paper. Staff DD stated Staff CC, NAC, was the aide assigned to Resident 33 and they would know where to find Resident 33's oral care items. Staff CC, NAC, stated they brushed Resident 33's teeth daily, after breakfast, when they worked. Staff CC stated Resident 33's oral hygiene supplies were in a kidney basin, which they were unable to locate after looking in the closet, bathroom, and Resident 33's side of the room. Staff CC stated when they had a day off and returned, they were unable to find the kidney basin with Resident 33's oral hygiene supplies.
In an interview on 10/31/2023 at 9:45 AM, Staff CC stated they had located the kidney basin with Resident 33's oral hygiene supplies, and it had been found with the roommate's belongings.
Refer to WAC 388-97-1060 (2)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly provide professional standards of care and services for 2 of 5 residents (Resident 28 and 73) reviewed for unnecessary medications and 1 of 1 resident (Resident 86) reviewed for medication management. The facility failed to obtain laboratory samples per physician orders, and to recognize low blood pressure (BP) results, reassess abnormal BP values, and notify the provider of abnormal findings. This failed practice placed residents at risk for medication complications, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Vital Signs, dated 2021, showed licensed nurses were responsible for knowing the usual range of a residents vital signs, analyzing, and interpreting routine vital signs, and notifying the physician of abnormal findings.

Resident 86 was admitted to the facility on [DATE] with cardiac diagnoses to include hypertension (high b/p) and vascular disease (disease of the blood vessels).
Review of Resident 86's 09/25/2023 through 10/29/2023 physician's orders directed the nurses to give amlodipine, lisinopril and hydrochlorothiazide (three medications used to treat hypertension) daily and hold the medication if the systolic blood pressure (SBP- the first number, called systolic blood pressure, measures the pressure in your blood vessels when your heart beats) was less than 100.
Review of Resident 86's Medication Administration Records (MARs) from 09/25/2023 until 10/29/2023, showed the following BP results pertaining to the cardiac medication administration and the medications were not held per the physician orders:
- On 09/26/2023, the BP was 112/44.
- On 09/27/2023, the BP was 116/40.
- On 09/29/2023, the BP was 135/38.
- On 10/02/2023, the BP was 128/39,
- On 10/04/2023, the BP was 153/47.
- On 10/05/2023, the BP was 133/46.
- On 10/07/2023, the BP was 118/40.
- On 10/08/2023, the BP was 128/38.
- On 10/13/2023, the BP was 126/43.
- On 10/15/2023, the BP was 134/36.
- On 10/18/2023, the BP was 136/48.
- On 10/19/2023, the BP was 128/46.
- On 10/20/2023, the MAR showed NA (not applicable) for the medication but there were no documented vital signs or documentation as to why the BP was not assessed.
- On 10/22/2023, the BP was 111/43.
- On 10/23/2023, the BP was 126/40.
- On 10/24/2023, the BP was 134/40.
- On 10/27/2023, the BP was 122/40.
- On 10/28/2023, the BP was 112/38.
- On 10/29/2023, the BP was 108/38.
Review of Resident 86's medical record showed no further assessment or evidence that vital signs were re-assessed. There was no documentation or physician notification when the diastolic blood pressure readings were low.
In an interview on 10/30/2023 at 12:17 PM, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, stated it was their expectation nurses held BP if the systolic was under 100 and diastolic was less than 60. CC 2 said they did not review all the vital signs on their visits and expected the nurses to inform them of held doses or trends. CC2 looked at the BP recorded since admission and said it would have been reasonable to hold those doses and let them review the readings. CC2 said they would now decrease one of the medications. CC2 said the nurses had not informed them of the low diastolic readings.
In an interview on 10/30/2023 at 12:30 PM, Staff G, Nursing Assistant Registered (NAR), stated they took BP's using an automatic cuff. They stated if the systolic was over 145, they would take the BP manually. They said they would report abnormal readings to the nurse.
In an interview on 10/30/2023 at 12:43 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager, reviewed Resident 86's BP's since admission. Staff D said they were unaware of the diastolic BP's in the 30's and 40's. They stated they would expect the nurse to recheck the BP and notify the provider of the low diastolic readings.
In an interview on 10/30/2023 at 12:55 PM, Staff E, Registered Nurse (RN), stated the providers did not set parameters for the diastolic readings. Staff E said they would recheck the BP if there was a low BP's. Staff E said they tried to go back and document the new BP. they would recheck the BP if there was a low BP's.
RESIDENT 28
Resident 28 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (mood disorder with episodes of mania-depression), anxiety, and depression.
Review of the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 08/03/2023, showed Resident 28 had severe cognitive impairment.
Review of Resident 28's physician order, dated 10/18/2021, showed a laboratory (lab) order to have the residents comprehensive metabolic panel (CMP a test that measures 14 different substances in the blood) to be drawn every six months in October and April.
Review of Resident 28's electronic medical record and electronic treatment record (EMAR/ETAR) since admission on [DATE], showed no record a CMP had been drawn for the resident.
RESIDENT 73
Resident 73 was admitted to the facility on [DATE] with diagnoses to include psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality), dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and depression.
Review of the Quarterly MDS assessment, dated 08/15/2023, showed Resident 73 had severe cognitive impairment.
Review of Resident 73's physician order, dated 06/14/2023, showed an order for a lipid (fat compound stored in our blood cells) panel test, A1c test (blood test that shows blood sugar level of time), and Vitamin D level lab draw. The order read to be done once a year starting on 08/01/2023.
Review of Resident 73's EMAR/ETAR for 08/01/2023 through 10/30/2023, showed no record the labs had been done.
In an interview on 10/30/2023 at 12:50 PM, Staff L, Registered Nurse/Nurse Manager, stated the labs orders would usually be placed on the EMAR/ETAR for the nurse to sign off on. Staff L stated they would investigate if Resident 28 and Resident 73 had their labs completed.
In an interview 10/31/2023 at 9:36 AM, Staff L stated there were no record the labs order had been completed for Resident 28 and Resident 73.
In an interview on 10/31/2023 at 12:56 PM, Staff B, Director of Nursing Services, stated the expectation was labs were completed as orders and was unaware the labs had not been done for Resident 28 and Resident 73. No additional information was provided.
Refer to WAC 388-97-1060(1)(3)(k)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the occurrence of avoidable Pressure Ulcer/Pressure Injury (PU/PI) for 1 of 4 sampled residents (Resident 32) who was admitted without a PU/PI and had multiple co-morbidities with an increased risk for PU/PI development. Resident 32 experienced harm when they developed a Stage 3 (defined as full thickness loss of tissue) PU/PI to the resident's coccyx (tailbone region). The facility did not document refusals to reposition, or recognize the need to evaluate/modify the interventions to prevent a PU/PI when Resident 32 was non-compliant with repositioning. Thes failures placed other residents at risk for developing PU/PI's, medical complications, and unmet care needs.
Findings include .
Review of the Minimum Data Set (MDS), an assessment tool, 3.0 Resident Assessment Instrument manual, dated 2019, shows a PU defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. A stage 3 PU is defined as full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (non-viable [dead] tissue) may be present but does not obscure the depth of tissue loss.
Review of the facility policy titled, Skin Integrity - Skin Tears and Pressure Injury, undated states that the facility will manage in accordance with professional standards of practice to prevent PU/PI. The attending physician will assume responsibility for the overall care and treatment of the residents wound, with referral to wound care specialist. The facility will notify the attending physician of the progression of the wound or lack of healing. The interventions will be modified in the resident's plan of care if the resident is non-compliant.
Resident 32 admitted to the facility on [DATE] with diagnoses including depression, heart failure, and low nutritional levels (had low potassium and magnesium levels in their blood).
Review of the admission MDS Assessment, dated 09/23/2023 showed Resident 32 had a moderate cognition impairment, had no refusal of care, required extensive assist from one person for bed mobility, transfers, ambulation, toilet use and personal hygiene. The resident was always incontinent (no voluntary control) of bowel and bladder. The resident admitted without a PU/PI and was deemed at risk to develop a PU/PI, interventions were to be a reduction mattress (a mattress to evenly disperse body weight) and topical ointment (prescribed ointment applied directly to the skin).
Review of the Braden Assessments (pressure ulcer assessment tool) for Resident 32, dated 09/15/2023, 09/18/2023, 09/26/2023, and 10/4/2023 placed the resident at risk for development of a PU/PI.
Review of the nutritional assessment for Resident 32, dated 09/15/2023 showed the resident was deemed malnourished.
Review of Resident 32's care plan with a focus, dated 09/28/2023 showed the resident had potential for development of a PU/PI related to dehydration, decreased mobility, incontinence, malnutrition, and depression. Interventions included administer treatment and monitor effectiveness, educate on repositioning, follow facility policy and procedures for prevention/treatment of skin breakdown, if the resident refused care the Interdisciplinary Team (IDT) was to determine alternative methods to gain compliance, and document the alternatives.
Review of Resident 32's skin evaluation, dated 09/26/2023 showed the residents coccyx area was red in color.
Review of Resident 32's skin evaluation, dated 10/04/2023 showed the resident's coccyx area had an open area that measured 1.6 centimeters (cm) in length by 0.8 cm wide. The evaluation stated the resident laid supine (on their back) only.
Review of Resident 32's progress note, dated 10/04/2023 at 9:38 PM, showed the resident's had developed an open area to their coccyx.
Review of Resident 32's care plan with a focus, dated 10/05/2023 showed the resident had an actual PU/PI with interventions for a pressure reduction mattress for the bed.
Review of Resident 32's progress note, dated 10/20/2023 at 7:27 PM, showed the open area to the coccyx measured 1.7cm in length by 0.5cm wide by 0.1cm in depth. Review of the Resident 32's medical records dated 10/04/2023 - 10/20/2023, showed no documentation that the open area to the coccyx had been monitored, or whether the interventions put in place were effective.
Review of Resident 32's physician orders, showed on order, dated 10/05/2023, instructed the nurse to clean the coccyx wound, apply a prescription wound treatment and cover with a secured dressing as needed.
Review of Resident 32's nursing notes or Treatment Administration Record (TAR) or electronic medical record (EMR), showed no documentation the as needed dressing had been implemented.
Review of Resident 32's physician orders, showed on order, dated 10/07/2023, instructed nursing to cleanse the coccyx wound, apply prescription wound treatment and cover with a secure dressing every Wednesday and Saturday.
Review of Resident 32's EMR, from 10/04/2023 through 10/26/2023, showed no assessment of the effectiveness of the wound treatment.
Review of Resident 32's physician orders, showed an order, dated 10/20/2023, showed a referral to the wound care specialist.
In an observation on 10/25/2023 at 9:23 AM, and 3:28 PM, Resident 32 was observed lying on an air mattress on their backside in bed where their wound was located. Resident 32 was not interviewable.
In an observation and interview on 10/25/2023 at 1:22 PM, Collateral Contact (CC) 4, Physician Assistant for the wound care specialist, was at Resident 32's bedside to assess the coccyx area wound. CC4 stated they were going to surgically debride (remove dead tissue) from the wound. CC4 stated the wound was a Stage 3, and it appeared the resident had not been repositioning from lying on their back.
Review of Resident 32's wound care specialist note, dated 10/25/2023, showed that the nursing had reported the resident had a PU/PI to the coccyx. The note stated wound has had delayed wound closure likely secondary to poor repositioning from lying on their back. The resident was encouraged to rotate sides every two hours.
In an observation on 10/26/2023 at 8:40 AM, and 9:32 AM, Resident 32 was observed lying on their back in bed.
In an observation on 10/27/2023 at 8:05 AM, 10:32 AM, and 1:07 PM, Resident 32 was observed lying on their back in bed.
In an interview on 10/27/2023 at 10:37 AM, Staff J, Nursing Assistant Certified (NAC), stated Resident 32 would refuse to reposition off their back. Staff J was unaware that the resident had a PU/PI to their coccyx area.
In an observation on 10/30/2023 at 8:58 AM, 10:22 AM, 12:14 PM, and 2:51 PM, and 10/31/2023 at 9:08 AM, Resident 32 was observed lying on their backside in bed where their wound was located.
In an interview on 10/31/2023 at 9:20 AM, Staff M, NAC, stated they had tried to place pillows under Resident 32 to reposition them, but they will refuse and throw the pillows on the ground. Staff M stated they did not document refusals of care, only verbalized to the nurse.
In an interview on 10/31/2023 at 9:27 AM, Staff N, NAC/Restorative Aide (RA) stated they tried to place pillows on Resident 32's side to reposition them, but they refuse all the time. Staff N stated when a resident refused care, they were instructed to inform the nurse, they can also chart in the electronic record as well.
In an interview on 10/31/2023 at 9:31 AM, Staff O, Licensed Practice Nurse (LPN) stated Resident 32 required encouragement to reposition. Staff O stated they were not consistent about documentation of resident refusal of care/treatment.
In an interview on 10/31/2023 at 9:36 AM, Staff L, Registered Nurse (RN)/Nurse Manager stated they notified the provider on 10/04/2023 when they first discovered the open area to the coccyx. Staff L was unaware if the provider had assessed the open area. Staff L stated they had tried to encourage the resident to reposition on of their back. Staff L was asked what was done when the resident continued to refuse the interventions in place, Staff L did not provide an answer.
In an interview on 10/31/2023 at 10:00 AM, CC2, Nurse Practitioner (NP), stated they were aware the resident had an open area to the coccyx. CC2 stated they had not discussed the status of the wound, or the ineffectiveness of the interventions that had been in place with the facility. CC2 stated they were aware that the wound care specialist had been in to assess and that the wound was a Stage 3 PU/PI.
In an interview on 10/31/2023 at 12:56 PM, Staff B, Director of Nursing Services (DNS) stated that all residents are assessed for potential skin breakdown when they are admitted to the facility. A Braden Assessment was completed, and based on the results of that interventions were put into place. Staff B stated they discussed all skin issues on a weekly basis, that was documented in the resident's medical record. Staff B stated the expectation was that if the wound had worsened the provider would be notified and modifications to the plan of care should occur. Staff B was asked if Resident 32's interventions were discussed and if there was any collaboration with the provider on the plan of care for the wound, Staff B did not offer any information.
Refer to WAC 388-97-1060(3)(b)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure services were provided to maintain, increase, and/or prevent further decrease in range of motion for 1 of 1 resident (Resident 100) reviewed for limited range of motion. This failure placed the resident at risk for a decline in their functional ability and their quality of life.
Findings included .
Review of a facility policy titled Restorative Nursing Documentation, undated, showed the facility was to maintain complete, accurate, and organized documentation of restorative treatments and the response to those treatments.
Resident 100 admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis (damaged muscles that release protein into the blood), a fall at home, and a failure to thrive (a term used to describe broad declines in multiple areas to include weight loss, decreased appetite, poor nutrition, and inactivity).
Review of Resident 100's admission Minimum Data Set assessment (an assessment tool), dated 08/25/2023, showed the resident had moderate cognitive impairment and required extensive staff assistance for activities of daily living.
Review of Resident 100's care plan, dated 09/22/2023, showed the resident had a nursing restorative program that included ambulation six to seven days a week and Nustep (bicycle) six to seven days a week.
Review of Resident 100's restorative documentation from 09/22/2023 through 09/30/2023 showed there were six days without services being performed. Review of documentation from 10/01/2023 through 10/30/2023 showed there were 18 days without services being performed.
In an interview on 10/24/2023 at 3:26 PM, Resident 100 stated they had not been receiving restorative therapy. The resident stated they wanted to participate in restorative to be able to discharge home.
In an interview on 10/30/2023 at 12:55 PM, Staff V, Restorative Assistant, stated they were frequently pulled to work the floor related to staffing shortages. Staff V stated when restorative assistant staff were pulled to the floor, residents did not receive restorative services as scheduled. Staff V stated Resident 100 was not receiving restorative services as ordered. Staff V stated Resident 100 was more alert when they received restorative services consistently.
In an interview on 10/30/2023 at 1:04 PM, Staff R, Licensed Practical Nurse/Restorative Nurse, acknowledged that Resident 100 was not receiving restorative services consistently.
In an interview on 10/31/2023 at 12:38 PM, Staff B, Director of Nursing Services, stated the expectation was for residents to receive restorative services as ordered.
Refer to (WAC) 388-97-1060 (3)(d)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 3 of 3 (Resident 53, 33, and 67) residents reviewed for urinary catheters (flexible tubes inserted into the bladder to drain urine) received the necessary care and services to achieve their optimal level of urinary function. Failure to identify the reason for a resident's treatment with a urinary catheter, to maintain documentation to support why an indwelling catheter was replaced and a trial void order was not completed as ordered, there was a lack of documentation why the physician was not notified per their physician order when there was a low urinary output, and there was a failure to documentation the facility had counseled the resident/representative of the risks and benefits of a urinary catheter. These failures placed residents at risk for infection, pain, discomfort, bleeding, and complications related to urinary catheter use, and a diminished quality of life.
Findings included .
Review of the facility policy titled, Urinary Indwelling Catheters, undated, showed an indwelling urinary catheter would be utilized only when a resident's clinical condition demonstrated the catheterization was necessary. Any resident that admitted with a urinary catheter would be assessed for removal as soon as possible . the resident and representative would be included in the discussion about indications, potential benefits, and risk .use of the urinary catheter would be in accordance with physician orders.

Resident 53 admitted on [DATE] with a diagnosis of stroke affecting their left non-dominant side. The resident did not have a diagnosis or indications for having the urinary catheter.
According to the 10/16/2023 admission Minimum Data Set (MDS -an assessment tool) assessment, Resident 53 had an indwelling catheter. Review of the Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned) for urinary catheter use showed the resident triggered for risk of a Moisture Associated Skin Disorder related to an indwelling Catheter. The resident admitted with a fungal rash and inverse psoriasis. The resident was incontinent of bowel and bladder over a year at baseline.
Review of the clinical record showed no documentation of medical justification/rationale for Resident 53's catheter.
In an interview and observation on 10/25/2023 at 8:56 AM, Resident 53 was sitting in their wheelchair at bedside. Staff I, Licensed Practical Nurse (LPN), responded to the resident's call light. Resident 53 asked Staff I when can I get this catheter out? Staff I said they would see when they could get rid of it. The resident stated it was very uncomfortable sitting with this catheter in. Resident 53 said the catheter had been in since the hospital and they didn't know why. Staff I said they did not know why the catheter was in. Staff I said one of the providers would be there today and they would ask them about discontinuing the catheter. The resident said they have never had a problem urinating.
Review of Resident 53's treatment administration records (TAR) for October 2023, showed the catheter was removed on 10/25/2023 and the staff were to measure post-void residual (PVR - amount of urine that remained in the bladder after urinating) every shift for three days and notify the provider if the amount was greater than 350 cubic centimeters (CC).
Review of Resident 53's care plan, dated 10/27/2023, showed the resident had an indwelling catheter related to skin breakdown. The care plan was not revised to include the discontinuation of the catheter or the new orders to measure for PVR.
In an interview on 10/27/2023 at 12:00 PM, Resident 53 stated they were thankful the catheter had been removed.
In an interview on 10/30/2023 at 1:00 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager (NM), said they noted on Resident 53's admission they did not have urinary retention or other indications for indwelling catheter use. Staff D said the hospital discharge summary documented the catheter was in place for a rash and the resident had said the rash was chronic. Staff D said they questioned Collateral Contact 3, Physician, about the lack of indications for the catheter and they were finally able to discontinue it.
Resident 67 originally admitted to the facility on [DATE] and most recently admitted following hospitalization from 07/30/2023 - 08/14/2023 with diagnoses to include a urinary tract infection) and the presence of indwelling urinary catheter.
Review of Resident 67's Significant Change MDS assessment, dated 08/21/2023, showed the resident had severe cognitive impairment, required extensive assist with bed mobility, toilet use, and personal hygiene, and had an indwelling urinary catheter. Review of the urinary catheter Care Area Assessment did not show a rationale or medical justification for the use of the urinary catheter.
Review of Resident 67's catheter physician orders, dated 08/14/2023, showed orders for the type, size, and management of care of the catheter and urine collection bag. The orders did not include the indications for use of the catheter. Review of the hospital Discharge summary, dated [DATE], did not show the indications for use of the urinary catheter. The orders did include an order to monitor for urinary output and to notify the physician for urinary output 250 cc (cubic centimeter) or less in 8 hours.
Review of Resident 67's care plan, dated 10/29/2023, showed the urinary catheter was used for fluid volume overload and to track urinary output. There was no documentation the risks and benefits of the use of the catheter were discussed with the resident or their representative.
Review of Resident 67's urinary output documentation from 10/01/2023 - 10/30/2023 showed documentation there were 15 shifts (8 hour periods) in which the resident's urinary output was 250 cc or less. Review of the resident's records showed no documentation the physician was notified of those 15 shifts.
In an interview on 10/30/2023 at 2:09 PM, Collateral Contact 6, Resident 67's representative, stated the use of the urinary catheter was discussed with Hospice at the hospital and it was decided to keep the urinary catheter in place for comfort.
In an interview on 10/31/2023 at 10:08 AM, Staff S, RN/NM, reviewed Resident 67's records and stated they were unable to show documentation the physician was notified of the episodes when the resident's urinary output was less than 250cc in a shift, or documentation the facility had counseled the resident or their representative of the risks and benefits of use of catheter.
Refer to WAC 388-97-1060(3)(c)

Resident 33 admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (progressive disease that destroys memory and other important mental functions).
Review of Resident 33's discharge orders, dated 06/27/2023, showed Resident 33 was ordered to have a urology consult prior to removal of their catheter due to multiple failed attempts at removal.
In an interview on 10/24/2023 at 11:26 AM, Collateral Contact 5 (CC5), Resident 33's Power of Attorney, reported that Resident 33 had a catheter placed in the hospital, had started medication to assist them in emptying their bladder, and had asked several times to have the catheter removed.
Review of Resident 33's progress notes, dated 10/25/2023, showed Staff Y, Registered Nurse (RN)/NM, had spoken to CC5 regarding removal of Resident 33's catheter for a voiding trial. Staff Y had to get an order from Resident 33's provider and would discontinue the catheter in the evening.
In an interview on 10/30/2023 at 10:00 AM, Staff Y said that Resident 33 had a catheter since they admitted . Staff Y stated that CC5 had asked twice about having Resident 33's catheter removed for a voiding trial. Staff Y stated they were unaware of any orders related to Resident 33's catheter at admission. Staff Y stated that Resident 33 had not seen a urologist prior to removal of their catheter. No other information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 32) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the resident received oxygen as it was prescribed by the physician and failed to ensure oxygen (O2) administration tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for contaminated care equipment, not receiving physician ordered services, unmet care needs and a diminished quality of life.
Findings included .
Review of the facility policy titled, Oxygen Administration, undated, showed oxygen is administered under orders of a physician. Staff were to monitor ongoing assessment of the residents' oxygen use and notify if there is a need for changes. Oxygen tubing is changed weekly and as needed if it became soiled or contaminated. Staff were to initial and date the tubing. When oxygen tubing was not in use, it is stored in a pouch.
Resident 32 admitted to the facility on [DATE] with diagnoses including respiratory failure, heart failure, and pneumonia (infection of the lungs).
Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/23/2023, showed Resident 32 had moderate cognitive impairment, had no refusal of care, required extensive assist from one person for bed mobility, transfers, ambulation, toilet use and personal hygiene.
Review of Resident 32's physician orders showed included following:
- Apply O2 (per nasal tubing - a tube from an O2 machine to nose) at two to four liters per minute continuously to keep the resident's oxygen saturation levels above or equal to 90 percent (%), start date 09/15/2023.
- Change and date the oxygen tubing twice a month, every two weeks on Friday night, start date 09/15/2023.
Review of Resident 32's care plan showed a focus area, dated 09/16/2023, the resident was on supplemental O2 related to pneumonia, and they had trouble breathing. Interventions included to encourage the resident to position themselves every two hours to promote lung movement, give prescribed medication as ordered by the physician, ensure the resident had the head of the bed elevated at least 30 degrees to improve breathing, and O2 rate at two to four liters continuously through a nasal tube.
Observation on 10/24/2023 at 9:54 AM, and 10/25/2023 at 9:23 AM, 3:28 AM, Resident 32 was observed lying flat in bed. The resident was not wearing the O2, and the tubing was observed to be lying on the floor, undated. The O2 concentrator O2 concentrator (a medical device that provides pure O2) machine was running.
Observation on 10/25/2023 at 10:34 AM, Resident 32 was observed in the activity room not wearing any supplemental O2.
Observation on 10/26/2023 at 8:40 AM, and 9:32 AM, Resident 32 was observed lying flat in bed. The resident was not wearing the O2, and the tubing was observed to be lying on the floor, undated. The O2 concentrator machine was running.
Observation on 10/26/2023 at 11:38 AM, and 1:35 PM, Resident 32 was observed in the activity room not wearing any supplemental O2.
Observation on 10/27/2023 at 8:05 AM, 10:32 AM, and 1:07 PM, Resident 32 was observed lying flat in bed. The resident was not wearing the O2, and the tubing was observed to be lying on the floor, undated. The O2 concentrator machine was running.
In an interview on 10/27/2023 at 10:37 AM, Staff J, Nursing Assistant Certified (NAC), stated Resident 32 was supposed to always be wearing the supplemental O2 and the machine should be on. If the resident refused care, they would notify the nurse.
Observation on 10/30/2023 at 8:58 AM, 10:22 AM, 12:14 PM, and 2:51 PM, Resident 32 was lying flat in bed, O2 tubing was lying at the head of the bed not on the resident and the concentrator was off.
In an interview on 10/30/2023 at 9:58 AM, Staff K, Registered Nurse (RN), stated Resident 32 sometimes would wear their supplemental O2. Staff K stated if the tubing had been on the floor the staff were supposed to switch it out for a new one and date the tubing accordingly.
In an interview on 10/30/2023 at 12:50 PM, Staff L, RN/Nurse Manager, stated Resident 32 required supplemental O2 continuously as their saturation levels would decrease quickly without it. Staff L stated if the tubing had been on the floor the staff were supposed to switch it out for a new one and date the tubing accordingly.
In an interview on 10/31/2023 at 12:56 PM, Staff B, Director of Nursing Services, was unaware Resident 32 had not received their supplemental O2 as prescribed by the physician, and the tubing had been on the floor and undated.
Refer to WAC 388-97-1060(3)(j)(vi)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an adequate rationale for not following pharmacist recommendations for 3 of 5 residents (Resident 86, 310, and 14) reviewed for unnecessary medications. This failure placed the residents at risk for experiencing the use of unnecessary medications and a potential diminished quality of life.
Findings included .

Review of the pharmacy consultant Medication Regimen Review (MRR), dated 10/12/2023, showed a request to evaluate citalopram hydrobromide (a medication used to treat depression) due to the off label/non-Food and Drug Administration (FDA) approved indication mood disorder being used. The pharmacist requested clarification if Resident 86 had a diagnosis of depression, or the medication was being used off label as mood disorder. Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner (ARNP), circled used off label for mood disorder. CC2 signed the pharmacist recommendation on 10/18/2023 as agree but did not include a written rationale for the off-label use of citalopram.
In an interview on 10/30/2023 at 12:43 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager (NM), reviewed Resident 86's consult and said they were unsure of why the provider did not include a rationale for their decision.
In an interview on 10/30/2023 at 12:17 PM, CC2 said they were informed from the pharmacist citalopram cannot be used for mood disorder, but they disagreed. CC2 said they did not know if Resident 86 had a diagnosis of depression, but it would take some research.
Resident 310 was admitted to the facility on [DATE] with diagnoses to include fractured rib, heart failure and Chronic Obstructive Pulmonary Disease (COPD) (constriction of airways and difficulty or discomfort breathing).
Review of Resident 310's Electronic Medical Record (EMR) did not show an acceptable diagnosis for the use of Seroquel (anti-psychotic medication).
Review of Resident 310's Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form, dated 10/12/2023, showed the resident did not have a diagnosis of SMI, psychotic, mood, anxiety, delusional or personality disorders.
Review of Resident 310's October 2023 Medication Administration Record (MAR), showed the resident had orders for Seroquel 25 milligrams (mg) in the afternoon to prevent agitation, initiated 10/13/2023 and Seroquel 25 mg every six hours as needed for agitation/anxiety, initiated 10/13/2023.
Review of Resident 310's MRR, dated 10/23/2023, showed the pharmacist recommended changes to the Seroquel medication order, stated that prevent agitation was not an acceptable diagnosis for the use of Seroquel. The facility provider signed and dated the recommendation on 10/23/2023 at 11:50 PM with the box checked physician notified-no new suggestions.
In an interview on 10/31/2023 at 11:04 AM, Staff F, Social Services Assistant (SSA), stated they reviewed the chart and the diagnoses for all residents admitted to the facility. Staff F stated they would be able to tell if a resident was on psychotropic medications even without a diagnosis as it shows up on their EMR dashboard alerts. Requested any documentation related to Resident 310's diagnoses for use of the antipsychotic medication Seroquel. None was provided.
In an interview on 10/31/2023 at 2:42 PM, Staff B, Director of Nursing Services (DNS), stated they would expect a more appropriate diagnosis for Resident 310's use of Seroquel. Staff B stated they were unsure why the provider would not use an acceptable diagnosis after they reviewed the MRR dated 10/12/2023 with suggestion to have an acceptable diagnosis for use of Seroquel. Staff B was unable to locate any documentation from the provider as to why they did not follow the pharmacy recommendations.

Resident 14 was admitted to the facility on [DATE] with diagnoses to include respiratory failure, heart failure, and dementia.
Review of Resident 14's PASRR evaluation, dated 09/29/2023, showed the resident had received risperidone (antipsychotic medication) nightly for sundowning (state of confusion in the late afternoon lasting into the night).
Review of Resident 14's MRR, dated 10/04/2023, showed the pharmacist suggested to change the diagnosis used for the scheduled medication risperidone or to discontinue use. The facility provider checked the box that showed no new suggestions after provider notification, signed on 10/04/2023.
Review of Resident 14's October 2023 MAR showed that Risperidone was initiated on 09/30/2023, with a diagnosis of toxic encephalopathy, dementia, discontinued on 10/03/2023. Risperidone new order started on 10/04/2023 with the same diagnoses, discontinued on 10/12/2023. Risperidone new order started on 10/12/2023 showed a diagnosis of psychosis, delusional thinking, and hallucinations.
In an interview on 10/31/2023 at 11:04 AM, Staff F stated they were unaware of Resident 14's diagnosis for use of Risperidone. Staff F stated that they would look at the Residents' diagnoses and provide any further information.
In an interview on 10/31/2023 at 2:42 PM, Staff B stated they were unaware of why there was no follow up on Resident 14's pharmacy recommendation from 10/04/2023 to include an appropriate diagnosis for use of scheduled risperidone. Staff B stated that they do not understand why a provider would not do something as simple as change a diagnosis. Staff B was unable to locate provider documentation for rationalization of why they did not follow pharmacy recommendations.
Refer to WAC 388-97-1300 (4)(c)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 4 of 5 residents (Resident 86, 14, 83, and 73) were free of unnecessary drugs due to: 1) lack of specific target behavior monitoring, 2) not obtaining the monthly orthostatic vital signs, 3) not developing and implementing non-medical behavioral interventions, and 4) not having appropriate indication, documentation, and goals for use of psychotropic medications. These failures placed residents at risk for receiving unnecessary medications and for experiencing medication-related adverse side effects.
Findings included .
Review of the Food and Drugs/Drug (FDA) Safety Information reference, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA Boxed Warning, which accompanied, second-generation anti-psychotics stated, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death.
Review of the facility policy titled, Use of Psychotropic Medication, revised 2023, showed the residents were not to be given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication.
Review of Center for Medicare and Medicaid Services (CMS) document titled, Atypical Antipsychotic Medications: Use in Adults, dated 2015, showed vascular dementia was not a qualified diagnosis for use of mood stabilizers and anti-psychotic medications.

Resident 86 admitted to the facility on [DATE] with diagnoses to include stroke with dysphagia (difficulty swallowing). Review of the admission PHQ-9 (an assessment for depression) assessment, dated 10/02/2023, showed the resident had a severity score of 12 indicative of moderate depression. The resident had no diagnosis of depression.
Review of Resident 86's 09/25/2023 through 10/31/2023 Medication Administration Records (MARs), revealed the resident received the citalopram hydrobromide daily for a mood disorder.
Review of Resident 86's Order Summary Report, for active orders as of 10/30/2023, revealed there was an order for citalopram hydrobromide to be administered daily for a mood disorder. There was an order beginning 09/25/2023 to check the resident's Orthostatic Blood Pressures (b/p's), lying, sitting, and standing, once monthly on the 25th of the month, and to document the b/p's under the vital signs tab in Point Click Care (electronic health record).
On 10/30/2023, a review of blood pressure documentation in Point Click Care, revealed no orthostatic b/p's were done in September or October 2023. There was no documentation Resident 86 refused to do orthostatic b/p's on or around September or October 25th.
In an interview on 10/30/2023 at 11:16 AM, Staff F, Social Services Assistant, stated Resident 86 was on Celexa (citalopram) for maybe pain. Staff F said they completed the PHQ-9 assessment on the resident that indicated a 12 which was moderate depression. Staff F said the process was to inform the nurse manager of the results, but they were unsure if they had done that.
In an interview on 10/30/2023 at 12:17 PM, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner (ARNP), stated they were not informed of Resident 86's PHQ-9 assessment results. When asked what the diagnosis was for the use of citalopram, CC2 said they would have to go through the resident's records to see why they prescribed the medication.
In an interview on 10/30/2023 at 12:43 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager (NM), said they thought Resident 86 was on Cymbalta (a different anti-depressant). Staff D said the pharmacist had questioned the lack of a depression diagnosis. Staff D commented the resident did cry at times. Staff D said the facility had psychotropic medication meetings, but they did not always attend them.
In an interview on 10/30/2023 at 2:11 PM, Resident 86 stated they were sleepy and didn't want to live any longer and had elected hospice services. The resident stated they had been on Celexa (citalopram) long before hospitalization for depression. They stated their provider had put them on the medication to make them feel better, but it didn't work.
In an interview on 10/30/2023 at 2:45 PM, Staff E, Registered Nurse (RN), stated Resident 86 could be tearful and they were on citalopram imagined to be for depression.

Resident 14 was admitted to the facility on [DATE] with diagnoses to include respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood), heart failure, and dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems).
Review of Resident 14's provider orders showed that they were prescribed risperidone (antipsychotic medication) 0.25 milligrams (mg) every night at bedtime, initiated 09/30/2023.
Review of Resident 14's October 2023 MAR, showed there was a medication side effects (s/e) monitor for the antipsychotic medication, initiated 10/02/2023, and nurses were to document every shift a 'y' for yes if any s/e's were observed and to chart using the 'other, see nurses notes' and provide documentation. Nurses were to document 'n' for no if no s/e's were observed.
Resident 14's antipsychotic medication s/e monitor had no place to document 'y' or 'n' and there was a checkmark for all documentation. There were no instructions documented related to a checkmark.

Resident 83 was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, and an infection after surgery to remove their gallbladder (organ beneath the liver in which bile is stored).
Review of Resident 83's provider orders showed they were prescribed quetiapine (antipsychotic medication) 25 mg every night for psychosis, initiated 08/24/2023, and mirtazapine (antidepressant medication) 7.5 mg every night at bedtime.
Review of Resident 83's 08/01/2023 through 10/31/2023 MAR's, showed there was a medication s/e's monitor for the use antipsychotic medication, initiated 08/27/2023, and a monitor for s/e's for the use of the antidepressant medication, initiated on 09/09/2023. Side effect monitor orders showed nurses were to document every shift a 'y' for yes if any s/e's were observed and to chart using the 'other, see nurses notes' and provide documentation. Nurses were to document 'n' for no if no s/e's were observed. Resident 14's MAR had no place to document 'y' or 'n' and there was a checkmark for all documentation. There were no instructions indicating what a checkmark meant.
In an interview on 10/31/2023 at 2:42 PM, Staff B, Director of Nursing Services (DNS), stated their expectations were that all psychotropic medications required monitors would have all components, including the supplementary documentation. Staff B stated the admission nurse and NM's should be a safety net to catch all components of the orders were implemented and documented correctly. Staff B stated the directions to document 'y' or 'n' were in the order, so there should be corresponding documentationto catch all components of the orders were implemented and documented correctly.

Resident 73 was admitted to the facility on [DATE] with diagnoses to include psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality), vascular dementia, and depression.
Review of the Quarterly MDS Assessment, dated 08/15/2023, showed Resident 73 had severe cognitive impairment.
Review of Resident 73's electronic medical record and electronic treatment record (EMAR/ETAR) showed the resident had the following physician orders:
- Risperdal twice a day for psychosis, start date 02/14/2022.
- Depakote Extended Release (mood stabilizer medication that treats a mood disorder with episodes of mania-depression) twice a day for vascular dementia with agitation (inappropriate diagnoses), start date 12/15/2021.
Review of Resident 73's care plan on 10/30/2023, showed the resident was taking psychotropic medications, did not reflect the actual prescribed anti-psychotic and mood stabilizer with specific signs and symptoms, and interventions to prevent specific disorders.
Review of Resident 73's medical record showed the resident had not been offered a gradual dose reduction (GDR is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for their Depakote since 12/15/2021. The resident had received the Depakote for vascular dementia with behavioral disturbance.
In an interview on 10/30/2023 at 12:50 PM, Staff L, RN/MN, stated they were unaware vascular dementia was an inappropriate diagnosis for use of Depakote.
In an interview on 10/31/2023 at 9:36 AM, Staff L stated there was never a GDR completed for Resident 73's Depakote.
In a joint interview on 10/31/2023 at 12:56 PM, Staff C, Assistant Director of Nursing Services (ADNS), stated they meet monthly to review psychotropic medications. The residents were reviewed on the quarterly MDS schedule, as well as any new admits, and any residents with recent behavioral changes. Staff A, Administrator, and Staff B stated they were unaware Resident 73 had an invalid diagnosis for use with Depakote, and there had been no GDR offered.
Refer to WAC 388-97-1060(3)(k)(i)(4)
.

Based on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 3 (Central/South and Southeast) medication refrigerator observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency.
Findings included .
In an observation on 10/26/2023 at 1:31 PM, the thermometer in the shared Central/South medication room's refrigerator temperature was 48 degrees Fahrenheit (F). The refrigerator contained vaccines, resident medications, and over the counter medications. The refrigerator temperature form showed temperatures should range from 36 degrees F to 46 degrees F with instructions to notify maintenance if recorded temperatures are above or below range on 2 sequential readings 30 minutes apart.
Review of the shared Central/South Unit medication room refrigerator temperature log, dated 10/01/2023 through 10/26/2023, showed 20 missing readings with 10 out of range temperatures for the night shift and 7 missing readings with three out of range for the evening shift. Staff EE, Licensed Practical Nurse/admission Nurse, confirmed vaccinations were stored in the refrigerator. Staff EE stated the refrigerator required documentation of refrigerator temperatures two times daily and the missing documentation on the temperature log.
In an observation and interview on 10/26/23 at 2:18 PM, the medication refrigerator on the Southeast Unit was observed to contain vaccines and resident medications. Review of the Southeast Unit medication refrigerator temperature log dated 10/01/2023 through 10/26/2023, showed seven missing readings for the evening shift. Staff E, Registered Nurse, stated the nurse on shift was responsible for documenting refrigerator temperatures and stated there were instructions on the temperature log for temperatures that were out of range.
In an interview 10/26/2023 at 1:51 PM, Staff B, Director of Nursing Services, stated all medication refrigerator temperature logs should be completed. Staff B stated the nurse on shift was responsible for documenting refrigerator temperatures and the nurse managers should be reviewing documentation for completion. Staff B stated the vaccinations and medications may be compromised.
Refer to WAC 388-97-1300 (2)
.

Based on observation, interview, and record review, the facility failed to ensure cognitively impaired residents were fed by assistants that were properly trained for 2 of 4 sampled staff (Staff W and Staff X) observed providing feeding assistance to residents (Resident 26 and 28). This failure placed residents at risk of choking and aspiration (inhalation of food or fluid into the lungs) and a diminished quality of life.
Findings included .
In the entrance conference meeting on 10/24/2023 at 8:58 AM, Staff A, Administrator, stated they did not have any paid feeding assistants in the facility.
<STAFF W>
Review of Staff W's employee record showed they were hired on 03/16/2020. Staff W was currently employed as an activity assistant, and there was no record the staff had been trained as a paid feeding assistant.
Review of Resident 26's Minimum Data Set (MDS - an assessment too) assessment, dated 10/11/2023, showed the resident had severe cognitive impairment.
Review of Resident 26's nutritional assessment, dated 10/04/2023, showed the resident had an altered diet due to difficulty chewing with meals.
In an observation in the memory care unit on 10/26/2023 at 12:12 PM, Staff W was observed to sit at the table with Resident 26. Staff W was observed to physically assist the resident to eat by holding the spoon, gathering food onto the spoon, and placing the food into the resident's mouth. Staff W was observed to continue to assist the resident to eat their lunch for 15 minutes.
In an interview on 10/26/2023 at 1:36 PM, Staff W stated they had worked in the activity department for about six months, and previously drove the facility van. Staff W stated they primary worked in the memory care unit and would occasionally assist the residents eat their meals. Staff W stated they had not participated in a paid feeding assistant program or had any training/education at the facility regarding feeding residents. Staff W stated they were not a Nursing Assistant Certified (NAC).
<STAFF X>
Review of Staff X's employee record showed they were hired on 07/09/2012. Staff X was currently employed as the Activity Director, and there was no record the staff had been trained as a paid feeding assistant.
In an observation in the memory care unit on 10/26/2023 at 12:04 PM, Staff X was observed to sit at the table with Resident 28. Staff X was observed to physically assist the resident to eat by holding the spoon, gathering food onto the spoon, and placing the food into the resident's mouth. Staff X was observed to assist the resident to eat their lunch for 10 minutes.
Review of Resident 28's MDS assessment, dated 08/03/2023, showed the resident had severe cognitive impairment.
Review of Resident 28's medical records showed their diet was downgraded to a puree (smooth) diet per the speech evaluation dated 09/21/2023. The resident had difficulty chewing and coughing with meals.
In an interview on 10/26/2023 at 1:51 PM, Staff X stated they had not participated in a paid feeding assistant program or had any training/education at the facility regarding feeding residents. Staff X stated they were not a NAC.
In an interview on 10/26/2023 at 1:51 PM, Staff A confirmed the facility did not have a paid feeding assistant program. Staff A stated they had no policy on feeding residents. Staff A stated they were unaware of non-certified/licensed staff were assisting residents with swallowing and chewing deficits to eat at mealtime. Staff A stated their expectation was only certified or licensed staff should be feeding residents.
Refer to WAC 388-97-1060
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety for 1 of 4 nutrition refrigerators/freezers (North Hall) reviewed for food storage. Failure to label foods with dates they were opened or discard dates, and discard expired food, placed residents at risk for food-borne illness.
Findings included .
Observation on 10/24/2023 at 10:10 AM, the North Hall Pantry Refrigerator/Freezer a sign on the refrigerator stated: Attention Staff -When a resident has food brought in, it must have their name on it. I will throw it away otherwise. All food will be thrown out after three days unless it has a manufacturer date on it, like yogurt or cheese sticks etc. All other items regardless of where it came from can only be in the fridge for 3 days. After 3 days, I toss out foods and put any container in the sink to be picked up. Only the resident's foods are allowed to be in the fridge. NO Staff food or drinks.
Observation on 10/24/2023 at 10:10 AM, the North Hall Pantry of the refrigerator/freezer there were multiple expired food items observed:
- A plastic baggie of [NAME] bell cheese with an expiration date of 09/13/2023.
- A bottle of Hershey's chocolate syrup with no open or discard date labeled and expired on 07/2023.
- A bottle of Pure Leaf Sweet Tea was opened without an open or discard date.
- A gallon of milk was opened without an open or discard date.
- A container of Darigold cottage cheese was opened without an open or discard date and expired on 09/21/2023.
- Three small plastic containers of thickened orange juice with an expiration date of 09/11/2023.
- The shelves to the refrigerator were covered in a black/brown discoloration throughout the shelves, and the freezer contained debris of unknown source and human hair.
In an interview on 10/24/2023 at 10:31 AM, Staff DD, Certified Nursing Assistant (NAC), stated the food in the refrigerator was to have the name and date on it and if not, the kitchen staff would throw it away. Staff DD stated the kitchen staff usually checked the refrigerator and freezer daily.
In an interview on 10/24/2023 at 10:35 AM, Staff II, Dietary Manager, stated the kitchen staff and the nursing aides were responsible for removing expired food, dating food with an open or discard dates, and discarding expired foods. Staff II stated the expired thickened orange juice was placed in the refrigerator from the kitchen and should have been discarded. Staff II stated food items should have dates on them when they were opened.
Refer to WAC 388-97-1100(3)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to follow infection control standards during medication administration for 1 of 5 residents (Resident 116) observed for medication administration, and 1 of 1 residents (Resident 67) observed during care of a urinary catheter (a tube inserted into the bladder to drain urine.) This failure placed residents at risk for developing infections and for experiencing a decreased quality of life.
Finding included .

Resident 67 was originally admitted to the facility on [DATE] and most recently following hospitalization on 08/14/2023 with diagnoses to include heart disease/failure, urinary tract infection and presence of an indwelling urinary catheter (is a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag).
In an observation and interview on 10/23/2023 at 1:05 PM, Staff FF, Nursing Assistant Certified (NAC), was observed providing catheter care (washing the external portion of catheter and insertion site) for Resident 67. Staff FF was observed to complete catheter care and bowel incontinent (loss of voluntary control) care. Staff FF removed their soiled gloves and donned (placed on) new gloves. Staff FF did not wash their hands or perform hand hygiene after removing their soiled gloves and prior to applying a new pair of gloves. Staff FF stated they just put clean gloves on after cleaning the resident and before assisting the resident with putting on a clean brief.

Resident 116 admitted to the facility on [DATE] with diagnoses including diabetes, macular degeneration (an eye disease that causes vision loss), ocular hypertension (high blood pressure in the eye) and glaucoma (an eye disease that can cause loss of vision).
Review of the Minimum Data Set (an assessment tool) assessment, dated 10/17/2023, showed Resident 116 had minimal cognitive impairment and required staff assistance with activities of daily living.
Observation on 10/27/2023 at 8:25 AM, Staff Q, Registered Nurse (RN), was observed performing a blood glucose check (measurement of the amount of sugar in the blood), administered insulin by injection, and administered eye drops to Resident 116. Staff Q did not perform hand hygiene or don (apply) clean gloves after performed a blood glucose check, administered an insulin injection, and prior to administering the eye drops to the resident.
In an interview on 10/27/2023 at 8:45 AM, Staff Q stated they should have removed their gloves and performed hand hygiene prior to administering Resident 116's eye drops.
In an interview on 10/31/2023 at 12:38 PM, Staff B, Director of Nursing Services, stated hand hygiene needed to be done after removing soiled gloves and prior to applying clean gloves. Staff B stated Staff Q should have removed their gloves, performed hand hygiene, and applied clean gloves prior to administering the eye drops to Resident 116.
Refer to WAC 388-97-1320 (1)(c)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse/neglect policy and procedure to thoroughly investigate injuries of unknown source for potential abuse/neglect for 2 of 4 residents (Resident 57 and 75) reviewed. Failure to thoroughly investigate injuries of unknown source placed residents at risk for continued abuse/neglect.
Findings included .
Review of the facility policy titled, Policy and Procedure Abuse, Neglect, Abandonment, Financial Exploitation and Misappropriation of Resident Property, dated January 2017, showed the facility will ensure that all alleged violations involving abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and injuries of unknown sources are reported immediately to appropriate agencies in accordance with federal and state law.
<RESIDENT 57>
Resident 57 admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnosis to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
Review of Resident 57's Quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 09/18/2023, showed the resident had moderate cognitive impairment.
Review of Resident 57's progress note, dated 06/21/2023, showed the resident was found to have a band aid on their toe, which was removed, and started to bleed. The note indicated the skin under the resident's toenail had been nicked. The note indicated the resident had been seen by a podiatrist on 06/20/2023.
Review of an incident report, dated 06/22/2023, showed Resident 57 was found to have a band aid on the end of their right third toe. The incident report showed the resident was interviewed and they were unaware of how the injury occurred.
Review of Resident 57's podiatry progress note, dated 06/23/2023, showed the resident was seen by a podiatrist, but there was no notation the resident's skin had been nicked or that a band aid had been applied.
In an interview on 10/31/2023 at 11:42 AM, Staff B, Director of Nursing Services (DNS), stated they completed Resident 57's incident report and recalled having a conversation with the podiatrist. Staff B stated they were unaware of the date discrepancy related to the podiatrist note. Staff B stated the podiatrist report would not have been attached to the incident report if the facility had not received it by that date, and they had finished the report. Staff B stated all incident reports should be ruling out potential abuse and neglect. Staff B stated Resident 57 was alert, and they would be able to tell the staff if something had happened to them. Staff B stated they planned on making sure all pertaining documents were attached to the incident reports and the findings were more complete.
<RESIDENT 75>
Resident 75 admitted to the facility on [DATE], and had most recently readmitted on [DATE], with diagnosis to include dementia (impaired ability to remember, think, or make decisions that interfered with doing everyday activities).
Review of Resident 75's Quarterly MDS assessment, dated 10/16/2023, showed the resident had moderate cognitive impairment.
Review of Resident 75's incident report, dated 9/25/2023, showed the resident had a bruise to their right forearm. The incident report described Resident 75 as having moderately impaired cognition. The incident report showed Resident 75 was interviewed and did not know how the bruising occurred. The incident report did not show how abuse and/or neglect was ruled out. The incident report lacked any witness statements, staff statements, and other resident interviews.
In an interview on 10/31/2023 at 11:42 AM, Staff B stated all incident reports should be ruling out potential abuse and neglect. Staff B stated they planned on making sure that all pertaining documents were attached to the incident reports and the findings were more complete.
Refer to WAC 388-97-0640(6)(a)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative describing the reason for transfer for 2 of 2 sampled residents (Residents 48 and 6) reviewed for transfer notifications regarding hospitalization. This failed practice disallowed the residents and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharges.
Findings included .

Resident 48 was admitted to the facility originally on 06/24/2021 and then again on 08/22/2022 following hospitalization.
Review of Resident 48's medical records showed the resident transferred to the hospital on [DATE] related to acute changes in their medical status. The medical record did not show documentation that a written notice of transfer and discharge was provided to Resident 48, their representative, and to the Office of the State Long-Term Care Ombudsman.
In an interview on 10/31/2023 at 9:40 AM Staff F, Social Service Assistant (SSA), was unable to find documentation a written notice of transfer and discharge was provided to Resident 48, their representative and to the Office of the State Long-Term Care Ombudsman.
Resident 6 admitted to the facility on [DATE], most recently admitted on [DATE] diagnoses include paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own), encephalopathy (damage or disease that affects the brain), and unspecified dementia (mild memory disturbance due to known physiological condition).
In a review of Resident 6's progress note, dated 07/09/2023, showed the resident was sent to the emergency room related to a tachycardia (irregular heart rhythm). Resident 6 was admitted to the hospital.
In a review of Resident 6's Electronic Medical Record (EMR) progress note, dated 07/12/2023, showed Resident 6's family member was contacted regarding a bed hold, three days after the resident was transferred to the hospital.
In an interview on 10/31/2023 at 9:56, AM Staff U, SSA, stated that nursing staff was is responsible for providing a discharge/transfer notice to a resident or their designated representative. Staff U stated that they could not locate a discharge/transfer notice for Resident 6 in their EMR.
Refer to WAC 388-97-1020(2)(a-d)
.

Based on observation, interview, and record review, the facility failed to provide a dignified and homelike dining experience in 2 of 3 (Southeast and South) dining rooms during 3 of 3 dining observations for dignity. These failures placed residents at risk for feelings of frustration, diminished self-worth, embarrassment, and a potential decline in nutritional status.
Findings included .

Observation on 10/24/2023 at 11:37 AM, Resident 101's meal tray was served. The resident's tablemates, Resident 76, and Resident 33, were observed to watch Resident 101 eat until their lunch arrived at 11:43 PM, six minutes later. The resident's food and drinks were not removed from the serving tray for the dining experience.
Observation on 10/27/2023 at 11:28 AM, trays were delivered to the unit. Resident 33's meal was served at 11:30 AM, followed by their tablemates Resident 76's at 11:34 AM and Resident 1's meal at 11:35 AM. At the same table Resident 101 was staring at their tablemates eating and inquiring as to where their food was. Collateral Contact 1 (CC1), Resident 101's, significant other, commented that maybe the facility had put them (Resident 101) on a diet. Resident 101's lunch was delivered at 11:37 AM. Resident 101's food and drinks were not removed from their serving tray for the dining experience.
Observation on 10/30/2023 at 11:37 AM, Resident 117's lunch was served. Resident 101 was seated at the table and watching Resident 117 eat until their tray was delivered at 11:41 AM. Resident 101's food and drinks were not removed from the serving tray for the dining experience.
In an interview on 10/30/2023 at 12:30 PM, Staff G, Nurse's Aide Registered (NAR), said they leave the plates and cups on the tray during meals unless the resident requested otherwise. Staff G said they served the meals in the order of the meal cart arrangement.
In an interview on 10/30/2023 at 2:45 PM, Staff E, Registered Nurse (RN), said they always served the meals on the tray and kept them on the tray so that resident's would know whose food was who's. Staff E said they tried to serve meals to the table at the same time, so others were not waiting and watching others eat.
Observation on 10/24/2023 at 12:01 PM, the staff were observed to serve Resident 52, and Resident 105 their lunch. The residents food and drinks were not removed from the serving tray for the dining experience.
Observation on 10/24/2023 at 12:02 PM, the staff were observed to serve Resident 65, Resident 28 and Resident 16 their lunch. The residents food and drinks were not removed from the serving tray for the dining experience.
Observation on 10/24/2023 at 12:03 PM, the staff were observed to serve Resident 80 their lunch without removing their food and drinks from the serving tray. Resident 77 lunch arrived at 12:07, four minutes later. The resident's food and drinks were not removed from the serving tray for the dining experience.
In a continuous observation on 10/24/2023 at 12:05 PM, the staff were observed to serve Resident 26, Resident 33, Resident 17, and Resident 38 their lunch. The resident's food and drinks were not removed from the serving tray for the dining experience. Resident 26 was observed to have their head tucked into their shirt, their food was sitting placed in front of them, uncovered and untouched. At 12:16 PM, staff was observed to verbally tell Resident 26 to eat their lunch, Resident 26 did not respond. At 12:21 PM, 16 minutes after their food had been delivered, staff were observed to stand over Resident 26 and provide physical assistance to the resident to eat one bite of food then the staff walked away. At 12:27 PM, a staff member sat down next to Resident 26 and provided physical assistant to the resident to eat their lunch, 22 minutes after their food was placed in front of them.
Observation on 10/26/2023 at 11:51 AM, the staff were observed to serve Resident 38 and Resident 17 their lunch. There were two other residents (Resident 33 and Resident 26) that sat at the same table, they were not served their lunch till 11:57, six minutes after the first tray was delivered.
In a continuous observation on 10/26/2023 at 11:51 AM, the staff were observed to serve Resident 65 their lunch to their table. Resident 73 was sitting at the table with Resident 65. Resident 73 then moved in their wheelchair over to the food cart full of trays and stated to staff where is mine? Resident 73 then moved in their wheelchair back to the table and leaned over at Resident 65, pointed at the food, and stated, I want some of that, it looks good. At 11:55 AM, Resident 73 lunch was placed in front of them, four minutes later.
In an interview on 10/26/2023 at 1:28 PM, Staff P, Activity Assistant, stated they assist with meal delivery at times. Staff P stated they try to pass to one table at a time, but they were not always able to.
In an interview on 10/30/2023 at 9:58 AM, Staff K, RN, stated they pass the trays to the residents as they were stacked in the meal cart when it was delivered.
In an interview on 10/30/2023 at 12:50 PM, Staff L, RN/Nurse Manager, stated the expectation in the dining room was all residents at the same table were served their meal at the same time. All items on the meal tray should be removed and placed on the table.
In an interview on 10/31/2023 at 12:56 PM, Staff A, Administrator, stated the management team was unaware the staff had been not removing the food items off the tray during meal service. Staff A stated they were also unaware residents were not served one table at a time. Staff A stated the expectation was, staff were to serve one table at a time, with food and drinks removed from the serving tray.
Refer to WAC 388-97-0860 (1)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 2 of 3 sample residents (Resident 75 and 94), reviewed for quality of life. This failure placed residents at risk of unmet care needs and diminished quality of life.
Findings included .
<RESIDENT 75>
Resident 75 admitted to the facility on [DATE], most recently readmitted on [DATE], diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), and weakness.
Review of Resident 75's care plan, dated 04/18/2022, showed the resident had a deficit in their ability to care for themselves related to weakness and was at risk for falls. Interventions included to encourage Resident 75 to use their call light for assistance and to have their call light within reach.
In an observation and interview on 10/25/2023 at 11:21 AM, Resident 75's call light was observed on the floor. Resident 75 stated they would like a glass of cold ice water. There was no pitcher or water observed in Resident 75's room.
In a continuous observation on 10/27/2023 beginning at 9:04 AM until 9:58 AM, Resident 75's call light was observed on the ground next to their bed, out of their reach.
In an interview on 10/27/2023 at 9:58 AM Staff Y, Registered Nurse (RN)/Nurse Manager, stated staff should be checking on residents all the time. Staff Y stated they did not know how long Resident 75 had been without their call light, noticed the call light on the floor right away, and placed it within Resident 75's reach.
<RESIDENT 94>
Resident 94 admitted to the facility on [DATE] with diagnoses included congestive heart failure (condition in which the heart doesn't pump blood as efficiently as it should), weakness, and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) of the right knee.
Review of Resident 94's care plan, dated 04/18/2023, showed Resident 94 had a history of not remembering to use their call light and was at risk for falls. The intervention noted was to ensure the call light was within reach, encourage the resident to use their call light, and to place frequently used items within the resident's reach to include the call light.
In a continuous observation on 10/27/2023 starting at 9:08 AM Resident 94's call light was on the ground next to their bed on the right side. At 9:45 AM observed Staff AA, Licensed Practical Nurse (LPN), enter Resident 94's room and then exited. Resident 94's call light remained on the floor. At 10:07 AM Staff Z, Certified Nursing Assistant, entered Resident 94's room and upon exiting stated that the resident's call light was on the floor and placed it within their reach.
Refer to WAC 387-97-0860 (2)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD's) for 5 of 12 sampled residents (Residents 160, 32, 75, 6 and 100) reviewed for AD's. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.
Findings included .

Resident 160 was admitted to the facility on [DATE] with diagnosis including aftercare following left leg amputation. Resident 160's profile information records showed the resident was self- responsible in making their own decisions.
Review of Resident 160's records on 10/25/23 and 10/31/2023, showed no documentation of AD's.
Review of email received on 10/31/2023 at 12:02 PM, Staff A, Administrator, indicated Resident 160's admission paperwork had not yet been completed that included information regarding AD's.

Resident 32 admitted to the facility on [DATE] with diagnoses including depression and heart failure.
Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/23/2023, showed Resident 32 had moderate cognitive impairment.
Review of Resident 32's admission paperwork, dated 10/10/2023, stated the resident's family member was their durable power of attorney (DPOA).
Review of Resident 32's medical record on 10/27/2023, showed no record of a DPOA that was on file.
Review of Resident 32's progress note, dated 09/24/2023, showed Staff F, Social Service Assistant (SSA), documented they had no DPOA on file and would follow up.
In an interview on 10/27/2023 at 10:30 AM, Staff F stated they had not followed up with the family member regarding the DPOA paperwork. Staff F stated they possibly had discussed that in the care conference but was unsure as there was no documentation of the conversation.
In an interview on 10/31/2023 at 12:56 PM, Staff A stated they were unaware that the AD's had not been obtained for Resident 32.

Resident 75 admitted to the facility on [DATE], most recently readmitted on [DATE], diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), and weakness.
In a review of Resident 75's Electronic Medical Record (EMR) on 10/24/2023, showed the resident had a Power of Attorney (POA) for finances on file.
In an interview on 10/26/2023 at 2:32 PM, Staff U, SSA, stated Resident 75 had an advanced directive on file and stated it was a POLST (Physician Orders for Life Sustaining Treatment). Staff U stated Resident 75 had a POA, was able to locate the financial POA, but not the healthcare POA.
In an interview on 10/26/2023 at 3:29 PM, Staff U provided a copy of Resident 75's POLST and an admission document describing AD's. Staff U stated they were unable to locate the POA document for healthcare and they would follow up with Resident 75's family to obtain the document.

Resident 6 admitted to the facility on [DATE], most recently admitted on [DATE] diagnoses include paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own), encephalopathy (damage or disease that affects the brain), and unspecified dementia (mild memory disturbance due to known physiological condition).
In an interview on 10/26/2023 at 2:32 PM, Staff U stated Resident 6 had an advanced directive on file and that was a POLST. Staff U stated Resident 6 had a POA but was unable to locate the document.
In an interview at 10/26/2023 at 3:56 PM, Staff U provided the POA document for Resident 6.
In an interview on 10/27/2023 at 12:46 PM, Staff U stated they received the POA document the day prior (10/26/2023) after requesting it from Resident 6's family member.
Resident 100 admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis (damaged muscles that release protein into the blood) and falls at home.
Review of the resident's admission MDS assessment, dated 08/25/2023, showed the resident had moderate cognitive impairment.
Review of Resident 100's medical record on 10/24/2023, showed no documentation of AD's.
Review of Resident 100's progress notes, showed no documentation of staff discussing AD's with the resident.
In an interview on 10/30/2023 at 9:20 AM, Staff T, Medical Records, stated there was no advanced directive in Resident 100's medical record.
In an interview on 10/30/2023 at 9:56 PM, Staff U stated Resident 100 does not have an AD. Staff U stated resident 100 had declined an AD and stated there was no documentation in the resident's record.
Refer to WAC 388-97-0280(3)(a)(c)(i)
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff documented completely on behavior flowsheets for 3 of 3 residents (Resident 1, 2, and 3) reviewed for Resident-to-Resident altercations. Failure to have complete data on behavior flowsheets could cause incorrect and/or inadequate assessments of resident behaviors and medication effectiveness.
Findings included .
<RESIDENT 1>
Resident 1 had admitted to the facility on [DATE]. Resident 1 had diagnoses to include dementia (impacts memory and decision making) with agitation, psychosis (condition that results in difficulties determining what is real and what is not real) and depression.
Review of Resident 1's May 2023 behavior flow sheet, showed staff were to monitor for: 1- refusing care or meals and 2- verbal or physical aggression. The behavior flowsheet had a space for day, evening, and night, to document if behaviors were noted during the shift. The monitor for refusing care or meals had two blanks under the evening shift and 25 blanks under the night shift. The monitor for verbal or physical aggression had two blanks under the evening shift 25 blanks under the night shift.
Review of Resident 1's June 2023 behavior flow sheet, showed the monitor for refusing care or meals had two blanks under the evening shift and 24 blanks under the night shift. The monitor for verbal or physical aggression had two blanks under the evening shift and 24 blanks on the night shift.
<RESIDENT 2>
Resident 2 had admitted to the facility on [DATE]. Resident had a diagnosis of dementia with agitation.
Review of Resident 2's May 2023 behavior flow sheet, showed staff were to monitor for: 1- refusing therapy or meals, 2- sexually inappropriate comments, and 3- delusions (misinterpreting sounds or visions). The behavior flowsheet had a space for day, evening, and night shift to document behaviors. There were four blanks on the evening shift and 25 blanks on the night shift for each behavior being monitored.
Review of Resident 2's June 2023 behavior flow sheet, showed the same behaviors were being monitored. Each behavior area had two blanks on the evening shift and 24 blanks on the night shift.
<RESIDENT 3>
Resident 3 had admitted to the facility on [DATE]. Resident had a diagnoses to include dementia, psychosis, and depression.
Review of Resident 3's May 2023 behavior flow sheet, showed staff were to monitor for: 1- agitation/ delusions/paranoia, 2- wandering, and 3- depression/ anxiety. The behavior flowsheet had a space for day, evening, and night shift to document behaviors. There were two blanks on the evening shift and 25 blanks on the evening shift for each behavior being monitored.
Review of Resident 3's June 2023 behavior flow sheet, showed the same behaviors were being monitored. Each behavior area had two blanks on the evening shift and 24 blanks on the night shift.
During an interview on 07/06/2023 at 2:34 PM, Staff A, Director of Nursing Services, stated the behavior flow sheets should be documented on every shift, or three times a day. Staff A verified that the flowsheets had several blanks for Residents 1, 2, and 3; and the nurses should have documented each shift.
WAC Reference 388-97-1720 (1)(a)(i)