Arlington Health And Rehabilitation

F-F684. The facility removed the immediacy on 08/19/2024 after they terminated the staff that failed to assess, treat and timely notify the physician of Resident 1's acute change in condition. They audited the records of all residents, educated staff on what to do when a resident has a change in condition, educated staff on identifying abuse and neglect and implemented a plan of correction to sustain ongoing compliance.

Findings included .

Review of the facility policy titled, Notification Policy, revised 04/17/2020 states the facility should promptly notify the resident, their physician, and primary contact of changes in the residents condition or status .the nurse will notify the physician when there was a change in condition in their physical, mental, or psychosocial status, involvement in any incident, need to alter the residents treatment, and when necessary in the best interest of the resident.

Resident 1 admitted to the facility on [DATE REDACTED] with diagnoses to include atrial fibrillation (irregular heartbeat), long term use of anti-coagulant (medication that thins the blood), diabetes (medical condition in which the body doesn't use insulin properly), and history of stroke. The significant change in condition Minimum Data Set (MDS - an assessment tool) assessment, dated 05/11/2024 showed the resident had intact cognition, no refusals of care, was dependent on staff for toileting, and personal care. The MDS showed the resident was incontinent of bowel and bladder and was taking an anticoagulant medication.

Resident 1's physician order for sustaining life (POLST) form dated 02/21/2024 showed that the resident choice indicated selective treatment that designated the primary goal was to treat medical conditions while avoiding invasive measures whenever possible. The resident chose to receive medical treatment, intravenous (IV) fluids (fluids administered through a needle and tubing injected directly into the vein), medications, and cardiac monitor as indicated. The resident chose to have airway support with oxygen and wanted to be transferred to hospital if indicated.

Review of a nursing progress note dated 07/22/2024 at 9:45 PM, showed Resident 1 had experienced abdominal discomfort, received an antacid (medication to reduce abdominal discomfort) twice without relief.

Review of a nursing progress note dated 07/23/2024 at 4:56 AM, showed Resident 1 continued to experience abdominal discomfort.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 505351 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505351 B. Wing 08/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Health and Rehabilitation 620 South Hazel Street Arlington, WA 98223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of a nursing progress note dated 07/23/2024 at 1:51 PM, showed Resident 1 had only experienced small bowel movements the last 48 hours, and that the resident needed to be assessed. No assessment was Level of Harm - Immediate documented. jeopardy to resident health or safety Review of a nursing progress note dated 07/23/2024 at 11:44 PM, showed Resident 1 continued to have abdominal pain, and bowel sounds were slow. Residents Affected - Few

Review of a nursing progress note dated 07/24/2024 at 2:20 AM, showed Resident 1 had been restless all night, had called out for assistance multiple times, nursing staff were unable to relieve discomfort with antacids. Staff documented that the resident was calling out, crying and disruptive to their roommate. The note stated staff had to remove Resident 1's roommate from the room as the roommate was in distress from

the resident's constant calling out. There was no documentation of additional assessments or that the physician was notified until approximately two hours later.

Review of a nursing progress note dated 07/24/2024 at 4:19 AM, showed the nurse notified the physician by fax regarding Resident 1's constant abdominal discomfort, loose stools, and increased restlessness and crying out. The physician responded at 5:36 AM they would come by to see resident later that morning.

Review of a nursing progress note dated 07/24/2024 at 6:46 AM, showed Resident 1 was found at the beginning of the shift (6:00 AM) to be vomiting a dark coffee colored substance The resident was short of breath with an oxygen saturation (amount oxygen was absorbed into the body) of 85% (residents' baseline was 96%). The nurse documented that the resident's lung sounds appeared decreased on the right and left side of their body, and that the right lower area of their abdomen was painful. The resident's hands, and feet were cold to touch. The resident was sent to the hospital.

Review of Resident 1's vital sign (measurements of body's basic functions i.e. heart rate, blood pressure, oxygen saturation, temperature, and respiratory rate) report showed the last time the residents vitals were assessed was on 07/23/2024 at 3:52 PM. There was no documentation that the residents' vitals were assessed again until 6:00 AM on 07/24/2024, when the resident was found to be vomiting.

In an interview on 08/06/2024 at 7:56 AM, Staff C, Nursing Assistant Certified (NAC) stated that at the start of their shift at 11:00 PM, they were told Resident 1 had been uncomfortable, having pain and discomfort in their abdomen and back. Staff C stated that the resident was calling out all shift, placing their call light on as soon as they would leave the room. Staff C stated they were in and out of the room all night, it was a long night. Staff C stated the resident would call the staff's name out, cry, and yell out constantly to the point that

it was disrupting the roommate, so staff moved the roommate to another room down the hall. Staff C stated when they got ready to start their last rounds between 4:00 AM and 5:00 AM the nurse [Staff D, License Practical Nurse (LPN)] told them that they would take care of Resident 1 for them as they needed a break. Staff C stated they did not go back into Resident 1's room the rest of their shift. Staff C stated that they did notice around 5:00 AM Resident 1's door was shut, they could not recall if the call light was on. Staff C stated

they gave report to the next shift around 6:00 AM, and that was then they learned Resident 1 had vomited and the resident was going to be sent to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 505351 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505351 B. Wing 08/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Health and Rehabilitation 620 South Hazel Street Arlington, WA 98223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview on 08/06/2024 at 11:10 AM, Staff D, LPN stated they have worked for the facility for about a year. Staff D stated they were educated by the facility that when a resident had a change in condition, they Level of Harm - Immediate were to call and notify the physician. Staff D stated they were told in report at the start of their shift on jeopardy to resident health or 07/23/2024 at 11:00 PM that Resident 1 had been experiencing abdominal discomfort. Staff D stated during safety their shift the resident had been uncomfortable all night, was calling out, yelling and crying all night for staff to come into the room and help them. Staff D stated Resident 1's behavior was not their baseline and was Residents Affected - Few disruptive to their roommate, so they moved the resident's roommate out of the room. Staff D stated they were aware that the resident had reported abdominal discomfort for a couple of days, as they worked the night before and the resident mentioned then they were having abdominal discomfort and pain then. Staff D was asked if they ever assessed the resident for the source of their abdominal pain and discomfort, Staff D stated they did not and realized that they should have checked the resident's vitals and conducted a head-to-toe assessment. Staff D stated they faxed the doctor; however, they should have called the physician earlier as the abdominal discomfort had been occurring for a couple of days. Staff D stated they probably needed further testing. Staff D confirmed that they shut the door to Resident 1's room between 5:00 AM - 5:30 AM on 07/24/2024 as they had been so disruptive to the other residents all night and was trying to allow the NAC's time to assist other residents. Staff D stated they did not check on the resident after they shut the door to the room.

In an interview on 08/07/2024 at 10:08 AM, Staff G, Registered Nurse (RN) stated they have been employed at the facility for a little over a month. Staff G stated that they would call the physician if a resident had a change in condition, faxing the physician was for non-urgent needs. Staff G was receiving report from the overnight nurse (Staff D) when the day shift NAC approached them and stated that Resident 1 had coffee (dark brown) colored vomit all over them and was having difficulty breathing. Staff G stated they immediately went to the resident and assessed their vitals and completed a physical assessment. Staff G stated they asked another nurse to contact the physician to request to send the resident to the hospital. Staff G had not received report on Resident 1, stating they were not aware of the abdominal pain, and the restlessness of

the resident until after they were sent to the hospital.

In an interview on 08/07/2024 at 10:26 AM, Staff E, NAC stated they were not the staff that found Resident 1

on the morning or 07/24/2024. Staff E stated they arrived shortly after Staff G was assessing the resident. Staff E stated when they arrived in the room the resident was covered in dark brown vomit, the bed was a big mess. Staff E stated they assisted in cleaning the resident up, while they were preparing to send them to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 505351 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505351 B. Wing 08/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Health and Rehabilitation 620 South Hazel Street Arlington, WA 98223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview on 08/07/2024 at 11:27 AM, Staff F, NAC stated they were the staff member that found Resident 1 on the morning of 07/24/2024. Staff F stated when they came on shift, the previous NAC (Staff C) Level of Harm - Immediate reported to them that Resident 1 had been calling out all night and was having abdominal pain and jeopardy to resident health or discomfort. Staff F stated when they started their shift, they noticed that Resident 1's door was shut. Staff F safety stated that they have worked with Resident 1 since they admitted and knew that the resident did not prefer their door shut. Staff F stated when they entered the room, the room was very cold, and they noticed that the Residents Affected - Few window was open. Staff F stated that the resident had no covers on them, and their bare legs were exposed.

The call light was not within the reach of the resident. Staff F stated the resident was covered in dark brown vomit, their lips were discolored, and their skin was very cold. Staff F stated the resident was saying help, help,. Staff F stated they tried to talk to the resident, but they were not making sense, and this was not Resident 1's baseline, so they ran to get a nurse. Staff F stated that Staff G, RN showed up immediately and began assessing the resident, and was preparing to send the resident to the hospital.

Review of Resident 1's hospital records dated 07/24/2024 showed the resident presented to the emergency department (ED) at 7:57 AM on 07/24/2024. The physician note stated the resident presented with coffee-ground emesis (vomit), weakness, and low blood pressure. The ED physician documented that the resident appeared toxic and altered. The ED Physician documented that they were concerned with sepsis (blood infection) and septic shock (blood infection causes low blood pressure, widening of the blood vessels (vasodilation) and organ failure). Resident 1's laboratory blood result showed the resident had a high white blood cell (WBC) count that was indicative of an infection. The note stated that the resident had an acute critical illness with potential for imminent deterioration from septic shock and artery blockage to the abdominal organs. At 11:44 AM, the resident had been transferred to the intensive care unit. The physician noted that they had attempted to stabilize the resident, however the resident had been struggling to breath, and their heart rate was very low. The physician noted that they advised the family present that the resident was likely to only survive for a few more hours. At 3:43 PM the physician noted that Resident 1 had passed away.

In an interview on 08/07/2024 at 11:50 AM, Staff H, LPN/Nurse Manager stated their expectation was the licensed staff would complete a vital sign assessment as well as a head-to-toe assessment of a resident whenever a resident was having a change in condition. Staff H stated they were not at the facility on the morning of 07/24/2024 and arrived after Resident 1 had been sent out to the hospital. Staff H stated they would have expected the nurse (Staff D) to have checked the resident's vitals and done a head-to-toe assessment on the resident during their shift.

In a joint interview on 08/07/2024 at 2:33 PM, with Staff A, Administrator and Staff B, Director of Nursing Services (DNS), Staff B stated their expectation for all their staff was that the physician was called for any urgent matter or change in condition of the resident. Staff B stated that if a resident was having a change in condition, they expected their licensed staff to assess and monitor the resident continuously, notify the physician by calling them on the phone. Staff B was asked to clarify monitor and assess, and they stated

they should be routinely checking their vitals and complete a head-to-toe assessment of the resident to report any findings to the physician. Staff B confirmed that Resident 1 was not properly assessed on the overnight shift of 07/23/2024 - 07/24/2024. Staff B was asked if they were aware that Resident 1's door was closed, and the call light was not within reach on the morning of 07/24/2024, Staff B did not offer any additional information. Staff B confirmed more should have been done for the resident. Staff A stated, In hindsight more should have been done to help the resident. Staff B stated they were alerted around 3:00 PM

on the 24th that the resident had passed away.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 505351 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505351 B. Wing 08/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Health and Rehabilitation 620 South Hazel Street Arlington, WA 98223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Refer to WAC 388-97-1060(1)

Level of Harm - Immediate jeopardy to resident health or safety

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 505351