Arlington Health And Rehabilitation

F-F758

Reference WAC 388-97-1040 (1) (a-c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 47047 Residents Affected - Few Based on observation and interview the facility failed to ensure drugs and biologicals (diverse group of medicines made from natural sources) were refrigerated after opening from 2 of 2 medication carts (Medicare and North Hall) and expired medications and biologicals were disposed of timely in accordance with professional standards from 1 of 2 medication rooms (Medicare Hall). These failures placed residents at risk to receive expired medications, ineffective medication from lack of refrigeration, to experience adverse side effects and other potential negative health outcomes.

Findings Included .

On 02/03/2025 at 9:49 AM observed the refrigerator of the medication room to contain 3 vials of lorazepam (an antianxiety medication) in a small, clear bag with the expiration date of 10/2024. In addition, observed a small bag with a label that read, Promethegan, the expiration date printed on the label (2023) was crossed out and replaced by a handwritten date of 04/2025.

On 02/03/2025 at 10:45 AM observed an open bottle of Acidophilus, a probiotic, with directions to refrigerate

after opening in the medication cart on the Medicare Hall.

Staff U stated all nurses, when time allows, should be going through their medication carts for expired medications.

In an interview on 02/03/2025 at 9:49 AM Staff U, Licensed Practical Nurse, stated the night shift was responsible for removing and destroying/returning expired medication located in the medication room. Staff U observed the expiration date on the three vials of lorazepam and stated that they were expired in October of 2024. Staff U stated all nurses, when time allows, should be going through their medication carts for expired medications. Staff U stated they did not know who had crossed out the date on the Promethegan and stated

it had come from the emergency kit.

In an interview on 2/03/2025 at 11:48 AM Staff U stated the night shift was responsible for ensuring the medication in the medication cart was stored as directed on the label. Staff U stated they had checked the medication cart on North Hall and found Acidophulius of the same brand as the Medicare Hall and replaced it with a new manufacturer that did not call for refrigeration after opening.

Refer to WAC 388-97-1300(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47047 potential for actual harm Based on observation, interview and record review, the facility failed to ensure foods were served in a timely Residents Affected - Few manner and were palatable for 1 of 1 Halls (South Hall) and 1 of 1 organized resident groups (Resident Council) who were interviewed about the food palatability and temperatures. Failure to meet these requirements could negatively impact the residents' nutritional status, appetite, and meal acceptance.

Findings Included .

In a review of facility policy titled Long Term Care Policy & Procedure Manual labeled food temperatures, undated, showed the facility recommended ranges of temperatures for the safe holding, storage and serving of foods such as hot cereal and hot beverages (coffee and tea) was at 165 degrees Fahrenheit or above.

These are the standards suggested for food acceptance and palatability as well as safety.

On 01/31/2025 at 8:47 AM observed a full cart of meals on trays in the hallway of South Hall. None of the trays had been served.

In an interview on 01/31/2025 at 8:47 AM Staff I, Licensed Practical Nurse (LPN), stated the carts had just arrived a few minutes ago. Staff I stated they had two nursing aides working on the South Hall with another one due to come in.

In an observation on 01/31/2025 at 8:52 AM Staff D, Nursing Aide Certified (NAC), arrived and started passing meal trays to the residents on South Hall.

In an interview on 01/31/2025 at 8:52 AM Staff D stated the other aide they were working with was stuck in a room. When asked how long the trays had been sitting in the hallway, Staff D stated a few minutes. Staff D stated when they need assistance, like this morning, other staff come to assist them such as the nurse. When asked what time the trays are typically delivered to the South Hall, Staff D stated at around 8:00 AM.

In an interview on 01/31/2025 at 8:59 AM Staff HH, Dietary Manager, stated they believed the meal trays went out to South Hall at around 8:15 AM. At 8:59 AM observed Staff HH, check the temperature of oatmeal

on one of the remaining trays in the cart, the temperature 124 degrees Fahrenheit. When asked if the oatmeal was too cold, Staff HH stated it was not warm enough for the resident and removed the oatmeal from the tray.

Review of the dining times provided on 01/29/2025 showed mealtimes for residents eat in their room would be provided between 7:45 AM - 8:45 AM.

Review of the facility menu provided on 01/29/2025, breakfast on 01/31/2025 included oatmeal or cream of wheat, waffle, egg, half of banana, margarine/syrup and milk/hot beverage.

During Resident Council on 01/30/2025 residents reported the food served was consistently cold and late and was especially bad on the weekends when Staff HH was gone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0804 Reference: WAC 388-97-1100(1)(2)

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 47047

Residents Affected - Many Based on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2-nourishment refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food.

Findings Included .

On 01/29/2025 at 9:23 AM observed the following in the facility kitchen refrigerator:

- applesauce in a container with a green lid-undated and not labeled

- opened cottage cheese container with no open date

-opened freezer jam with no open date.

Observed a note on the front of the refrigerator which read, all items in the refrigerators/freezers need to have labels with item and date on them no exceptions.

On 01/29/2025 at 9:23 AM observed a cabinet which contained a refrigerator labeled Fruit Bar. The lower portion of the cabinet was a refrigerator containing trays with multiple small containers containing salad dressings. Two trays marked as blue cheese, and thousand island dressing contained no date as to when

they had been prepared.

On 01/29/2025 at 9:23 AM observed the refrigerator located outside of the building which contained four cucumbers on the top shelf, the cucumbers were wrapped in plastic and had visible black circles on them and were mushy to touch.

In an interview on 01/29/2025 at 9:50 AM Staff HH, Dietary Manager, stated all open food items in the refrigerators should be dated, if not dated they should be thrown away. Staff HH stated the cucumbers were spoiled, they were delivered about five days prior and they had thrown them away.

On 01/29/2025 at 1:10 PM observed the refrigerator/freezer in the small dining room/conference room which contained snacks and sandwiches for residents. The refrigerator contained undated and unlabeled foods items which consisted of the following:

-an unlabeled/undated fast-food bag with a roast beef sandwich

-Egg Nog opened, with no open date

-gallon of milk, opened with no open date

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0812 -med pass supplement, opened dated 8-4

Level of Harm - Minimal harm or -coconut drink opened with no open date potential for actual harm

The freezer had a note on the front which read, no ice packs. The freezer contained an ice pack. Residents Affected - Many

In an interview on 02/03/2025 at 1:15 PM Staff II, Dietary Aide, stated they checked and maintained the nourishment refrigerators on a weekly basis, usually on Mondays, and cleans it out. Staff II stated the opened items in the refrigerator could only be kept for three days and then needed to be thrown out.

Refer to WAC 388-19-1100 (3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 47047

Residents Affected - Few Based on interview and record review, the facility failed to have a system in place that ensured effective consistent communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 3 residents (Resident 22) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care and integrate it into the facility care plan. This failure placed the resident at risk for not receiving necessary care and services and/or unmet care needs.

Findings included .

Review of the facility contract with hospice, titled Nursing Facility Services Agreement dated 02/04/2020 showed in section 2.1.2 coordination with hospice regarding plan of care included design of plan, modification and monitoring of residential hospice patient. The nursing facility shall coordinate with hospice in development of a plan of care. Nursing facility agreed to abide by the plan of care.

In a review of Resident 22's progress notes dated 11/13/2024 showed resident was admitted to hospice care.

Review of Resident 22's electronic health record (EHR) showed no hospice plan of care but showed multiple hospice notes.

Review of Resident 22's care plan dated 11/14/2023 showed resident had a terminal prognosis related to end stage disease process which included recent hip fracture, labs and decline in condition. The goal showed Resident 22 would be free of depression and anxiety through the review date and their comfort would be maintained through the review date of 01/31/2025. Interventions included encouraging resident to express their feelings, to keep the environment calm with low lighting and familiar objects near, and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.

Review of hospice notes found in the electronic health records showed no notation they were reviewed by anyone prior to being placed in the record. Review of hospice nursing note dated 12/23/2024 showed Resident 22 was confused and agitated with multiple calls from the evening nurse and resident's daughter coming into the facility to assist resident calm.

Review of progress note dated 12/27/2024 a late entry for 12/26/2024 showed Resident 22 had been anxious over the last few days with behaviors or self propelling up/down halls, and in and out of rooms, bumping into objects and almost running over other resident's toes. Resident 22 was also noted to be calling out for their daughter, unable to sleep, and calling into rooms of another resident while they were sleeping. Resident 22 was encouraged to call their daughter which helped them calm for short periods of time.

In an interview on 02/05/2025 at 8:54 AM Staff F, Social Services Director, stated hospice care plans are developed by the resident care manager and hospice services are coordinated through nursing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0849 In an interview on 02/05/2025 at 9:10 AM Staff W, Licensed Practical Nurse (LPN) stated hospice sends their care plan and medical records uploads it in the resident's EHR. Staff W stated they would try to find the care Level of Harm - Minimal harm or plan. potential for actual harm

In a follow up interview on 02/05/2025 12:05 PM Staff W provided a copy of the hospice care plan, date Residents Affected - Few stamped on the top with the date of 02/05/2025. Staff W stated they did not know why the hospice care plan was not in Resident 22's EMR.

No associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50725 potential for actual harm Based on observation, interview and record review, the facility failed to ensure that staff were compliant with Residents Affected - Some Infection Prevention and Control Guidelines and standards of practice for 3 of 4 hallways with Enhanced Barrier Precautions (EBP), 1 of 1 observations for wound care (Resident 33), 1 of 3 residents observed

during personal care (Resident 13) and 1 of 1 housekeeping staff observed for hand hygiene. The facility failed to ensure that staff used the Personal Protective Equipment ([PPE] - specialized clothing worn to protect from infection or illness) during high contact resident care activities and failed to perform proper hand hygiene. These failures placed all residents and staff at risk for the potential transmission of infections. The facility was currently in a gastrointestinal virus outbreak.

Findings included .

Review of a facility policy titled, Enhance Barrier Precautions, dated 10/03/2022 showed

- EBP to be implemented for residents with wounds, indwelling medical devices, or residents infected with drug resistant organisms.

- Hand hygiene to be performed when entering the room and when exiting the room.

- PPE to be used during high contact resident care activities such as toileting, transferring, and use of enteral tube (tube inserted into stomach used for medications and formula).

Review of recommendations from the Centers of Disease Control website, Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), showed a strong recommendation to maintain unobstructive urine flow to not rest the catheter bag (a urine collection bag attached to the catheter) on the floor.

Review of an undated facility policy titled, Hand Hygiene, showed hand hygiene was required after removing gloves.

<PERSONAL CARE>

Resident 33 was admitted on [DATE REDACTED] with a cholecystostomy tube (a thin, flexible tube inserted into the gallbladder to drain fluid and relieve pressure).

In an observation and interview on 01/29/2025 at 3:53 PM, Staff J, Nursing Assistant Certified (NAC), provided peri-care (the practice of washing the genital and anal area) to resident 33 after applying gloves but did not apply a gown prior to performing this high contact activity. Staff J removed gloves and applied a new pair without doing hand hygiene. Staff J stated they did not do hand hygiene prior to putting on new gloves, as it will take ten minutes to dry their hands.

<WOUND CARE>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0880 Resident 13 admitted on [DATE REDACTED] with a multi drug resistant bacteria in their lungs and a wound to right foot.

Level of Harm - Minimal harm or In an observation and interview on 01/31/2025 at 12:13 PM, Staff I, LPN, placed wound care supplies on the potential for actual harm overbed table. The overbed table was not covered and beside the wound care supplies were Resident 33's TV remote and drinking water container. Observed Staff I with mask and gloves, no gown. They took the old Residents Affected - Some gauze between the big toe and second toe in the right foot and used saline and q tip to cleanse the wound, with the same glove, they reached over the package of 4x4 and dried the wound. With the same gloves, Staff I opened an individually wrapped 4x4 and placed the gauze between the first and second toe. Using the same gloves, Staff I took the old dressing on the right outer malleolus, cleansed the wound with saline and using the same gloves reached over to the 4x4 package to dry the wound. Still with the same glove, applied new Opti foam dressing. Staff I then moved to the other side of the bed and with the same gloves, took the old dressing on the left outer malleolus, cleansed the wound with saline reached over the 4x4 gauze package and dried the wound. Using the same glove Staff I, covered the wound with Opti foam dressing. Staff I then took gloves off, covered resident and washed hands. They then took the package of 4x4 gauze and the box of gloves and put them in the treatment cart. When I asked Staff I when were they supposed to change gloves, they stated if their gloves were soiled or if they go from one area of the body to another, such as when they go from the buttocks to another area of the body. They stated since they were doing the feet of

the resident and did not go to another area of the body, they did not have to change their gloves.

<ENHANCED BARRIER PRECAUTION>

<BLUE RECTANGLE>

During an interview on 01/30/2025 at 8:00 AM, Staff Y, NAC, stated the blue rectangle on the door jamb for room [ROOM NUMBER] meant the resident in the room required two person assist with care, and the blue rectangle with a flower on the door jamb of room [ROOM NUMBER] meant that resident required two person assist because of behaviors.

During an interview on 01/30/2025 at 8:20 AM, Staff S, NAC, stated the blue rectangle on the door jamb to room [ROOM NUMBER] meant the resident was a fall risk.

<Resident 12>

Resident 12 was a long-term care resident at this facility. According to the MDS dated [DATE REDACTED], the Resident is severely cognitively impaired and required gastrostomy tube (a tube used to provide nutrition directly into

the stomach) for nutrition.

During an observation on 02/03/2025 at 9:21 AM, Staff GG entered Resident 12's room, did not perform hand hygiene, then proceeded to lift the resident's bedspread, touched the mattress next to the resident, and adjusted the air mattress controls without donning Personal Protective Equipment (PPE).

In an interview on 02/03/2025 at 11:03 PM, Staff GG replied that Resident 12 is not on precautions; the PPE supplies in Resident 12's room were from hospice. Staff GG answered that hand washing should be done

before everything, touching residents when they enter or leave the room, and removing their gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0880 In an interview on 02/03/2025 at 2:10 PM, Staff Z, NAC, replied that Resident 12 is on precautions due to his gastrostomy tube. Level of Harm - Minimal harm or potential for actual harm <RESIDENT 13>

Residents Affected - Some Resident 13 admitted on [DATE REDACTED] with a multi drug resistant bacteria in their lungs.

In an observation on 01/31/2025 at 8:43 AM, Resident 13's room did not show any signs that resident was

on any transmission based precautions.

In a record review on 01/31/2025, Resident 13's physician's orders showed Enhanced Barrier Precautions (EBP) related to history of respiratory MRSA (drug resistant staff aureus/bacteria) dated 01/07/2025.

In an interview on 01/31/2025 at 2:04 PM, Staff I, LPN, stated Resident 13 was not on EBP because it was a history of MRSA and resident was not coughing.

In an interview on 02/03/2025 at 12:56 PM, Staff K, LPN/Infection Preventionist (IP) Nurse, stated that residents who were on EBP will have a blue rectangular magnet placed by the resident's door frame and inside the room will have the PPE cart with sign that showed EBP. Staff K confirmed that Resident 33 should have been on EBP. Staff K stated that there was a miscommunication between them and the Resident Care Manager.

51551

<CATHETER CARE>

Resident 36 admitted to the facility on [DATE REDACTED].

In an observation on 01/29/2025 at 1:50 PM, Resident 36 was sitting at the edge of the bed. Their catheter bag was attached to the trash bin with the bottom of the catheter bag was touching the floor.

In an observation on 01/30/2025 at 9:19 AM, Resident 36's catheter bag was hanging at the edge of trash bin and the catheter bag was inside the trash bin. The bottom of the bag was touching the garbage.

In an observation on 01/30/2025 at 2:25 PM, Resident 36's catheter bag was hanging on the edge of the outside of trash bin with the bottom touching the floor.

In an observation on 01/31/2025 at 8:22 AM, Resident 36's catheter bag was inside the trash bin at the bedside lying on top of garbage.

In an observation and interview on 01/31/2025 at 10:01 AM, Resident 36's catheter bag was lying on the floor in the bathroom. Staff P, Certified Nurse Assistant, stated they were not sure why the catheter bag was

on the floor and the catheter bag was not supposed to touch the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 505351 Department of Health & Human Services Printed: 09/09/2025 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 02/05/2025

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 0880 In an observation and interview on 01/31/2025 at 11:14 AM, observed Resident 36's catheter bag attached to the trash bin with the bottom touching the floor. Staff K, Licensed Practice Nurse/Infection Preventive Level of Harm - Minimal harm or Nurse, stated the catheter bag should not be hanging on the trash bin. Staff K stated the catheter bag, the potential for actual harm tubing and the bottom should not touch the floor or garbage. Staff K stated it was infection risk and needed to be corrected. Residents Affected - Some <HAND HYGIENE>

In an observation and interview on 01/31/2025 at 11:18 AM, observed Staff R, Housekeeper took off the dirty gloves and put on clean gloves without hand hygiene between glove changes. Staff R stated their usual practice was not to perform hand hygiene between gloves change.

In an interview on 01/31/2025 at 11:32 AM, Staff K stated they expected staff to perform hand hygiene

before and after changing gloves.

42927

<ENTERIC CONTACT PRECAUTION>

During an observation on 01/29/2025 at 12:07 PM, Staff GG, Registered Nurse, applied a gown and gloves and entered room [ROOM NUMBER]. A sign outside the doorway of room [ROOM NUMBER] showed Enteric Contact Precautions. The sign showed to apply a gown and gloves prior to entering the room, wash hands with soap and water when leaving room and to clean and disinfect equipment before leaving room. Outside the door was a plastic cart with drawers that had disposable gloves and gowns inside.

During an observation on 01/29/2025 at 12:13 PM, Staff GG was observed standing at sink just inside room [ROOM NUMBER]. Staff GG removed their gloves and was noted to be holding a blue inhaler (device to deliver medication to lungs by taking a breath) in their bare hands. Staff GG was still wearing a gown but had not done hand hygiene. Staff GG walked to doorway of room and placed the inhaler on top of the plastic bin, which then fell into the open drawer that had disposable gowns inside. Staff GG then removed the disposable gown they had been wearing and discarded in the garbage can. Staff GG exited the room and used hand sanitizer on hands. Staff GG did not use soap and water for hand hygiene as the enteric contact precaution sign stated.

During an interview on 01/29/2025 at 12:20 PM, Staff GG reviewed the enteric contact precaution sign with surveyor. Staff GG stated that they had used hand sanitizer instead of washing their hands when leaving room [ROOM NUMBER] and that they did not disinfect the inhaler before leaving the room. Staff GG stated

the gowns inside the plastic bin were contaminated since the inhaler had fallen on top of them.

51312

Refer to WAC 388-97-1320 (1)(c) (2)(a)(b)(5)(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 505351