Health Inspection - NORTH AUBURN REHAB & HEALTH CENTER

F-Tag F641

Harm Level: Minimal harm or 47836

Residents Affected: Few (Residents 6 & 7) reviewed for Pressure Ulcers (PUs), received appropriate pressure reducing measures

F-F641 Accuracy of MDS

REFERENCE: WAC 388-97-1060(3)(a).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 47836 potential for actual harm Based on observation, interview, and record review the facility failed to ensure 2 of 3 sampled residents Residents Affected - Few (Residents 6 & 7) reviewed for Pressure Ulcers (PUs), received appropriate pressure reducing measures and repositioning on a consistent basis. This failure placed all residents at risk for PU development, and a diminished quality of life.

Findings included .

According to a facility policy titled, Safety Device Application, revised 04/07/2023, showed the facility would apply the safety device as directed. The policy showed staff would follow the safety device Care Plan (CP) and interventions.

According to a facility policy titled, Wound Prevention and Treatment, revised 02/03/2023, the facility would reduce the occurrence of pressure over bony prominence to minimize injury, manage risk factors, and provide preventive interventions. The policy showed the staff would ensure residents received continuous preventative interventions to promote healing and prevent skin issues.

According to a 01/04/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 6 had no memory impairment. The MDS showed Resident 6 was at risk of developing PUs and had three PUs.

Review of Resident 6's health records showed a 04/22/2023 physician order for air mattress settings to be at alternate level 5 and staff would check for correct settings every shift. Residents 6's records showed a 10/24/2023 air mattress CP with an intervention for staff to monitor appropriate functioning of air mattress every shift. Resident 6's records showed a 03/05/2025 right heel PU CP with an intervention for staff to frequently reposition the resident to prevent new PU's or worsening of active PUs.

In an observation and interview on 04/14/2025 at 9:25 AM showed Resident 6's air mattress settings at float level 8. Staff S (Registered Nurse) stated Residents 6's air mattress should be at alternate level 5. Staff S stated nursing staff were responsible for checking the air mattress settings every shift to ensure they were set per physician orders to prevent skin breakdown.

In an interview on 04/14/2025 at 12:51 PM Resident 6 stated they depended on staff to reposition them in their bed with the air mattress. Resident 6 stated the staff were supposed to reposition them every two to three hours but often did not.

In a continuous observation on 04/17/2025 from 7:56 AM until 12:06 PM Resident 6 was lying in bed flat on their back.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0686 In an interview on 04/17/2025 at 11:46 AM Staff V (Certified Nursing Assistant) stated they were expected to reposition Resident 6 per their CP instructions. Staff V stated they repositioned Resident 6 off their left side Level of Harm - Minimal harm or and onto their back just before breakfast came out and were just about to get them up in their wheelchair. potential for actual harm Staff V stated this was not per Resident 6's CP instructions for repositioning.

Residents Affected - Few In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) stated they expected staff to reposition residents at a minimum of every two hours while in bed or up in a chair.

According to the 11/08/2024 Annual MDS Resident 7 had no memory impairment. The MDS showed Resident 7 was at risk for PUs. The MDS showed Resident 7 had a pressure a reduction device to their bed.

Review of Resident 7's health records showed a safety device air mattress with bolsters CP with an intervention to keep the air mattress set at 180 pounds and 30-minute cycle time/alternating. Resident 7's records showed a physician order to set the air mattress at 165 pounds and cycle time/alternating with the staff to check for correct settings every shift.

In an interview on 04/18/2025 at 8:28 AM Staff L (Resident Care Manager) stated Resident 7's bed was set incorrectly and should not be set at 340 pounds. Staff L stated the nursing staff are to monitor air mattress settings every shift to ensure they are set according to the physician order to prevent skin breakdown.

REFERENCE WAC: 388-97-1060 (3)(b).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0687 Provide appropriate foot care.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264 potential for actual harm Based on observation, interview, and record review the facility failed to provide necessary foot care and Residents Affected - Few treatment in accordance with professional standards, including provision of nail care and Podiatry Services. Deficient practice was identified for 3 (Residents 30, 17, & 23) of four residents reviewed for nail care. Failure to provide timely toenail care placed the residents at risk for negative health outcomes.

Findings included .

Resident 30 admitted to the facility on [DATE REDACTED] and according to the 03/05/2025 Significant Change Minimum Data Set (MDS - an assessment tool) the resident was cognitively intact and had multiple diagnoses including diabetes. Resident 30 was assessed with functional limitations in range of motion to both lower extremities and was dependant on staff for dressing the lower extremities. Record review showed no evidence Resident 30 received Podiatry services since admission.

Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with a moderate amount of crusty reddish debris on the inside of their left great toe nail bed. The resident stated, I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed .No, I haven't seen a podiatrist since I've been here.

In an interview on 04/16/2025 at 7:24 AM Staff G (Social Service Director) stated, Anyone who wants to be seen (by the Podiatrist -Foot doctor), anyone who has diabetes needs to be seen; I always check with nursing. Staff G elaborated, If we couldn't get an in house podiatrist, we would send them out for that service .

In an interview on 04/18/2025 at 10:50 AM, when asked how long after admission should a diabetic resident be seen by podiatry, Staff C (Corporate Nurse) stated, I prefer diabetic residents are seen quarterly; so a resident admitted in September should have been seen twice by now. Staff C confirmed Resident 30 should have, but did not receive, Podiatry services.

During observations on 04/18/2025 at 10:19 AM Staff B (Director of Nursing Services) stated Resident 30 appeared to have, ingrown toenails. Staff B confirmed the resident should be referred to Podiatry upon admission.

Resident 17 admitted to the facility on [DATE REDACTED] and according to the most recent Quarterly MDS assessment, was assessed as cognitively intact with multiple medically complex diagnoses, including diabetes.

Observations on 04/16/2025 at 10:31 AM showed the resident lying in bed. In an interview at that time the resident stated, It's been awhile since seeing a podiatrist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0687 Record review showed a 09/19/2024 Podiatry Consult that documented treatments received and recommended Follow up in 2-3 months or as needed for a more acute problem. Record review showed no Level of Harm - Minimal harm or documentation to support the resident had any subsequent Podiatry services. potential for actual harm

In an interview on 04/16/2025 at 7:24 AM Staff G provided a 02/26/2025 Podiatry Consult for Resident 17, Residents Affected - Few which was not in the record. Staff G stated there were problems with the previous Podiatrist which caused delay in services, but they currently had a new Podiatrist service.

In an interview on 04/18/2025 at 12:57 PM, Staff C stated Resident 17 should have been seen prior to the 02/26/2025 visit and staff did not ensure Podiatry follow up in 2-3 months as recommended at the 09/19/2025 visit.

46479

Review of the 02/08/2025 Quarterly MDS showed Resident 23 had diagnoses including heart failure, end-stage kidney failure, and diabetes (inability to control their blood sugar levels). The MDS showed Resident 23 had a diabetic foot ulcer.

Review of Resident 23's progress notes showed an 11/17/2025 consulting wound provider note recommending a Podiatry referral for management and evaluation of hammer toes as foot deformity may complicate wound healing. The consulting wound provider wrote additional notes recommending a podiatry referral for Resident 23 on 11/23/2024, 12/08/2024, 12/13/2024, 12/22/2024, 12/28/2024, 01/04/2025, 01/11/2025, 01/19/2025, and 01/24/2025.

Review of Resident 23's 04/14/2025 order summary showed a 01/14/2025 physician's order instructing staff to refer the resident to a podiatrist for a right foot wound.

Review of Resident 23's comprehensive records on 04/21/2025 showed no progress notes, orders, or scanned documents indicating facility staff followed the wound provider's recommendation to refer Resident 23 to a podiatrist.

In an interview on 04/21/2025 at 8:11 AM, Staff G stated they were responsible for arranging the facility's podiatry services and confirmed Resident 23 was not seen by a podiatrist since the referral made in November 2024. Staff G stated the facility was having issues with podiatry services and did not currently have a date of when the podiatrist would be available to the facility.

In an interview on 04/21/2025 at 9:17 AM, Staff E (Assistant Director of Nursing) confirmed Resident 23 was not seen by a podiatrist as recommended. Staff E stated staff should have followed the wound provider's recommendation for a podiatrist but they did not.

Refer to:

F-Tag F658

F-F658 - Services Provided Meet Professional Standards.

Refer to

F-Tag F684

Harm Level: Minimal harm or

Residents Affected: Few Based on observation, interview, and record review the facility failed to identify, assess, and implement

F-F684

REFERENCE: WAC 388-97-1060(3)(j)(viii).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 45941

Residents Affected - Few Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions to prevent accidents for 1 of 1 resident (Residents 62) reviewed for smoking. These failures left

the resident at risk for injury and a diminished quality of life.

Findings included .

Record review of the facility policy titled, Smoking, revised 06/2023, showed the facility would screen all residents for smoking via the nursing admission evaluation. Residents who wished to continue smoking would have smoking reflected in their care plan. The policy showed the facility would store all smoking materials in a locked storage cabinet in the resident's room, at the nurse's station, or another designated location in the facility.

According to the 01/03/2025 Admission Minimum Data Set (MDS - an assessment tool), Resident 62 had clear speech, their memory was intact, and they understood others during communication. The MDS showed Resident 62 required one person assistance with transfers, toileting, and bed mobility. The MDS showed Resident 62 used a wheelchair for mobility.

In an interview on 04/14/2025 at 10:57 AM, Resident 62 stated they smoked once or twice a day and had their smoking materials in a drawer in their room. Resident 62 stated they knew the rule to not smoke on facility property and they had to go 50 feet away from the facility property.

Review of Resident 62's record showed Resident 62 did not have a smoking assessment completed.

Review of a Social Services evaluation completed on 03/31/2025 showed Resident 62 as a smoker.

In an interview on 04/16/2025 at 7:44 AM, Resident 62 stated the facility staff knew they smoked. Resident 62 stated the facility staff provided them with a metal lock box to keep their smoking materials in their room in

a drawer. Resident 62 stated they last smoked yesterday around 5:00 PM.

Observation on 04/16/2025 at 7:50 AM showed Resident 62 had a curtain of cigarettes and a lighter in a metal box in a drawer in Resident 62's room.

In an interview on 04/16/2025 at 8:44 AM, Staff G (Social Services Director) stated Resident 62 was not smoking currently. Staff G stated Resident 62 was found vaping outside the facility a couple of months ago and it was discussed with the resident that the facility was a non-smoking facility. Staff G stated they were not aware of Resident 62 currently smoking or of the lock box in their room.

In an interview on 04/16/2025 at 9:10 AM, Staff B (Director of Nursing) stated they were a non-smoking facility and everyone had to follow the facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0689 In an interview on 04/16/2025 at 9:15 AM, Staff D (Chief Nursing Officer) stated the facility was a non-smoking facility. Staff D stated they were unaware Resident 62 smoked or that Resident 62 kept Level of Harm - Minimal harm or smoking materials in their room. Staff D stated the expectation was to assess residents who smoked to potential for actual harm determine if they were safe to smoke independently or needed supervision, but they did not complete the smoking assessment. Residents Affected - Few

In an interview on 04/16/2025 at 9:36 AM, Staff A (Administrator) stated they were unaware Resident 62 smoked. Staff A stated the facility staff should complete the smoking assessment but they did not.

REFERENCE: WAC 388-97-1060(3)(g).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters (device that drains urine from the bladder to an external bag) had a valid medical justification for the use of or

a plan for discontinuation for one (Resident 36) of two residents reviewed for catheter use. These failures placed residents at risk for urinary tract infections and decline of normal bladder function.

Findings included .

According to the facility policy on indwelling catheters dated 12/2024, all residents with an indwelling catheter required a medical justification for the initiation and continuing need for catheter use. A comprehensive assessment included underlying factors supporting medical justification, determination of which factors could be reversed and development of a plan for appropriate indications for continuing use of an indwelling catheter beyond 14 days which may include: urinary retention that could not be treated or corrected medically or surgically, and characterized by documented post void residual volumes in a range over 200 mls (milliliters), inability to mange the retention/incontinence with intermittent catheterization, and persistent overflow incontinence (a type of urinary incontinence where the bladder doesn't empty completely, causing urine to leak out when it becomes too full), symptomatic infections, and/or renal (kidney) dysfunction, contamination of . pressure ulcer wounds

Resident 36 admitted to the facility on [DATE REDACTED] and according to the 12/10/2024 Admission Minimum Data Set (MDS - an assessment tool) had diagnoses including renal insufficiency but no obstructive uropathy (a condition where the normal flow of urine through the urinary tract is blocked, potentially leading to kidney damage) and no neurogenic bladder (a condition where damage to the brain, spinal cord, or nerves affected bladder control, leading to issues like urinary retention, incontinence, or both) . This MDS showed the resident had an indwelling urinary catheter. The 03/12/2025 Quarterly MDS showed a new diagnosis of obstructive uropathy.

Observation on 04/14/2025 at 10:31 AM revealed Resident 36 lying in bed, a catheter bag was attached to

the bed frame. In an interview at that time, the resident could not recall how long they had the catheter or why they had it stating, I have a shoddy memory.

In an interview on 04/16/2025 at 7:31 AM, Resident 36's family member stated Resident 36 did not have the catheter until they were hospitalized prior to (the resident's) admission to the facility. The family member stated the resident had, No previous need for the catheter, never had urinary problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0690 According to progress notes dated 12/06/2024 staff documented, Patient to start voiding trial (procedure to determine if a patient could empty their bladder adequately without the need for a catheter. The process Level of Harm - Minimal harm or typically involves removing a catheter, encouraging the patient to void into a measuring cup or container, and potential for actual harm then measuring the amount of urine voided and the amount of urine left in the bladder after voiding.) on the 9th. Residents Affected - Few Staff documented on 12/09/2024 at 2:33 PM, Foley catheter [discontinued] per provider order. Will monitor for ability to urinate. At 11:28 PM on 12/09/2024 staff documented, Foley catheter [discontinued]. Resident can go bedside commode to urine out several times. There was no indication facility staff documented the number of times the resident urinated, the volume of urine output, or attempted post void residuals (catheterizing the resident after urination to determine if urine remained in the bladder). There was no further assessment of the resident's urinary status until a note on 12/10/2024 at 1:51 PM when staff documented, Resident noted with urinary retention Foley catheter placed with 1000 cc (cubic centimeters) of urine return noted. Foley catheter left in place. Provider aware.

According to the Urinary Elimination Care Plan dated 12/06/2024, interventions included, Urology consult as needed but the record revealed staff did not consider a urology consult to confirm the resident's urinary retention could not be treated or corrected medically.

Record review showed no documentation to support the resident had untreatable urinary blockage or any history of being unable to void prior to the most recent hospitalization . There was no indication in the record facility staff considered prolonged use of the indwelling urinary catheter could lead to a decrease in bladder tone and function, or what interventions might be done to mitigate those effects.

In an interview on 04/18/2025 at 9:23 AM Staff C (Corporate Nurse) confirmed no post void residuals were obtained and there was no attempt at bladder retraining stating, We could have done better. Staff C confirmed staff failed to follow the facility policy to ensure the catheter was necessary.

REFERENCE: WAC 388-97-1060(3)(c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264 potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents maintained Residents Affected - Few acceptable parameters of nutritional status for 1 of 2 residents (Resident 17) reviewed for nutrition and staff offered and provided hydration services to 2 of 2 residents (Resident 7 & 35) reviewed for hydration. Failure to ensure consistent, timely weights, and act on the Registered Dietician (RD) recommendations, including reweighs, placed the residents at risk for delayed identification of interventions, and continued weight loss. Failure to offer and provide hydration services to residents placed all residents at risk for dehydration and decreased quality of life.

Findings included .

Resident 17 admitted to the facility on [DATE REDACTED] and according to the 07/31/2024 Admission Minimum Data Set (MDS - an assessment tool) the resident had diagnoses which included a brain injury causing the loss of muscle function, either complete or partial, in part of the body, and diabetes (unstable blood sugar levels), and weighed 260 lbs (pounds). The 01/31/2025 Quarterly MDS assessed the resident at 233 lbs and identified a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, but was on a prescribed weight loss regimen.

Observation on 04/16/2025 at 10:30 AM revealed Resident 17 lying in bed. At this time the resident stated

they had lost a lot of weight within the last year.

Review of Resident 17's weights showed large weight fluctuations without reweighs or assessments. On 08/28/2024 the resident was assessed to weigh 232.4 lbs with the next weight documented as 254 lbs on 09/03/2025, a weight gain of 21.6 lbs in less than a week. There was no reweigh until three weeks later on 09/28/2024 (at 251 lbs) and no assessment of the almost 22 lb weight gain. Resident 17's record showed no subsequent weight until 11/06/2024 when the resident was noted to weigh 242 lbs, a loss of 9 lbs. Staff documented monthly weights for Resident 17 until 02/04/2025 with the next subsequent weight obtained over six weeks later on 03/21/2025.

Weight records showed the resident weighed 227.2 lbs on 03/21/2025 and on 04/03/2025 weighed 203 lbs. Four days later, on 04/07/2025 staff documented the 04/03/2025 weight was incorrect and reweighed the resident at 213 lbs, which was a 14.2 lb (6.25%) weight loss in less than three weeks.

Review of the Therapeutic nutritional risk Care Plan (CP) dated 08/01/2024, showed Resident 17's goal was No significant changes [related to] inadequate oral intake, although gradual weight loss as able maybe beneficial. Resident 17's goal weight was 175 lbs. The CP for Resident 17 showed staff would monitor weight per protocol and weight loss desired by the resident and the RD would review/confirm appropriate goal weight. There were no interventions that directed staff when to weigh or reweigh the resident, when or what weight deviations to report, or what an objective, measurable safe weight loss goal was for any given period of time for Resident 17.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0692 In an interview on 04/17/2025 at 1:39 PM, when asked how staff knew when to weigh or reweigh residents, Staff C (Nurse Consultant) stated it should be on the CP. After reviewing Resident 17's record, Staff C Level of Harm - Minimal harm or confirmed staff were not reweighing the resident with noted weight changes and there should be, but were potential for actual harm not, documented assessments of those weight changes.

Residents Affected - Few In an interview on 04/17/2025 at 1:48 PM Staff D (Corporate Nurse) stated, I expect reweighs for +/- 5 lbs on

the same day or the following day. Staff D stated, The resident should be reweighed and there should be a measurable goal for safe weight loss for example one to two pounds per week.

In an interview on 04/17/2025 at 2:00 PM when asked what an objective, measurable safe weight loss would be for Resident 17, Staff Q (RD) replied, I would say within 5% (weight loss) for a month; 2% in a week. Staff Q confirmed for Resident 17, Yes we identified it (weight loss) was 6%. Staff Q was asked how staff were to ensure a weight loss does not exceed 5% in a month, when the weight loss of 6% was not identified until

after it occurred. No further information was provided.

47836

Review of the 11/08/2024 Annual MDS showed Resident 7 had no memory impairment. The MDS showed Resident 7 did not have swallowing difficulties.

Review of Resident 7's health records showed an 11/14/2024 at risk for dehydration CP indicating staff would encourage fluids with each care. Resident 7's health records showed a 04/03/2025 diet order with no restrictions on fluids.

In an interview on 04/15/2025 at 9:21 AM, Resident 7 stated staff do not bring them water. Resident 7 stated

they were always thirsty. Resident 7 stated they had to ask staff to bring them a water pitcher and sometimes

they would get one, but sometimes they would not come back with one.

Observation on 04/16/2025 at 8:56 AM showed staff did not offer Resident 7 hydration services. Resident 7 asked staff to bring them a water pitcher with fresh water.

According to a 06/29/2024 Admission MDS, Resident 35's ability to make daily decisions was severely impaired. The MDS showed a dehydration/fluid maintenance care area was triggered for Resident 35 and staff would assess and manage their fluid needs.

Review of Resident 35's health records showed a 06/22/2024 peripheral vascular disease related to diabetes CP with an intervention for staff to encourage good hydration.

Observations on 04/15/2025 at 12:05 PM showed no water pitcher or fluids available in Resident 35's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0692 In an interview on 04/18/2025 at 12:05 PM, Staff E (Assistant Director of Nursing) stated they expected staff to offer and provide water pitchers to all residents every shift and as needed. Staff E stated they expected Level of Harm - Minimal harm or staff to automatically provide hydration services, and the residents should not have to ask to get them. potential for actual harm REFERENCE: WAC 388-97-1060(3)(h). Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47836 Residents Affected - Some Based on observation, interview, and record review the facility failed to provide risks and benefits of bed rail use prior to installation, ensure proper installation of bed rails, and provide ongoing maintenance of bed rails for 5 of 5 residents (Resident 7, 24, 28, 35, & 17) reviewed for bed rails and 2 supplemental residents (Residents 30 & 22) reviewed. These failures placed residents at risk for injury, entrapment, and other negative health outcomes.

Findings included .

According to a facility policy titled, Safety Device Application, revised 04/07/2023, the facility would review safety devices with the resident and/or representative. The policy showed the facility would ensure proper installation as directed for the bed rails.

According to a 11/08/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 7 had no memory impairment.

Review of Resident 7's health records showed a 06/10/2022 physician order for the bilateral bed rails. Resident 7's records showed an 11/13/2024 safety device assessment form for the bed rails with the resident's guardian name typed in the information provided to box on the form.

Observation and interview on 04/15/2025 at 9:56 AM showed bilateral bed rails to Resident 7's bed. Resident 7 stated staff had not discussed the bed rail use with them.

According to a 01/05/2025 Annual MDS Resident 24 had short term and long-term memory impairment. The MDS showed Resident 24's daily decision ability was moderately impaired. The MDS showed Resident 24's primary language was not English. The assessment showed Resident 24's family participated in the assessment.

Review of Resident 24's health records showed a 02/28/2023 physician order for the bilateral bed rails. Resident 24's records showed a 01/18/2025 safety device assessment form for the bed rails with son typed

in the information provided to box on the form.

In an interview on 04/14/2025 at 9:25 AM Staff S (Registered Nurse) stated the maintenance department was responsible for proper safety device maintenance and installation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0700 Observation on 04/15/2025 at 10:52 AM showed bilateral bed rails to Resident 24's bed. Resident 24's right bed rail completely folded inward onto the bed when grabbed and the left bed rail was very loose, making Level of Harm - Minimal harm or them both unsafe for the resident to use for positioning in bed. potential for actual harm <Resident 28> Residents Affected - Some According to a 02/28/2025 Admission MDS Resident 28 had no memory impairment.

Review of Resident 28's health records showed a 03/18/2025 physician order for the bilateral bed rails.

Observation and interview on 04/14/2025 at 12:25 PM showed bilateral bed rails to Resident 28's bed. Resident 28 stated they did not use the bed rails because they did not want to depend on them. Resident 28 stated staff did not discuss the bed rail usage with them.

According to a 04/01/2025 Quarterly MDS Resident 35 had short term and long-term memory impairment.

The MDS showed Resident 35's daily decision ability was moderately impaired.

Review of Resident 35's health records showed a 03/25/2025 physician order for the right-side bed rail. Resident 35's health records showed a 03/25/2025 safety device evaluation form for the right-side bed rail with resident typed in the information provided to box, no signature for consent. Resident 35's health records showed they had severe cognitive impairment and had a Power of Attorney (POA - designee to make decisions on part for the resident) for their healthcare decision making.

Observation on 04/15/2025 at 12:57 PM showed a bed rail to Resident 35's right side of bed.

In an interview on 04/17/2025 at 9:00 AM Staff O stated they were unaware Resident 35 was unable to consent at the time and during this interview observed Resident 35 had severe cognitive impairment and had

a POA in place. Staff O stated Resident 35's POA was not notified of the risks and benefits of the bed rail use.

In an interview on 04/18/2025 at 9:20 AM Staff O stated they were unable to provide a copy of the notification signed by the resident/representative or a confirmation email notification of risks and benefits for Resident's 7, 24, or 28's bed rail use.

In an interview on 04/18/2025 at 9:26 AM Staff H (Maintenance) assessed Resident 35's bed rails to be loose. Staff H stated maintenance was responsible for installing the bed rails, and the nursing staff were trained on how to tighten them when they become loose. Staff H stated the bed rails never stayed put and always became loose. Staff H stated maintenance was not responsible for monitoring the ongoing proper installation of the bed rails and nursing staff were supposed to fix them when they noticed the rails were loose.

20264

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0700 Resident 17 admitted to the facility on [DATE REDACTED] and according to the most recent Quarterly MDS dated [DATE REDACTED] was assessed with a brain injury which caused the loss of muscle function and required partial to moderate Level of Harm - Minimal harm or assistance with rolling from lying on the back to left and right side. potential for actual harm

Observations on 04/14/2025 at 12:01 PM showed Resident 17 had loose bed rails on both the left and right Residents Affected - Some side of the bed. These rails were noted perpendicular to the bed rather than parallel to the bed with the rails extending up over the mattress. In an interview at this time Resident 17 stated they used the rails for bed mobility but they were, loose. Similar observations of Resident 17's bed rails were noted on 04/16/2025 at 7:40 and 10:27 AM.

During an observation on 04/16/2025 at 12:06 PM Staff C (Nurse Consultant) confirmed Resident 17's bed rails were loose and they should be checked on a regular basis and tightened as needed. When asked if the rails were properly installed (perpendicular rather than parallel to the bed) Staff C referred to Staff H.

In an interview on 04/16/2025 at 1:02 PM Staff H confirmed the rails on resident 17's bed should not be installed perpendicular stating I put them (the rails) on there right, the aides keep changing it .I changed it back. Staff H confirmed the aides should not alter the application of the bed rails.

Resident 30 admitted to the facility on [DATE REDACTED] and according to the Significant Change MDS dated [DATE REDACTED]

the resident was cognitively intact and was assessed with functional limitations in range of motion to both lower extremities and required partial/moderate assistance with bed mobility.

Observations on 04/14/2025 at 1:22 PM showed bed rails were installed on both the right and left sides of Resident 30's bed. When the left rail was noted as loose, Resident 30 wiggled the right rail stating, Check

this other one, it's loose too. Similar observations of Resident 30's loose rails were noted on 04/16/2025 at 8:17 AM and 12:56 PM.

45941

According to the 03/13/2025 Quarterly MDS Resident 22 admitted to the facility on [DATE REDACTED], and had chronic pain in their knees. Resident 22 was cognitively intact, was assessed with functional limitations in range of motion to both lower extremities, and required extensive assistance with bed mobility.

Review of Resident 22's record showed the 09/23/2024 physician order under safety device for the bilateral bed rails for mobility. The 09/03/2024 physician order under nonpharmacological interventions to reduce pain for the resident was repositioning in bed.

Review of the 09/23/2024 Safety devise CP showed Resident 22 had bed mobility bars related to muscle weakness and instructed staff to observe the safety device for changes regarding effectiveness of the safety device and report changes to the charge nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0700 Observation and interview on 04/14/2025 at 12:04 PM showed Resident 22 lying in their bed on their back.

The observation showed side rails were installed on both the right and left sides of Resident 22's bed. The Level of Harm - Minimal harm or rail on the right side bed rail was up and the rail on the left side of the bed was down. Resident 22 stated potential for actual harm they reposition themselves with side rails in bed, but the left side of the bed rail was broken for a few days, and they could not reposition themselves in bed. Resident 22 stated staff knew about the left side rail was Residents Affected - Some broken and maintenance director was supposed to fix it, but it was not done yet. Similar observations of the left, non-functional side rail were noted on 04/15/2025 at 10:12 AM, 04/16/2025 at 9:03 AM and 2:24 PM, on 04/17/2025 at 12:25 PM.

In an interview on 04/17/2025 at 10:08 AM, Staff H stated they were not aware of the broken left side rail for Resident 22's bed. Staff H stated there was no record of Resident 22's left bed rail being broken on the maintenance log.

In an interview on 04/17/2025 at 12:55 PM, Staff E stated they were not aware of the broken side rail on Resident 22's bed. Staff E stated they expected staff to notify the maintenance department about the broken side rail so maintenance could fix it, but staff did not.

REFERENCE: WAC 388-97-1060(3)(g), -2100 (1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 20264 potential for actual harm Based on observation, interview, and record review the facility failed to ensure a medication error rate of less Residents Affected - Some than 5%. Failure to properly administer 5 of 25 medications for 3 of 4 residents (Residents 2, 30, & 19) observed during medication pass resulted in a medication error rate of 20%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications.

Findings included .

According to the facility policy on ophthalmic (eye) drops, dated 11/15/2024, when administering multiple medications to the same eye, staff would wait 3-5 minutes between drops and staff would apply gentle pressure to the tear duct after administration or instruct the resident to close their eye. Waiting between eye drops was important to maximize their effectiveness and prevent potential side effects. It allows each drop to be absorbed by the eye before the next one is administered, preventing dilution and ensuring the medication stays in contact with the eye longer. Failure to follow Physician Ordered time parameters between eye drops decreases effectiveness of the respective medication and constitutes a medication error. Pressing gently on

the tear duct, the small opening in the inner corner of the eye, after applying eye drops helps prevent the medication from draining into the nose and throat and ensures adequate dosage. This technique helps keep

the medication in the eye longer, allowing it to be absorbed more effectively and potentially reducing systemic side effects. The facility procedure for oral metered dose inhalers instructed staff to wait 20-30 seconds between administration of doses for the same medication, and 2-5 minutes if medications were different.

Observation on 04/16/2025 at 8:21 AM showed Staff J (Licensed Practical Nurse) bring multiple medications into Resident 2's room, administering them in quick succession. Staff J was observed to administer two drops of an eye drop into each of Resident 2's eyes at 8:26 AM. Staff J then administered a nasal spray according to physician orders at 8:26 AM. Staff J administered one drop of another medicated eye drop to

the left eye at 8:26 AM and proceeded to give a tissue to the resident who then wiped their eye. Staff J did not instruct Resident 2 to apply gentle pressure to the tear duct after eye drop administration or instruct the resident to close their eye per facility policy. These medications for Resident 2 were scheduled on the Medication Administration Record (MAR) to be given at 7:00 AM. Staff J administered another medicated inhaler at 8:26 AM to Resident 2. Staff J then administered a different medicated eye drop at 8:27 AM to Resident 2's left eye. The resident blinked and wiped their eye with a tissue. Staff J did not instruct Resident 2 to depress the tear duct or close their eye as directed in the facility policy. According to the manufacturer insert for this eye drop, there should be a 5-minute wait between eye drop administrations but the MAR instructed staff to wait only three to ten minutes between administration from other eye drops. Staff J then administered two puffs of another inhaler at 8:27 AM.

In an interview on 04/16/2025 at 8:29 Staff J stated, I know I gotta wait like 5 minutes between eye drops and

they want you to wait a couple of minutes between the inhaler.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0759 In an interview on 04/16/2025 at 9:23 AM Staff B (Director of Nursing) and Staff C (Nurse Consultant) stated

the spacing between the inhalers, should be at least five minutes. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/16/2025 at 1:50 PM, Staff B and Staff C confirmed this was an error and the medicated eye drops should be given before 8:00 AM and not within 3 minutes of other eye drops. Residents Affected - Some <Resident 30>

Observation of medication pass on 04/14/2025 at 12:50 PM showed Staff J obtain a blood sugar level of 230 from Resident 30, after the resident had started consuming their meal. Staff J then administered an injectable medication to Resident 30 based on blood sugar parameters in the physician order.

According to the April 2025 MAR, the blood sugar check and injectable medication coverage for the blood sugar results was ordered for 11:30 AM but completed at 12:52 PM.

In an interview on 04/16/2025 at 9:23 AM, Staff B and Staff C confirmed if the physician's order for blood sugar check and the injectable medication were scheduled at 11:30 AM, they should be done within 30 minutes of that scheduled time. Staff B and Staff C stated if the injectable medication was done late, You need to call the doctor .yes that would be an error.

47836

Observation of medication pass on 04/16/2025 at 7:00 AM showed Staff W (Licensed Practical Nurse) administer Resident 19 nine medications.

Review of Resident 19's physician orders on 04/16/2025 showed one of the nine medications administered to the resident was not ordered for Resident 19. Resident 19's records showed a single stool softener ordered for the residents that Staff W did not administer and instead Staff W administered a medication that had two stool softeners in one tablet.

In an interview on 04/16/2025 at 9:38 AM, Staff W stated they administered the wrong stool softener to Resident 19. Staff W stated they should have administered the single stool softener and not the medication with two stool softeners in it.

In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) stated they expected staff to follow physician orders when administering residents their medications. Staff E stated it was important to follow physician orders to ensure administration of correct medications.

REFERENCE: WAC 388-97-1060(3)(k)(ii).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264 Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with current accepted professional standards in 2 of 2 medication carts and 1 medication room reviewed. Additionally, the facility failed to ensure medications were stored in a secure manner for 1 (Resident 52) of 1 residents with medications at bedside. These failures placed residents at risk to receive expired and/or improperly administered medications and biologicals.

Findings included .

Observation of Medication Cart A on [DATE REDACTED] at 7:44 AM revealed a topical skin treatment that suppresses

the immune system for Resident 22 which was discontinued on [DATE REDACTED] and a topical cream used to treat fungal or yeast infections for which there was no current order. In an interview at this time, Staff S (Registered Nurse) indicated the resident no longer received either of the treatments stating, they should be discarded. A topical treatment to decrease inflammation was noted for Resident 49. Staff S stated, (The resident) doesn't have an order for that anymore, it should be removed.

Observation of Medication Cart B showed a bottle of heart medication used to treat chest pain for Resident 220 who discharged from the facility on [DATE REDACTED], over six months ago, and for Resident 221 who discharged from the facility on [DATE REDACTED], 10 months ago. Another bottle of this medication was noted and was not labeled with a resident name, prescribing physician, or directions for use. A Hemoccult test fluid (a chemical used to test stool samples) was stored in with the oral medications.

The medication cart contained: a topical treatment to treat dry or scaly skin for Resident 222 who discharged from the facility on [DATE REDACTED]. A medicated topical treatment to treat infected skin lesions was observed for Resident 23 which was discontinued on [DATE REDACTED]. An ointment used to treat fungus infections for Resident 23 which was ordered [DATE REDACTED] and discontinued on [DATE REDACTED]. A second treatment to treat fungal infections for Resident 23 was dispensed on [DATE REDACTED]. According to Staff J (Licensed Practical Nurse) the resident, doesn't use that anymore and, we should get rid of it. An open bottle of irrigation solution (used to clean wounds) was observed and dated [DATE REDACTED] but did not have a resident name on the bottle.

In an interview on [DATE REDACTED] at 10:11 AM, Staff J stated medications and treatments should be removed from

the medication cart when the treatments were discontinued or if the resident discharged from the facility. Staff J confirmed staff should have, but did not, remove the medications and treatments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 Observation of the Medication Room refrigerator on [DATE REDACTED] at 8:35 AM revealed an open, undated bottle of

an injectable medication used to test for Tuberculosis (a communicable respiratory disease) and a vaccine Level of Harm - Minimal harm or for shingles (a painful, blistering rash caused by a virus) syringe for Resident 39 that was dispensed on potential for actual harm [DATE REDACTED] but not administered. In an interview at this time, Staff L (Licensed Practical Nurse) stated the Tuberculosis testing solution should be dated when opened and the vaccine medication should be Residents Affected - Few administered or destroyed.

Observation at this time showed 15 bags of Intravenous antibiotics were identified in the refrigerator for Resident 28. While the order for the antibiotic was discontinued on [DATE REDACTED], additional bags of antibiotics were dispensed by the pharmacy on [DATE REDACTED] and [DATE REDACTED]. In an interview on [DATE REDACTED] at 10:33 AM, Staff C (Corporate Nurse) stated staff should have contacted the pharmacy after the medication was received on [DATE REDACTED] and destroyed the medication when there was no longer an order for it.

In an interview on [DATE REDACTED] at 10:35 AM Staff C stated staff should dispose of discontinued medications, as soon as possible, we try to do it once a week. When asked at what time, after a resident is discharged , their medications should be destroyed/removed from the medication cart, Staff C stated, I would take it out within 24 hours of discharge.

Observations on [DATE REDACTED] at 12:41 PM showed Resident 52 had a bottle of vision supplements for eye health and one bottle of multivitamins on their overbed table. Similar observations were noted on [DATE REDACTED] at 7:38 AM and [DATE REDACTED] at 8:31 AM.

In an interview on [DATE REDACTED] at 12:14 PM Staff E (Assistant Director of Nursing), confirmed the presence of the unsecured medications at the bedside and stated the resident should have their medications in a lockbox. Staff E stated staff should, but did not, report when they found medications at the bedside.

REFERENCE: WAC [DATE REDACTED](1)(B)(II), (c)(ii-iv)(2).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 20264

Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure food was served under sanitary conditions. Facility staff failed to: monitor and ensure adequate sanitation for the dishwasher and ensure staff reported when sanitation levels were inadequate. These failures placed residents at risk for food-borne illness.

Findings included .

Observation of the kitchen during rounds, on 04/17/2025 at 9:47 AM, showed Staff I (Dishwasher) running dishes from breakfast service through the dishwasher. Staff F (Dietary Manger) explained the facility used a low temperature dishwasher which required chemical sanitation (Chlorine used to kill viruses, bacteria, and other microorganisms to prevent foodborne illness) to clean dishes and kitchen utensils stating, I try to keep

it (test strips which registered chlorine) at 200 Parts Per Million. During this observation, Staff F, tested the dishwasher for proper sanitizing solution. The chlorine test strip was dipped into the dishwasher water and was noted to be white, indicating an absence of chlorine. Staff F tested for adequate levels of sanitizer two additional times with the same results of a white strip (no/low levels chlorine/sanitizer in the solution).

In an interview at 9:54 AM, Staff F stated the dishwasher checks for sanitizer three times a day with each meal but was unable to locate the log that staff used to documented testing of the dishwasher function.

Staff I, in an interview on 04/17/2025 at 9:47 AM stated the sanitizer test was really low when it was checked

before breakfast. Staff I acknowledged that if the test strip remained white it meant, there was no chemical. When asked to whom this issue was reported, Staff I replied, No one. In an interview at this time, Staff F stated Staff I should have reported there was no sanitizer and that the log on which staff documented the sanitation levels was missing.

Staff F proceeded to contact the company that services the dishwasher, and was instructed to Prime the sanitizer bucket by toggling a switch on the side of the dishwasher. Observations on 04/17/2025 at 10:52 AM, showed that after replacing the sanitizer bucket and priming the machine two times, chlorine levels were noted to meet required sanitizing levels.

Further interview revealed Staff F replaced the sanitizer bucket the previous day at 3:00 PM but was not aware of the need to prime the new sanitizer bucket. Staff F said it was reasonable to conclude the sanitizer was not functioned since then.

Staff F was requested to provide documentation to support staff were educated / trained on how to replace

the sanitizer bucket and what to do if inadequate amounts of sanitizer were noted. No information was provided.

REFERENCE: WAC 388-97-1100(3) & -2980.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264

Residents Affected - Few Based on interview and record review, the facility failed to maintain complete and accurate records for 10 (Residents 17, 52, 61, 40, 47, 6, 7, 36, 62, & 35) of 20 current sampled residents reviewed and 15 supplemental residents (9, 2, 51, 19, 27, 32, 4, 5, 18, 15, 29, 49, 24, 33, & 21) reviewed. The facility failed to ensure: physician orders were clear/accurate, assessment documents accurately reflected resident condition, behaviors were monitored, personal inventories were accurate/updated/available, informed consents were signed/dated, and resident inventory lists were complete. Failure to ensure clinical records were complete and accurate placed residents at risk of not having their needs met.

Findings included .

Resident 17 admitted to the facility on [DATE REDACTED] and according to the most recent Quarterly Minimum Data Set (MDS - an assessment tool) was assessed as cognitively intact with multiple medically complex diagnoses, including diabetes.

Record review showed a Podiatry Consult dated 09/19/2024 that was not scanned into the resident's record until 02/11/2025. Record review showed no subsequent Podiatry Consults.

In an interview on 04/16/2025 at 7:24 AM Staff G (Social Service Director) provided a 02/26/2025 Podiatry Consult for Resident 17, which was not in the residents records. Staff G stated the consults were provided to Medical Records, who should scan the consults into the record. Staff G stated they kept a notebook with the visits as backup but confirmed it was important for medical consults to be scanned into resident records.

Resident 61 admitted to the facility on [DATE REDACTED] and according to the 04/04/2025 Quarterly MDS had multiple medically complex diagnoses, including diabetes.

Record review on 04/21/2025 showed no documented Podiatry Consults in Resident 61's health records.

In an interview on 04/16/2025 at 7:24 AM Staff G provided a 02/26/2025 Podiatry Consult for Resident 61, which was not in the record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0842 Record review for Residents 52, 40, 47, 6, 7, 36, 62, and 35 showed evidence these sample residents received Podiatry services on 02/26/2025. Record review performed on 04/21/2025 for supplemental Level of Harm - Minimal harm or residents 9, 2, 51, 19, 27, 33, 32, 4, 5, 18, 15, 29, 49, 24, & 21 showed they received Podiatry services on potential for actual harm 02/26/2025 had no documentation in the record to support the visits occurred. In an interview on 04/16/2025 at 7:24 AM, Staff G confirmed documentation to support these services occurred were not in the resident's Residents Affected - Few records.

Refer to

F-Tag F700

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264

Residents Affected: Some professional standards of practice for 7 of 20 (Residents 36, 54, 30, 17, 7, 64, & 52) residents reviewed.

F-F700- Bedrails

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264 potential for actual harm Based on observation, interview, and record review the facility failed to ensure services provided met Residents Affected - Some professional standards of practice for 7 of 20 (Residents 36, 54, 30, 17, 7, 64, & 52) residents reviewed. Nursing staff failed to: follow or clarify physicians orders when indicated, document for only those tasks completed, monitor residents for significant medication dose changes, follow up on appointment recommendations from outside providers, and to monitor residents for side effects for the treatment received at appointments in outside clinics. These failures placed residents at risk for medication errors, delay in treatment, adverse outcomes, and diminished quality of care.

Findings included .

Resident 52 admitted to the facility on [DATE REDACTED] and according to the most recent Quarterly Minimum Data Set (MDS-an assessment tool) received regularly scheduled and as needed pain medication.

Review of March 2025 Medication Administration Records (MARs) showed a Physician's Order for a pain patch Apply to bilateral (both) knees topically one time a day for Pain Do not exceed 3 patches for up to 12 hours (hr) with 24 hr period. Wash hands after handling and remove per schedule. The order directed staff to apply the patches at 9:00 AM and remove them at 5:59 AM next morning. According to the MAR, staff applied the patches for 15 hours per day rather than the 12 hours as directed.

A second order directed staff to apply a pain patch to Bilateral shoulders topically one time a day for (joint disease). Do not exceed 3 patches for up to 12 hrs with 24 hr period. Wash hands after handling and remove per schedule. This order similarly directed staff to apply the patches at 9:00 AM and remove them at 5:59 AM. According to the MAR, staff applied the patches for 15 hours per day rather than the 12 hours as directed.

After reviewing the MAR, in an interview on 04/16/2025 at 10:56 AM Staff C (Nurse Consultant) stated, The patch should only be on for 12 hours, the nurse should have clarified the order since the time code indicated

a time of greater than 12 hours. Staff C also confirmed that the nurses, by following the physicians orders would exceed the do not exceed 3 patches directive and should have clarified the order.

Observation of the resident on 04/15/2025 at 12:07 PM showed the resident had an undated white patch applied to the right shoulder. Observations on 04/16/2025 at 10:26 AM showed the resident had an undated white patch applied to the right shoulder.

During observations of the resident on 04/16/2025 at 10:56 AM, Staff C stated the nurse who applied the patch to the right shoulder should have, but did not, initial and dated it upon application.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0658 Examination of the resident's left shoulder revealed no pain patch. The resident stated at this time My left shoulder is fine, it's my neck that hurts. Further examination showed staff applied a pain patch to the Level of Harm - Minimal harm or resident's neck without a physician order to do so. In an interview on 04/16/2024 at 10:56 AM Staff C stated, potential for actual harm No, there shouldn't be a patch on the neck, there is no order. Nurses should not apply medicated patches without physician's orders. Residents Affected - Some Examination of the resident's knees showed pain patches to each knee dated 04/14/2025. In an interview on 04/16/2025 at 10:56 AM Staff C stated, The patches should be dated for today (04/16/2025).

Review of the April 2025 MARs showed nursing staff documented the 04/14/25 knee pain patches were removed and that new patches were applied and removed on 04/15/2025. In an interview on 04/16/2025 at 10:56 AM, Staff C confirmed Resident 52 did not get medications as ordered and that nursing staff signed for tasks that were not performed.

Additionally, according to April 2025 MAR staff were instructed to obtain weights on 04/01/2025 but documented, NA, rather than a weight.

In an interview on 04/16/2025 at 10:44 AM, Staff C stated, We don't force residents, but the nurses should reattempt the weight and document a progress notes as to why they couldn't get the weight, then reattempt it later.

Review of March and April 2025 MARs showed Resident 52 had as needed orders for as needed muscle relaxant and as needed pain medication at the same time on 03/06,15, 24, 29 and 30/2025 and on 04/05/2025 and 04/09/2025.

In an interview on 04/16/2025 at 10:39 AM. Staff C stated that nursing staff should give the muscle relaxant medications first to relieve the muscle spasms which might be causing the pain, then the pain medication if it was still needed. Staff C stated the medications should not be given together unless the order directs to do so.

Resident 17 admitted to the facility on [DATE REDACTED] and according to the Admission MDS dated [DATE REDACTED] had diagnoses which included anxiety disorder which required the use of antianxiety medication.

Record review showed Resident 17's antianxiety medication dose was doubled on 09/16/2024. Resident 17's records showed a 09/16/2024 progress note, Patient received new order antianxiety medication TID (three times a day) for Anxiety. There was no alert charting to monitor Resident 17 for any changes or effects of the significant increase in dosage.

In an interview on 04/18/2025 at 9:41 AM Staff C stated Yes, there should be alert charting for doubling the antianxiety medication, but no there wasn't.

Review of April 2025 MARs showed a physician order for (Medication used to treat heartburn) Give 1 tablet by mouth one time a day for GERD for 14 Days 30 minutes before other (medications). According to the MAR, this medication along with six other oral medications were scheduled for 0600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0658 In an interview on 04/16/2025 at 10:39 AM. Staff C stated the nurse should have clarified the orders to ensure the heartburn medication was given on an empty stomach. Level of Harm - Minimal harm or potential for actual harm <Resident 36>

Residents Affected - Some Resident 36 admitted to the facility on [DATE REDACTED] and according to the 12/10/2024 Admission MDS had multiple medically complex diagnoses, including Vitamin D deficiency.

Review of Resident 36's hospital discharge records showed orders for staff to administer Vitamin D supplement tablet once a week. Nursing staff transcribed this order for Resident 36 as daily and continued to administer it for nine days until 12/18/2024. Pharmacy review identified the vitamin D error for Resident 36.

In an interview on 04/17/2025 at 1:07 PM Staff C acknowledged failure of the nurse to transcribe the physician orders correctly resulted in a medication error for Resident 36 and did not meet professional standards of practice.

Observation of medication pass on 04/14/2025 at 12:50 PM showed Staff J (Licensed Practical Nurse) obtain

a blood sugar level of 230 from Resident 30, after the resident had started consuming their meal. Staff J then administered three units of an injectable medication based on the sliding scale order.

In an interview on 04/16/2025 at 9:23 AM, Staff B (Director of Nursing) and Staff C confirmed the physician's order for blood sugar check and the injectable medication was scheduled at 11:30 AM, which was before lunch and obtaining blood sugars after Resident 30 initiated a meal placed the resident at risk for elevated blood sugars which would require higher doses of the injectable medication.

45941

According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility on [DATE REDACTED] and had diagnoses including rectal cancer, malnutrition, and chronic pain. The MDS showed Resident 54 was independent with daily activities and ambulation.

In an interview on 04/14/2025 at 1:34 PM, Resident 54 was awake, sitting on the edge of their bed in their room, stating they were tired. Resident 54 stated they had cancer and had appointments with cancer doctors at least 4 days a week. Resident 54 stated they were going to be out of the facility for appointments on 04/15/2025, 04/16/2025, 04/17/2025, and 04/18/2025 and then had no appointments for two weeks.

Observation on 04/17/2025 8:45 AM showed Resident 54 was walking in their room, stating their appointment was longer yesterday. Observation showed an Intravenous (IV) catheter on Resident 54's right chest, covered with a dressing. Resident 54 had a pump in their hand with tubing attached to their IV catheter and stated their cancer doctor provided them this pump for cancer medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0658 Review of Resident 54's health record showed nursing progress notes on 04/15/2025 and 04/16/2025 indicating Resident 54 was out of the facility for appointments. No documentation showed Resident 54 came Level of Harm - Minimal harm or back from the appointments with any new medication orders or recommendations. potential for actual harm

Review of Resident 54's April 2025 physician orders showed no order for the IV catheter, dressing change, Residents Affected - Some to monitor the IV site for any symptoms of infection, and to monitor the resident for any side effects of chemotherapy medications Resident 54 received at the cancer clinic during the appointments.

In an interview on 04/17/2025 at 1:03 PM, Staff E (Assistant Director of Nursing) stated they were not aware Resident 54 had an IV catheter on their right chest area or a pump for medication. Staff E reviewed Resident 54's record and stated there was no order for an IV line or pump. Staff E stated staff should check with the resident for any new orders from oncologist when Resident 54 returned from appointments and document in their record, but they did not.

46479

According to the 03/11/2025 Admission MDS, Resident 64 had unclear speech, was usually understood, and was able to understand others. The MDS showed Resident 64 had diagnoses including stroke, malnutrition, and a swallowing disorder due to the stroke. The assessment showed Resident 64 received nutrition via a tube surgically placed in their stomach.

Review of Resident 64's 04/16/2025 order summary report showed the resident had a 03/04/2025 order directing staff the resident was to have nothing by mouth.

Review of Resident 64's April 2025 MAR showed an order directing staff to offer the resident a snack at bedtime and document the percentage of the snack consumed by Resident 64. The MAR showed from 04/01/2025 to 04/17/2025, staff documented Resident 64 ate 100% of the snack offered on 11 of 17 opportunities. Staff documented not applicable on one occasion and a dash or 0 on 4 occasions.

In an interview on 04/18/2025 at 10:21 AM, Resident 64 stated staff did not bring them or offer snacks at bedtime because they were unable to swallow.

In an interview on 04/21/2025 at 10:20 AM, Staff E confirmed Resident 64 had a nothing by mouth order. Staff E stated staff should not be documenting tasks that were not done and staff should have clarified the order to provide Resident 64 with a snack at bedtime.

47836

According to a 11/08/2024 Annual MDS Resident 7 experienced frequent 6/10 pain on a pain scale of 1-10 with 10 being the worst pain they've experienced. The MDS showed Resident 7 received scheduled pain medication during the assessment period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0658 Review of Resident 7's health records showed a 02/24/2025 physician order for an as needed pain medication without parameters. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/17/2025 at 9:24 AM Staff O (Resident Care Manager) stated Resident 7 had no pain level or maximum dose in 24 hours parameter in place for their as needed pain medication. Staff O stated Residents Affected - Some Resident 7's pain medication should not exceed 3000 milligrams in 24 hours and the order should include this.

REFERENCE: WAC 388-97-1620(2)(b)(ii).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264 potential for actual harm Based on observation, interview, and record review the facility failed to provide assistance with Activities of Residents Affected - Some Daily Living (ADLs) for 5 of 12 (Residents 61, 22, 62, 54, & 31) who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance including bathing, oral care, and nail care as required, left residents at risk for poor hygiene, soiled long nails, diminished feelings of self-worth, and other negative health outcomes.

Findings included .

Resident 61 admitted to the facility on [DATE REDACTED] and according to the 04/04/2025 Quarterly Minimum Data Set (MDS - an assessment tool) was assessed with a brain injury which caused the loss of muscle function and aphasia (a disorder that affects a person's ability to communicate), and was dependent on tube feeding (a method of delivering nutrients to individuals who cannot or will not eat or drink enough food to meet their nutritional needs). This MDS assessed the resident as dependant on staff for all care, including personal hygiene.

According to the resident's 01/22/2025 Care Plan (CP) for ADLs staff should provide oral care every shift with a toothette or glycerin sponge.

Observations on 04/14/2025 at 12:13 PM revealed Resident 61 had long fingernails to both hands and dried debris along the left side of their mouth. A partial view of the resident's mouth showed yellow film/debris on their teeth and along the gum line. Similar observations were made on 04/16/2025 at 1:02 PM and 04/17/2025 at 1:22 PM.

During an observation on 04/18/2025 at 10:44 AM, Staff B (Director of Nursing) stated, (The resident) has really bad breath, the teeth look brown and do not look clean. Staff B confirmed it appeared no oral care was done stating, It does not look like oral care has been happening

45941

According to the 03/13/2025 Quarterly MDS, Resident 22 had intact memory and had a diagnosis of depression and edema (swelling caused by fluid build up in body tissues) on both legs. The MDS showed Resident 22 was dependent on staff for showers, toileting hygiene, and lower body dressing. Resident 22 required one-person assistance with personal hygiene and transfers. The MDS showed Resident 22 did not refuse care during the assessment period.

The 10/21/2024 revised ADL Self Care deficit CP showed Resident 22 was totally dependent on staff for bathing and Resident 22 preferred showers twice a week. The CP showed Resident 22 required extensive assistance from staff for personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0677 Observations on 04/14/2025 at 11:55 AM, 04/15/2025 at 9:21 AM, and 04/17/2025 at 12:08 PM, showed Resident 22's fingernails were long and dirty, their toenails were thick, and there was dry flaky skin on both Level of Harm - Minimal harm or feet. Their lower legs were wrapped with elastic bandages. potential for actual harm

In an interview on 04/14/2025 at 11:55 AM, Resident 22 stated they wanted to have showers twice a week, Residents Affected - Some but staff provided only bed baths because of the bandages wrapped on Resident 22's legs. Resident 22 stated staff did not wash their feet for a few weeks.

Review of the Certified Nursing Assistant (CNA) documentation from 03/25/2025 through 04/19/2025 showed Resident 22 received four bed baths in 30 days and no shower was provided. This documentation showed no nail care was documented as provided. There were no documented refusals of nail care assistance.

In an interview on 04/17/2025 at 12:52 PM, Staff E (Assistant Director of Nursing) reviewed Resident 22's CP and stated Resident 22 should receive showers twice a week but staff provided bed baths. Staff E stated staff should remove Resident 22's bandages from their legs and provide showers but they did not. Staff E stated nail care was important for dependent residents. Staff E stated shower aides and nurses were educated to clip resident's nails weekly and as needed, but staff did not follow the instructions.

According to the 01/03/2025 Admission MDS, Resident 62 required one person assistance from staff with personal hygiene, toileting needs, and bathing. The MDS showed no refusal of care behaviors during the assessment period.

The 01/08/2025 revised ADL Self Care deficit CP showed Resident 62 required extensive assistance from staff with personal hygiene needs.

Observations on 04/14/2025 at 10:46 AM, 04/16/2025 at 7:38 AM, and on 04/17/2025 at 10:41 AM showed Resident 62 had long fingernails and had black debris under their nails. Resident 62 stated they need assistance from staff to clip their fingernails.

In an interview on 04/17/2025 at 12:55 PM, Staff E stated staff should provide nail care to all residents weekly on their shower days and as needed. Staff E stated any refusals should be documented in resident's records and notify the supervisor.

According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility with rectal cancer and chronic pain, and required one person assistance from staff for bathing. The MDS showed no refusal of care

during the assessment period.

Observation on 04/14/2025 at 11:22 AM and 04/15/2025 at 12:40 PM showed Resident 54 had long, sharp, and broken fingernails and had black debris under their fingernails. Resident 54 stated they need help to cut their fingernails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0677 Review of April 2025 CNA documentation showed no nail care was documented to be provided. There were no documented refusals of nail care assistance. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/17/2025 at 1:00 PM, Staff E stated staff should provide nail care to all residents weekly

on their shower days and as needed. Staff E stated any refusals should be documented in resident's records Residents Affected - Some and notify the supervisor.

46479

According to the 02/25/2025 Admission MDS, Resident 31 was cognitively impaired, had clear speech, was usually understood, and could usually understand others. The assessment showed Resident 31 required supervision or touching assistance with personal hygiene.

Observation on 04/17/2025 at 11:27 AM showed Resident 31 lying in bed, with their right foot exposed. The toenails were long, extending past the toes. At that time, Staff X (CNA) observed and confirmed Resident 31's toenails were long. Staff X removed Resident 31's sock on the left foot revealing long toenails to the resident's left foot.

Review of Resident 31's April 2025 CNA task documentation showed staff were to document every day shift if staff provided nail care to the resident. This documentation showed staff documented Y for yes-nail care was provided to the resident on 04/15/2025. This documentation did not specify if the nail care provided was to the resident's finger or toe nails.

Review of Resident 31's 04/16/2025 physician orders and 03/31/2025 Activities of Daily Living CP showed no orders or directions to staff regarding what assistance the resident required for finger or toe nail care, or who was to provide the care and when.

In an interview on 04/21/2025 at 9:28 AM, Staff E stated nail care should be done as needed. Staff E stated

they expected CNAs to report to the nurse if they noted long toe nails on a resident. Staff E stated they expected nurses to note long toe nails on weekly skin checks and provide trimming as needed.

REFERENCE: WAC 388-97-1060(2)(c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46479 potential for actual harm Based on observation, interview, and record review the facility failed to: ensure residents received follow up Residents Affected - Few appointments as recommended for wound treatment for 1 (Resident 23) of 1 resident reviewed for referral follow up, ensure residents' skin was assessed, monitored, and treated as required for 2 (Resident 30 & 52) of 5 residents reviewed for non-pressure skin, and ensure blood work was obtained for 1 (Resident 7) reviewed. These failures placed all residents at risk for delay in treatment, worsening of conditions, unmet care needs, and a decreased quality of life.

Findings included .

Review of the 02/08/2025 Minimum Data Set (MDS - an assessment tool) showed Resident 23 had diagnoses including heart failure, end-stage kidney failure, and diabetes (inability to control their blood sugar levels). The MDS showed Resident 23 had a diabetic foot ulcer.

Review of Resident 23's physician orders showed an 11/20/2024 order directing staff to refer the resident to infectious disease for a bone infection to their right, second toe.

Review of an 11/22/2024 consulting wound provider progress notes showed Resident 23 was being treated for a diabetic foot ulcer. This note showed Resident 23 had a bone infection to the ulcer area. The wound provider referred Resident 23 for an infectious disease consult.

Review of a 01/08/2025 staff progress note showed Resident 23 had an appointment with infectious disease scheduled for that day but the appointment was rescheduled to 01/22/2025.

Observation on 04/14/2025 at 10:27 AM showed Resident 23 lying in bed. Resident 23 had a small, open, scabbed area to their second toe on their right foot.

Review of Resident 23's comprehensive records on 04/18/2025 showed no further progress notes indicating Resident 23 went to their appointment with infectious disease on 01/22/2025 as scheduled. There were no scanned documents or appointment recommendations in the resident's record.

In an interview on 04/18/2025 at 9:09 AM, Staff E (Assistant Director of Nursing) reviewed Resident 23's records and confirmed the resident did not attend their appointment on 01/22/2025. Staff E stated it was important for staff to ensure Resident 23 attended their infectious disease appointment to ensure the resident did not have an underlying infection.

20264

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 Resident 30 admitted to the facility on [DATE REDACTED] and according to the 03/05/2025 Significant Change MDS, the resident was cognitively intact and required care related to fractures and other multiple traumas. Resident 30 Level of Harm - Minimal harm or was assessed with multiple skin issues including pressure ulcers, functional limitations in range of motion to potential for actual harm both lower extremities, and was dependant on staff for toileting, bathing, and dressing the lower extremities.

Residents Affected - Few Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with a moderate amount of crusty, reddish debris on the medial (inside) left great toe nail bed. The resident stated, I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed .No, I haven't seen a podiatrist since I've been here.

During observations on 04/18/2025 at 10:19 AM, Staff B (Director of Nursing) confirmed the resident had brownish rust colored discharge to both the left and right great toes and the resident appeared to have, ingrown toenails. Staff B stated nursing staff should have noted these skin issues during the daily treatments to the feet and notified the provider to ensure treatment.

Review of April 2025 Treatment Administration Records (TARs) showed staff provided daily treatments to both feet. According to the 04/16/2025 Total Body Skin evaluation weekly form, there was a treatment to the right heel, an open area left lower leg, and a pressure ulcer to their tailbone.

Resident 52 admitted to the facility on [DATE REDACTED] and according to the 02/24/2025 Quarterly MDS, Resident 52 had heart disease, and was dependant on staff for toileting, bathing, and was assessed as not able to walk due to medical condition or safety concerns.

Review of the Cardiovascular Care Plan (CP) dated 04/30/2024 staff were directed to observe edema daily.

A CP dated 10/22/2024 showed the resident had, edema and lymphedema (a condition causing swelling due to a buildup of lymph fluid in the body's tissues). This CP directed staff to Monitor/document for excessive edema and encourage resident to elevate legs.

Review of 12/18/2024 Physician Orders directed staff to apply compression stockings to Resident 52's bilateral lower extremities on in the morning and remove them on night shift, and to assess edema every morning. According to staff, the resident had edema assessed as 1 (Immediate rebound of skin tissue with 2-millimeter (mm) pit.)

Observations on 04/14/2025 at 2:12 PM showed Resident 52 lying in bed with lower extremities exposed. No compression stockings were applied. The resident's lower legs were enlarged and puffy. The lower extremities were not elevated on pillows. The resident stated at this time that they did experience some edema but staff did not offer to elevate their legs. Similar observations of the resident having enlarged lower extremities without benefit of compression stockings were made on 04/15/2025 at 12:41 PM, 04/16/2025 at 11:44 AM, and 04/18/2025 at 12:30 PM.

During observations on 04/18/2025 at 12:30 PM Staff C (Corporate Nurse) confirmed the resident had what was described as 3+ (Tissue rebound greater than 15 seconds but less than 60 seconds with 5 to 6 mm pit pitting edema in the bilateral lower extremities. At that time, Staff C confirmed the treatment records that reflected edema levels of 1+ were not reflective of the resident's lower extremity edema.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 47836

Level of Harm - Minimal harm or <Resident 7> potential for actual harm According to an 11/08/2024 Annual MDS, Resident 7 had a diagnosis of, but not limited to, Vitamin D Residents Affected - Few Deficiency.

Review of Resident 7's health records showed a physician order for a high dose Vitamin D supplement. Resident 7's records showed no blood work was obtained to check their Vitamin D level.

In an interview on 04/17/2025 at 9:26 AM, Staff O (Resident Care Manager) stated they would expect a Vitamin D to be obtained prior to implementing a high dose Vitamin D Supplement, but a Vitamin D level was not completed for Resident 7.

In an interview on 04/18/2025 at 12:05 PM Staff E reviewed Resident 7's health records and stated they did not see a Vitamin D level was ever obtained for Resident 7, but it should be, prior to starting the high dose Vitamin D supplement. Staff E stated it was important to obtain the Vitamin D level to ensure they were not administering unnecessary medications.

REFERENCE: WAC 388-97-1060 (1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264 potential for actual harm Based on observation, interview and record review the facility failed to ensure residents received proper Residents Affected - Few treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident 30) of 2 residents reviewed for vision services. Failure to ensure Resident 30 received assistance in obtaining vision devices placed this resident at risk for decline in Activities of Daily Living (ADLs) related to vision.

Findings included .

Resident 30 admitted to the facility on [DATE REDACTED] and according to the 09/13/2024 Admission Minimum Data Set (an assessment tool) had adequate vision and did not require the use of corrective lenses.

Observation on 04/14/2025 at 1:20 PM showed Resident 30 lying in bed, a pair of eyeglasses were noted on

the overbed table. In an interview at this time, Resident 30 indicated they needed an eye exam stating, I put

in for an eye exam a few months ago, but it didn't happen, nobody's gotten back to me.

In an interview on 04/16/2025 at 8:19 AM, Resident 30 stated. I can't read and when attempting to read a written document stated, it's a blur. The resident clarified at this time, I got glasses over two years ago . I need new glasses.

Record review showed a progress note dated 11/01/2024 which indicated, Resident scheduled to be seen by [NAME] Vision on 11/01/2024, (resident) has declined due to feeling ill. Next F/U (follow up) will be December 2024. Record review showed no evidence Resident 30 received vision services.

In an interview on 04/21/2025 at 9:16 AM, Staff G (Social Service Director) stated the facility has an eye service that comes in and sees residents when requested. Staff G confirmed staff should have, but did not, reschedule the resident until survey staff brought it to their attention on 04/17/25 with the next available appointment being in June. Staff G indicated they forgot about Resident 30.

Refer to

F-Tag F758

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20264

Residents Affected: Few prevention and control program designed to provide a safe and sanitary environment to help prevent the

F-F758 - Free From Unnecessary Psychotropic Medications.

REFERENCE: WAC 388-97-1720 (1)(a)(i-iv); (2)(a-m).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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** 20264 potential for actual harm Based on observation, interview, and record review the facility failed to establish and maintain an infection Residents Affected - Few prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to: ensure staff performed hand hygiene before and after resident care for 3 of 3 staff observed, ensure proper labeling and containment of resident's personal care items observed in 2 resident rooms, administer medications while maintaining infection control measures, and wear facility required face masks appropriately to prevent the spread of infection. These failures placed residents at risk for the development of infectious diseases and living in an unclean environment.

Findings included .

According to the facility's October 2023 revised Handwashing/Hand Hygiene policy, all personnel were trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. This policy showed staff were expected to perform hand hygiene before applying non-sterile gloves and before touching a resident.

Observations during initial rounds showed: on 04/14/2025 at 9:14 AM the bathroom for room [ROOM NUMBER] had a blue basin on the floor that was not bagged or labeled, two unlabeled urinals with no lids on

the back of the toilet and a bag of garbage on the floor. Similar observations of the unbagged basin on the floor and unlabeled urinals on the toilet were made on 04/16/2025 at 5:52 AM and 04/17/2025 at 2:17 PM.

Observation of the bathroom for room [ROOM NUMBER] on 04/14/2025 at 9:14 AM showed a lidless urinal

on the back of the toilet not labeled or bagged; a blue basin in a bag on floor which was not labeled, one graduate cylinder (a plastic container used to collect or measure bodily fluids) on the back of the toilet labeled for 32-2 but not bagged, and a denture cup at the sink which was not labeled. Similar observations of

the urinal, basin, graduate cylinder were noted on 04/16/2025 at 6:06 AM.

In an interview on 04/21/25 12:15 PM Staff E (Assistant Director of Nursing) stated that personal care items

in bathrooms should be labeled with resident names, anything stored on the floor should be bagged. and urinals should have lids and be stored in a bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 Observation on 04/14/2025 at 8:35 AM showed Staff J (Licensed Practical Nurse) administer medications to Resident 2. Staff J was observed to place three bottles of eye drops, two inhalers, and a nasal spray on the Level of Harm - Minimal harm or resident's bed without a barrier, then proceeded to administer each medication. Staff J placed the now cross potential for actual harm contaminated medication containers on top of the medication cart without cleaning medication bottles or using a barrier. Residents Affected - Few

Observation on 04/15/2025 at 8:18 AM showed Staff J remove a hand held inhaler from their pocket and place into Medication Cart B.

In an interview on 04/16/2025 at 9:23 AM, Staff B (Director of Nursing) stated staff should use barriers to prevent cross contamination during medication pass.

Observations on 04/14/2025 at 11:43 AM showed unidentified therapy staff walking a resident in C Hall wearing their face mask below their nose.

Observation and interview on 04/16/2025 at 5:31 AM showed Staff Y (Restorative Aide) sitting in a chair on A hall without a mask on. Staff Y stated the facility required staff to wear a surgical mask while in care areas of residents. Staff Y stated they should always wear a surgical mask in the resident hallways but forgot to put one on.

46479

Observation of personal care provided to Resident 36 on 04/17/2025 at 9:33 AM showed Staff K (Certified Nursing Assistant - CNA) and Staff U (Lead CNA) initiate catheter care for Resident 36. Observation showed Staff K don gloves, then empty urine from the catheter into an unlabeled urinal touching the bathroom door with the now contaminated right hand used to clamp the urinal tubing. Staff K then changed gloves without performing hand hygiene. Staff U directed Staff K to remove their gloves and perform hand hygiene. As there was no hand sanitizer in the room, Staff K left the room to use the hand sanitizer in the hall before returning to the room. At this time the resident stated, That's not helpful, (they) touched the doorknob then touched it again on the way back in. Staff K received a soiled washcloth from Staff U to place in a bag retrieved from

the overbed table which was then moved to the foot of the bed. With contaminated hands, Staff K then dried

the resident as Staff U performed catheter care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 56 505195 Department of Health & Human Services Printed: 08/28/2025 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 505195 B. Wing 04/21/2025

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

North Auburn Rehab & Health Center 2830 I Street Northeast Auburn, WA 98002

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 Review of Resident 64's 04/16/2025 physician orders showed a 03/12/2025 order directing staff to provide nutrition by enteral feeding (method of delivering nutrition directly into the gastrointestinal tract through a Level of Harm - Minimal harm or tube). A 03/04/2025 order directed staff to use enhanced barrier precautions related to the resident's enteral potential for actual harm feeding tube.

Residents Affected - Few Observations on 04/18/2025 at 11:37 AM showed Staff W (Licensed Practical Nurse) preparing to stop Resident 64's enteral feeding for the day. Staff W put on a gown prior and entered Resident 64's room without performing hand hygiene and was observed talking with the resident. Staff W had their surgical mask below their nose and proceeded to use their bare hand to reposition the mask. Staff W grabbed pair of gloves and did not complete hand hygiene prior to putting on the gloves. Staff W removed a new syringe and placed it in a graduate cylinder used for Resident 64's enteral feeding. Staff W instructed Resident 64 to lift their gown, Staff W stopped the feeding and removed the external portion of the enteral feeding tube from

the resident. Staff W placed a plug in the resident's enteral tube and repositioned their gown. Staff W removed their gloves, completed hand hygiene, and exited the room.

47836

Observation on 04/17/2025 at 12:06 PM showed Staff V (CNA) providing incontinent cares to Resident 6 for

an incontinent episode of loose stool in their brief. Staff V was observed to clean Resident 6's loose stool off their catheter (tube inserted into the bladder to drain urine) tubing. Staff V changed their gloves between dirty and clean cares without performing hand hygiene.

04/17/2025 at 1:45 PM Staff V stated they should have performed hand hygiene between dirty and clean care glove changes, but they did not.

In an interview on 04/21/2025 at 9:40 AM Staff P (Infection Preventionist) stated they expected staff to wear surgical masks in resident areas. Staff P stated they expected staff to perform hand hygiene upon entering a resident room, prior to providing resident care, between clean and dirty cares, and between glove changes.

REFERENCE: WAC 388-97-1320 (1)(c)(2)(a).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 56 505195

North Auburn Rehab & Health Center

Inspection Findings

F-Tag F641

F-Tag F658

F-Tag F684

F-Tag F700

F-Tag F758

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