Shuksan Healthcare Center

F-F770- Labratory Services Residents Affected - Many Reference WAC 388-97-1620 (1) Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 505098 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 505098 B. Wing 05/01/2025

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

Shuksan Rehabilitation and Health Care 1530 James Street Bellingham, WA 98225

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 0837 Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing Level of Harm - Minimal harm or the facility. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37890 Residents Affected - Many Based on interviews and record review, the facility Governing Body failed to ensure the facility's finances were maintained. The Governing Body was aware the facility was behind on vendor payments and receiving notices for discontinuation of services. The Governing Body's failure to ensure oversite of the facility Administration to meet their financial obligations to vendors resulted in the facility laboratory services provider discontinuing services to the facility and placed all 41 residents at risk of not receiving necessary care and services.

Findings included .

Review of the undated facility policy titled Administrative Management (Governing Board), stated the Governing Board had full legal authority and responsibility for the management and operation of the facility.

Based on record review the following vendors sent demand bill notices to the facility:

Trident Lab corporation, past due $9,536.92 with a hold for non-payment.

City of [NAME] water, a shut off notice was sent on 04/07/2025 with shut off date of 05/07/2025 with a past due amount of $2,487.91

Cascade Natural Gas invoice with urgent past due notice dated 04/14/2025 requested payment of $1877.85 be received by 5:00 PM on April 22, 2025, or service may be disconnected.

Kavala staffing agency owing $191,210.01

Clipboard staffing agency owing $2,563.89, with a notice they will cease to send staff after May 5.

KCI (a medical supply company) invoice owing $12,550 with a notice on 04/21/2025 demand bill to pay by 04/21/2025.

According to the Office of Rates Management, as of 04/07/2025, the Safety Net Assessment (SNA) account for Shuksan HealthCare was 60 days past due in the amount of $119,996.01, which included a new outstanding balance for December 2024 days of $29,377.00, due to be paid 01/20/2025.

In an interview with the facility lab services provider on 04/25/2025 at 1:42 PM, CC5, the lab provider confirmed that the facility lab services were placed on a non-payment hold on 04/23/2025 which had not been corrected in their system. This lack of lab services impacted 4 Residents (Residents 10, 34, 95, and 7) and potentially additional residents if new orders were received.

Resident 10, Depakote level (lab to determine therapeutic drug level for seizure medication) was not obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 505098 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 505098 B. Wing 05/01/2025

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

Shuksan Rehabilitation and Health Care 1530 James Street Bellingham, WA 98225

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 0837 Resident 34 Depakote level (lab to determine therapeutic drug level for seizure medication) was not obtained. Level of Harm - Minimal harm or potential for actual harm Resident 95 Comprehensive Metabolic Panel (test to determine overview of the body's chemical and metabolic status) and Complete Blood Count (test to determine number and types of blood cells) was not Residents Affected - Many obtained.

Resident 7 Hemoglobin A1C (test to determine average blood sugar levels) was not obtained.

In an interview on 04/25/2025 at 12:32 PM, Staff F, Resident Care Manager stated the lab was supposed to come on Sundays, Mondays, Tuesdays and Thursdays. The labs due were kept in a binder at the nurse's station and should be getting audited for completion and then results usually come in a day or two depending

on the type of test. Staff F was asked to review some missing laboratory results and Staff F confirmed that residents 7,10,34 and 95 had labs ordered to be drawn on 04/23/2024 which were not done. Staff F stated

they could not see documentation about why those labs had not been ordered but stated the lab may not have come, I heard something about a bill not being paid. Staff F was asked if there was an alternative option or an alternative laboratory available and Staff F said there was a different lab they used only for urinalysis. Staff F was asked if the providers for those residents had been notified that those labs had not been obtained and Staff F stated they did not know.

In an interview on 04/25/2025 at 1:08 PM, with Anonymous staff, the facility had delayed payroll on one recent occasion at which time staff lost benefits for a period of time and staff had to pay out of pocket for medical appointments and prescriptions.

In an interview on 04/25/2025 at 1:08 PM, Staff L, Business office Manager, stated invoices came to them and Staff A, Administrator, and they were processed and sent to the corporate office for payment. The corporate office actually cuts the checks and pays the vendors unless we were instructed by corporate to pay for something by credit card. Regarding the laboratory bill, there was a payment that was not received, and

an overnighted check that was supposed to have been sent and that prevented the non-payment hold. Staff L stated they get calls daily from vendors regarding overdue balances and all they could do was forward on that information to corporate.

In an interview on 04/25/2025 at 1:55 PM, Staff A, Administrator, stated they get the invoices for all the bills, and they are all forwarded to the corporate office for payment. Staff A stated they were aware of the lab services hold but thought it had been taken care of. Staff A was aware of a recent demand bill from the natural gas company and that the facility was paying bills late or had payment plans in place with some vendors. Staff A stated the facility had used a company credit card to obtain some resident supplies.

In an interview on 04/25/2025 at 4:47 PM, Staff D, Chief Operating Officer, stated the corporation managed vendor contracts and payment plans according to the individual arrangements. Staff D stated they receive invoices every week and they are processed. The laboratory payment was stated to have been sent. The facility was managing cash flow.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 505098 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 505098 B. Wing 05/01/2025

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

Shuksan Rehabilitation and Health Care 1530 James Street Bellingham, WA 98225

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 0837 In an interview on 04/29/2025 at 2:11 PM, Staff E, Chief Operating Officer, stated the facility was behind on

the Safety Net Assessment (SNA) payments, which had been referred for collection to the Office of Financial Level of Harm - Minimal harm or Recovery. This resulted in unannounced garnishments which have impacted the facility cash flow. Staff E potential for actual harm stated they have reached out to the contacts for the SNA and they have had to prioritize payments which has meant allowing some accounts to go to collections. Residents Affected - Many Reference WAC 388-97-1620 (2) (C)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 505098

F-F835. The facility removed the immediacy on 04/26/2025 as confirmed by an onsite verification by a surveyor after the facility ensured past due resident lab testing had been completed and an active laboratory services vendor was in place. The facility provided evidence of vendor contract payments to ensure continuity of essential services, audited all resident laboratory orders, and obtained ordered laboratory testing for affected residents. The immediate jeopardy was determined to begin on 04/23/2025 when laboratory services were not provided timely.

Findings included .

Review of the undated facility policy titled Administrative Management, stated the Facility Administrator appointed was accountable to facility management and operations, which would be reported to a governing board.

Based on record review the following vendors sent demand bill notices to the facility:

- Trident Lab corporation, past due $9,536.92 with a hold for non-payment with invoices beginning 11/30/2024.

- City of [NAME] water, a shut off notice was sent on 04/07/2025 with shut off date of 05/07/2025 with a past due amount of $2,487.91.

- Kavala staffing agency statement #3545 dated 03/26/2025 total amount owed $191,210.01 for invoices from 11/25/2024 through 03/21/2025.

- Clipboard staffing agency owing $2,563.89, with a notice they will cease to send staff after 05/05/2025.

- KCI (a medical supply company) invoice owing $12,550 with a notice on 04/21/2025 demand bill to pay by 04/21/2025 with invoices beginning 10/21/2024.

-Cascade Natural Gas invoice with urgent past due notice dated 04/14/2025 requested payment of $1877.85 be received by 5:00 PM on April 22, 2025, or service may be disconnected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 505098 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 505098 B. Wing 05/01/2025

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

Shuksan Rehabilitation and Health Care 1530 James Street Bellingham, WA 98225

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 0835 -According to the Office of Rates Management, as of 04/07/2025, the Safety Net Assessment (SNA) account for Shuksan HealthCare was 60 days past due in the amount of $119,996.01, which included a new Level of Harm - Immediate outstanding balance for December 2024 days of $29,377.00, due to be paid 01/20/2025. jeopardy to resident health or safety In an interview with the facility lab services provider on 04/25/2025 at 1:42 PM, CC5, the lab services provider confirmed that the facilities lab services were placed on a non-payment hold on 04/23/2025 which Residents Affected - Many had not been corrected in their system. This lack of lab services impacted four residents (Residents 10, 34, 95, and 7) and potentially additional residents if new orders were received or delayed due to the lab vendor Note: The nursing home is not coming out due to the nonpayment) Resident 10's Depakote level (critical lab to determine therapeutic disputing this citation. drug level in the body and prevent toxicity for seizure medication) was not obtained. Resident 34's Depakote level (critical lab to determine therapeutic drug level in the body and prevent toxicity for seizure medication) was not obtained. Resident 95's Comprehensive Metabolic Panel (test to determine overview of the body's chemical and metabolic status) and Complete Blood Count (test to determine number and types of blood cells) were not obtained. Resident 7's Hemoglobin A1C (test to determine average blood sugar levels) was not obtained.

In a joint interview and record review on 04/25/2025 at 12:32 PM, Staff F, Resident Care Manager, stated the lab was scheduled to come on Sundays, Mondays, Tuesdays and Thursdays. The labs due were kept in a binder at the nurse's station and should be audited for completion and then results usually come in a day or two depending on the type of test. Staff F was asked to review some missing laboratory results, and they stated that Residents 7, 10, 34 and 95 had labs ordered to be drawn on 04/23/2025 which had not been completed as of this interview. Staff F stated they could not see documentation about why those labs had not been ordered but stated the lab may not have come, I heard something about a bill not being paid. Staff F was asked if there was an alternative option or an alternate laboratory available and they stated there was a different lab they used only for urinalysis (lab test to analyze urine samples). Staff F was asked if the providers for those residents had been notified that those labs had not been obtained, and they stated they did not know.

In an interview on 04/25/2025 at 1:08 PM, Anonymous facility staff stated the facility had delayed payroll on one recent occasion at which time staff lost benefits for a period of time and staff had to pay out of pocket for medical appointments and prescriptions.

In an interview on 04/25/2025 at 1:08 PM, Staff L, Business office Manager, stated invoices, came to them and Staff A, Administrator, and they were processed and sent to the corporate office for payment. The corporate office cuts the checks and pays the vendors unless we were instructed by them to pay for something by credit card. Staff L stated in regard to the laboratory bill, there was a payment that was not received, and a check that was supposed to have been sent overnight and that prevented the non-payment hold. Staff L stated they get calls daily from vendors regarding overdue balances and all they could do was forward that information to corporate.

In an interview on 04/25/2025 at 1:55 PM, Staff A stated they receive the invoices for all the bills, and they are all forwarded to the corporate office for payment. Staff A stated they were aware of the lab services hold but thought it had been taken care of. Staff A was aware of a recent demand bill from the natural gas company and that the facility was paying bills late or had payment plans in place with some vendors. Staff A stated the facility had used a company credit card to obtain some resident supplies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 505098 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 505098 B. Wing 05/01/2025

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

Shuksan Rehabilitation and Health Care 1530 James Street Bellingham, WA 98225

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 0835 In an interview on 04/25/2025 at 4:47 PM, Staff D, Chief Operating Officer, stated the corporation managed vendor contracts and payment plans according to the individual arrangements. Staff D stated they receive Level of Harm - Immediate invoices every week and they are processed. The laboratory payment was stated to have been sent. The jeopardy to resident health or facility was managing cash flow. safety Refer to