Whitman Health & Rehab Center

F-F689 CFR S483.25 Free of Accident Hazards/Supervision/Devices. The facility removed the immediacy on 07/10/2024 with an onsite verification by surveyours ensuring all residents that smoked had a smoking assessment completed, education was provided on the safe disposal of cigarette butts to staff and residents, and a receptacle for the disposal of the cigarette butts were provided.

Findings included .

According to the facility policy titled Smoking Campus Policy, dated 11/28/2017 and updated 7/10/2024, residents were unable to smoke on the facility premises. It documented at the time the facility went tobacco free, if there were current residents still smoking, the current residents were allowed to use tobacco or tobacco products in a designated area outside, weather permitting. These residents were required to have a smoking assessment completed to determine the level of supervision to be provided and interventions to mitigate the risk of injury. Additionally, a smoking assessment was not required if a resident did not smoke and the policy would be enforced by asking residents to immediately comply, assessing for distress, and storing any tobacco products or lighting material at the nursing station with the resident's consent.

During the entrance conference meeting on 07/08/2024 at 9:04 AM, with Staff A, Interim Administrator, and Staff B, Director of Nursing (DON), when asked if the facility had residents who smoked, Staff B stated the facility was a non-smoking campus and residents who smoked were assessed on admission to ensure they were safe to smoke independently, and there were no designated smoking areas or times, since residents had to be independent to smoke. The facility had four residents who smoked (30, 31, 24, and 20).

Record review showed the following residents all had smoking assessments completed on 05/30/2024. Additional information is as follows:

*Resident 30, admitted [DATE REDACTED], no admission smoking assessment completed, the only smoking assessment found was the assessment on 05/30/2024

*Resident 31, admitted [DATE REDACTED], first smoking evaluation 01/03/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 *Resident 24, admitted [DATE REDACTED], no admission smoking assessment completed, the only smoking assessment found was the assessment on 05/30/2024 Level of Harm - Immediate jeopardy to resident health or *Resident 20, admitted [DATE REDACTED], no admission smoking assessment completed, first smoking assessment safety completed on 01/03/2024.

Residents Affected - Many <Observations>

On 07/10/2024 at 8:28 AM, Resident 31 was observed leaning up against the telephone pole at the top of the facility driveway smoking.

On 07/10/2024 at 11:15 AM, dry vegetation was observed at the end of the facility asphalt driveway, multiple cigarette butts were on the ground around the area, and a plastic garbage bin located by the facility front door contained paper, surgical masks, and approximately 50 cigarette butts. At 12:18 AM, discarded cigarette butts were observed lying in brown, brittle, dry grass in the facility front yard.

At 12:18 PM, 3 cigarette butts were observed lying in brown, dry, grass by the facility sign, 2 cigarette butts were lying on the ground by the fence along the facility driveway (where resident 31 was observed smoking), and 5 cigarette butts were lying on the ground under a facility window in the garden area parking lot. Resident 20 was also observed at this time sitting on their walker on the sidewalk at the end of the facility driveway smoking.

Review of the AccuWeather Forecast showed the outside temperature was 97 degrees Fahrenheit on 07/10/2024 and an extreme heat warning was in place. In addition, the Washington State Department of Natural Resources website, (https://fortress.wa.gov/dnr/protection/firedanger/) advised the risk of fire was high.

In an interview on 07/10/2024 at 1:58 PM, with Staff A, Staff B, Staff C (Clinical Resource Nurse), and Staff O, Corporate Nurse, when asked about the lack of safe disposal of cigarette butts and potential risk for fire, Staff B stated residents needed to dispose of cigarettes safely and stated they did not have a means to do that.

<Resident 22>

Per the 07/09/2024 assessment Resident 22 was cognitively intact and able to direct their own care. They required assistance for transfers, and supervision when using their wheelchair, and had diagnoses which included stroke, and hemiplegia (one-sided weakness or paralysis).

Review of Resident22's current physician orders, dated 01/23/2024, showed Varenicline Tartrate daily to decrease tobacco craving.

Review of the care plan dated 7/10/2024, showed Resident 22 wished to smoke, was determined to be dependent and unsafe to smoke, and could not smoke while at the facility.

A smoking evaluation dated 07/10/2024 by Staff B, documented Resident 22 had no independent smoking privileges allowed off premises due to safety concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 A Progress note by Staff E, Social Services Director, dated 3/11/2024 documented Resident 22 was found outside smoking a cigarette and had already been advised by Staff B that smoking wasn't allow on the Level of Harm - Immediate property. Additionally, the note documented Resident 22 wouldn't give their lighter to Staff E for safe keeping. jeopardy to resident health or safety A progress note by Staff B, dated 03/12/2024, documented on 3/11/24 Resident 22 was provided education regarding smoking. Staff B explained to Resident 22 the facility policy at that time, informed them they were Residents Affected - Many not safe to take themself off the property to smoke, and that they would need to be evaluated to make sure were safe to smoke independently. Staff B then let Staff E know Resident 22 was not safe to have a lighter in their possession. Additional review of Resident 22's care plan found no documentation that a smoking evaluation had been completed.

During an interview on 07/10/2024 at 9:55 AM, when asked if they smoked Resident 22 stated the last time,

they smoked was about one month ago at a doctor's appointment. They stated they kept their cigarettes and lighter in their bag and proceeded to remove a lighter and sealed pack of cigarettes from their bag.

During an interview on 07/16/2024 at 03:50 PM with Staff A, Staff O, and Staff C, Staff C stated they talked to Resident 22 about surrendering their cigarettes the prior week and Resident 22 became upset and stated

they would keep them in their purse. When asked what process was place in ensure safety since the resident refused to give the facility their cigarettes and lighter Staff O stated it should have been added to the care plan for nurses to check each shift.

In an interview on 07/22/2024 at 04:49 PM, Staff B stated a smoking evaluation and safety plan for Resident 22 should have been completed on 03/11/2024 when Resident 22 was identified as a smoker.

Reference (WAC): 388-97-1060 3(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 37544 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff obtained accurate and Residents Affected - Few timely weights 1 of 3 sampled residents (Resident 1) reviewed for nutrition. In addition, the facility failed to ensure the physician was notified of a change in a resident's condition (Resident 17) that impacted their nutrition. These failures placed the residents at risk for unrecognized, unplanned, significant weight loss, and nutritional complications.

Findings included .

<Resident 1>

The 05/10/2024 quarterly assessment documented Resident 1 had diagnoses which included dementia, malnutrition, depression, vascular dementia, nutritional deficiency, mild protein-calorie malnutrition.

Review of Resident 1's nutritional care plan documented the resident had an increased nutritional risk and interventions were implemented on 11/14/2019. A revision on 12/04/2023 instructed nursing staff to weigh

the resident weekly.

On 02/22/2024, a nutrition progress note by Staff RR documented the resident weighed 129.4 pounds which was a significant weight gain of 19.4 pounds (lbs.) in 16 days, and a reweigh was requested as the weight was believed to be an error.

On 03/05/2024, a second nutrition progress note by Staff RR again stated a requested a reweigh as the weight was up significantly from the resident's usual weight range.

Review of Resident 1's record showed the resident's weigh on 02/19/2024 was 129.4 lbs. No documentation was found to show the resident had been reweighed as requested by Staff RR until 03/19/2024, almost a month after the initial request. The resident's weight at that time was 105.6 lbs. which was within their normal weight range.

Additional review found the next documented weight was on 05/04/2024, 46 days after the last weight on 03/19/2024. The resident weight was 94 lbs., which was within their normal weight range. Following the weight on 05/04/2024, Resident 1 was being weighed weekly as care planned.

In an interview on 07/19/24 at 2:24 PM, Staff B, Director of Nursing, stated residents are weighed weekly for three days when admitted , then weekly for four weeks and then monthly as a facility standard. Staff B further stated that if there were concerns identified or the resident was on certain medications, the physician may order additional weighs to be taken. After review of Resident 1 record, Staff B acknowledged, the resident had not been weighed consistently, and weekly as instructed in the nutritional care plan.

46115

<Resident 17>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 According to the 04/29/2024 quarterly assessment, Resident 17 had diagnoses including malnutrition, depression and a stroke, was moderately cognitively impaired and was able to feed self. Level of Harm - Minimal harm or potential for actual harm A review of the weights showed the following weights for Resident 17:

Residents Affected - Few -07/17/2024 135.2 pounds (lbs.),

-06/11/2024 143 lbs.,

-04/17/2024 146.2 lbs.,

-01/27/2024 155.2 lbs., a 12.89% loss in 6 months, -7.52% in 3 months and -5.45% loss in 1 month

According to the 01/25/24 care plan, Resident 17 had nutritional risks related to their stroke and swallowing difficulties and the goal for the resident was not to have any unplanned significant weight loss.

The 02/19/2024 Nutritional evaluation documented Resident 17's average intake was 26-50% of meals and recommended that 1-3 teaspoons of margarine or sugar be added to each meal to promote adequate intake until Resident 17's intake improved.

Further record review showed no documentation that the recommendation had been followed up on.

A 06/25/2024 progress note documented Resident 17 had an 8.4% weight loss in 2 weeks related to recent acute changes in the resident's health. The resident had increased nausea that had started on 06/13/2024 and had been refusing meals and dietary supplements. Resident 17 had tested positive for COVID-19 (an acute respiratory illness caused by a virus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) on 06/17/2024 and had been sent to

the hospital for weakness and nausea.

In an interview on 07/18/2024 at 11:09 AM, Staff B, Director of Nursing, stated interventions for weight loss were added based off the recommendations from the dietician. Staff B confirmed the recommendation to add margarine or sugar to Resident 17's diet order had not occurred. Staff B added if Resident 17 would have been offered and accepted the recommendation it may have helped their weight.

During an interview on 07/17/2024 at 2:55 PM, Staff MM, Doctor, stated they were unaware Resident 17 had experienced nausea and was sent to the hospital. Staff MM stated if they would have been notified, they would have ordered labs and possibly changed the resident's medications. Staff MM added they were supposed to be notified of changes in the resident's condition by nursing staff and felt the nausea had impacted the resident's weight.

In an interview on 07/19/2024 at 10:20 AM, Staff SS, Dietician, stated the butter and sugar was not enough to have impacted Resident 17's weight and felt the weight loss was related to COVID-19 and nausea.

Reference: WAC 388-97-1060(3)(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 46115 potential for actual harm Based on observation, interview and record review, the facility failed to ensure that residents had current and Residents Affected - Few complete oxygen orders and failed to ensure that oxygen equipment was maintained in a clean manner for 4 of 4 sampled residents (Resident 16, 39, 14, 27) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Findings included .

A facility policy, dated 08/04/2023, titled Oxygen Therapy documented orders for oxygen were to be verified prior to initiating oxygen therapy. In addition, the policy documented to change disposable oxygen equipment routinely per manufacturer directives and PRN (as needed) soiling.

<Resident 39>

Per the 06/20/2024 quarterly assessment, Resident 39 had diagnoses which included COPD (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure and needed oxygen due to those conditions.

Review of the physician orders documented on 07/01/2024, the resident had been prescribed oxygen to maintain oxygen saturations between 88 and 98 percent, due to the diagnoses listed above, but did not contain the number of liters needed. The orders also documented to clean the oxygen concentrator filter weekly.

On 07/08/2024 at 10:00 AM, Resident 39 was observed asleep in bed. An inspection of the oxygen concentrator in the resident's room showed the concentrator was unclean with thick dust.

In an observation on 07/11/2024 at 10:28 AM, the cover of the oxygen filter was lying on the floor. The filter and inside where the filter was stored was covered in thick dust.

During an interview on 07/11/2024 at 11:37AM, Staff U, Registered Nurse confirmed the filter was unclean with dust and needed to be cleaned. Staff U, added it was important to keep the filters cleaned as uncleaned filters can contribute to respiratory infections.

During an observation and interview on 07/12/2024 at 8:47 AM, Resident 39's personal oxygen concentrator was in the red zone, meaning it was empty. The resident stated they could not feel any air and stated the tank needed to be changed and denied shortness of breath.

In an observation on 07/16/2024 at 9:05 AM, the filter on the oxygen concentrator was clean but the area where the filter was stored was full of dust.

During an observation on 07/17/2024 at 4:33 PM, Resident 39 was sitting in the hall and their personal concentrator was empty. The resident did not feel any air and denied being short of breath. The medication technician was asked to check the resident's oxygen concentration and it was 93 percent and they filled the tank.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0695 In an interview on 07/16/2024 at 12:24 PM, Staff B, Director of Nursing, stated the nurses would adjust the oxygen to keep it between the ordered levels and document what liters were used. Staff B added that oxygen Level of Harm - Minimal harm or filters were to be cleaned weekly and this was important as this was a risk for respiratory illnesses or an potential for actual harm exacerbation of an underlying condition.

Residents Affected - Few 47728

<Resident 16>

Per the 06/11/2024 assessment Resident 16 was cognitively intact, able to make their needs known, and had diagnoses including heart failure (a condition where the heart cannot pump blood as well as it should), asthma, and sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep).

A review of Resident 16's medical record documented no physician order or care planned interventions for oxygen, oxygen therapy, or maintenance and cleaning of the oxygen tubing and filters prior to 07/11/2024.

During an observation/interview 07/09/2024 at 9:48AM, Resident 16 stated they had been using oxygen at night for about two weeks. In a concurrent observation, there was no label on the oxygen tubing, that indicated when it was last changed. Resident 16 stated they did not know if the tubing had been changed.

The external filter of the oxygen concentrator (a medical device which provides extra oxygen by filter the surrounding air) was dusty with a visible thick whitish powder/residue.

During an observation/interview on 07/11/2024 at 8:57AM Resident 16 stated the oxygen tubing was changed a couple days ago. Observation of the oxygen tubing showed it was not labeled with the date it was changed and the external filter on the oxygen concentrator was covered in heavy dust.

During an interview on 07/11/2024 at 11:38 AM, Staff Z medication technician, stated they thought the aides changed the oxygen tubing if it needed to be changed but there was no set schedule, and the filters on the oxygen concentrators were cleaned every 2 weeks by the aides.

In an observation/interview on 07/11/2024 at 11:42 AM, Staff Z, and Staff C, corporate Registered Nurse (RN) looked at the external filter on the oxygen concentrator and confirmed it was dirty then Staff C opened

the filter compartment and removed the filter, which was covered in a thick layer of gray dust, and stated they were going to clean it

In an observation on 07/11/2024 at 2:15PM the external filter on the oxygen concentrator had been changed but the filter compartment remained coated with dust.

During an interview on 07/11/2024 at 2:03PM, Staff C stated the standard for the facility, for a resident using oxygen, was to have an order for weekly tubing and filter changes. Staff C also stated Resident 16 did not have a current order for oxygen and no order for changing the tubing and filter.

In an interview on 07/16/2024 at 1:52PM, Staff R, Medication Technician stated resident 16 had been getting oxygen at night since they returned from a hospital stay, 06/06/2024. Staff R then accessed the resident chart and displayed the order for oxygen dated 7/11/2024. There were no other oxygen orders documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0695 In an interview on 07/22/2024 at 4:49PM, Staff B, director of Nursing stated the facility did not have an order for oxygen for Resident 16 when they initiated it. They stated the facility should have obtained an order for Level of Harm - Minimal harm or the oxygen before initiating it because it was important in ensuring all staff had the same instructions and to potential for actual harm avoid complications

Residents Affected - Few <Resident 14>

Per the 04/16/2024 comprehensive assessment, Resident 14 had diagnoses which included Post-Polio Syndrome (a neurological condition that causes gradual muscle weakness and loss of muscle tissue) circulation problems, lung disease, and needed oxygen due to those conditions.

Review of the physician orders on the Medication Administration Records (MARS) from April 2024 to July 2024, documented Resident 14 was prescribed oxygen on 01/10/2024 to be used as needed, due to the lung conditions listed above. Another physician's order was documented for the resident's oxygen tubing, humidifier bottle and oxygen filter to be cleaned weekly.

On 07/09/2024 at 11:10 AM, Resident 14 was observed wearing oxygen while in sitting in their chair during

an interview. On 07/09/2024 at 11:37 AM, an inspection of the oxygen concentrator conducted in the resident's room showed the concentrator foam filter was unclean with visible thick and heavy dust.

An observation of the Resident 14 wearing oxygen while in bed was made on 07/10/24 at 05:08 PM.

A subsequent inspection of the oxygen concentrator on 07/11/2024 at 11:32 AM showed the foam and capsule filters were unclean with thick heavy dust and debris, as well as in the surrounding compartments.

During an observation and interview on 7/11/2024 at 11:39 AM, Staff U, Registered Nurse, verified that the oxygen foam and capsule filters were unclean, coated with thick heavy dust and debris, as well as in surrounding compartmental areas. Staff U stated that the concentrator needed to be cleaned.

On 07/11/2024 at 2:10 PM, another inspection of the concentrator was conducted showing new replacements of the foam and capsule filters, but the compartmental areas remained coated with heavy dust and debris.

On 07/11/2024 at 2:22 PM, Staff U confirmed that that the oxygen concentrators are to be cleaned, including changing the filters every week as stated in the physician's order.

Another observation of the resident wearing oxygen while in bed was made on 07/12/2024 at 01:31 PM.

On 07/18/2024 at 11:28 AM, an observation and interview with Resident 14 was conducted. The resident was observed wearing oxygen while lying in bed. Resident 14 stated they were feeling short of breath and recently applied the oxygen. The foam filter on the concentrator was covered with thick heavy dust patches of frayed particle pieces.

<Residents 27>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0695 Per the 07/01/2024 comprehensive assessment, Resident 27 had diagnoses which included acute respiratory failure (when the level of oxygen in the blood becomes dangerously low or the level of carbon Level of Harm - Minimal harm or dioxide becomes dangerously high) and needed oxygen due to that condition. potential for actual harm

Review of the Medication Administration Record (MAR) for July 2024 showed no documentation of physician Residents Affected - Few orders for oxygen and routine oxygen tube changing. The care plan completed on 05/27/2024 had no documentation to provide interventions for respiratory care.

On 07/09/2024 at 09:04 AM, Resident 27 was observed wearing oxygen while in their bed supplied by a concentrator.

Per review of the progress notes, it was documented that Resident 27 was administered three liters of oxygen continuously on 07/01/2024 and 07/02/2024.

On 7/11/2024 at 11:44 AM, an observation and interview were conducted. The concentrator was in Resident 27's room plugged in. The resident stated they were told by staff that they were no longer on oxygen.

Subsequent observations were made of the Resident 27 with a portable oxygen tank on the back of their wheelchair on 7/11/2024 at 01:58 PM and 7/11/2024 at 04:49 PM.

On 7/15/2024 at 7:06 AM, an observation of a portable oxygen tank was in the resident's room. On 7/15/2024 at 09:53 AM there was signage on Resident 27 door stating, Oxygen in Use.

In an interview on 07/17/24 at 01:23 PM, Staff AA, Registered Nurse, stated that Resident 27 became short of breath approximately three weeks ago, in which they required oxygen.

Reference: WAC 388-97-1060 (3)(j)(vi)

50027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or 50027 potential for actual harm Based on observation, interview and record review, the facility failed to provide person-centered pain Residents Affected - Few management for 1 of 2 sampled resident (Resident 294). Resident 294 was not offered pain medication and non-pharmacological pain interventions, non-pharmacological interventions were not documented when they were administered and failed to notify the physician and request additional pain management interventions.

These failures placed the resident at risk for increased pain and decreased quality of life.

Findings included .

Per the 06/25/2024 comprehensive assessment, Resident 294 had diagnoses which included a stroke, sacral ulcer (pressure sore near the lower back and spine) and quadriplegia (paralysis of the arms and legs) due to a motor vehicle accident. In addition, the assessment showed the resident was cognitively intact to make decisions regarding their care, exhibited verbal and physical aggressive behaviors and was dependent for all cares.

Review of the June 2024 and July 2024 Medication Administration Record (MAR) showed physician orders to administer scheduled Gabapentin (a seizure medication sometimes used for pain) 300 (milligrams) mg once a day in the morning. In addition, the physician also ordered Oxycodone (a narcotic used for moderate pain) 5 mg every six hours as needed and Baclofen (a medication that reduces pain and discomfort caused by muscle spasms) 5 mg every eight hours as needed. There was also a physician's order to document the resident's level of pain on a scale of 0 (no pain) to 10 (excruciating pain) at the beginning of every day and night shift.

Review of the care plan completed on 06/18/2024 addressed Resident 294's chronic pain and documented pain medication interventions and non-pharmacological intervention, such as repositioning.

Per record review on 07/11/2024, Resident 294's pain level was documented in the MARS to be generally higher (a pain level of 7 [severe] and above) during the night. There was no documentation found that showed the provider was contacted and what attempts were made to contact them.

During an observation and interview on 07/08/24 10:45 AM, Resident 294 was observed sitting in their wheelchair, leaning to their right side with their head turned mostly to the right. When asked about their pain,

the resident stated their pain was a 7 out of 10. Resident 294 stated that they were always in pain and stated their pain was not being managed at the facility. They stated that their bed was uncomfortable, and their feet pushed into the foot of the bed.

During an interview on 07/11/24 09:43 AM, Resident 294 stated that their pain level was 7 out of 10. An

observation was made of a new bed with a larger mattress. The resident stated that they received a new bed

on 07/09/2024 and staff left them in the bed last night without assisting with repositioning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0697 An observation and interview were conducted with Resident 294 on 07/12/2024 at 09:19 AM. They were covered in a blanket sitting in their wheelchair. The resident was short-tempered in their responses Level of Harm - Minimal harm or throughout the interview. The resident stated that they were not repositioned during the night. Resident 294 potential for actual harm stated their pain level was currently 7 out of 10 and they were waiting for their next dose of pain medications. Their location of pain was in their back, neck, and buttocks. The resident stated within the first two hours Residents Affected - Few after taking pain medications, their pain level is a 5/10 increasing to 7/10. The resident stated there was no response from the staff when they informed them that the pain medications were not lasting.

During an interview on 07/12/24 at 01:33 PM, Resident 294 stated that their pain level was an 8 out of 10.

They stated that they take Baclofen for pain, but it does not help.

During an interview with Resident 294 on 07/16/2024 at 02:43 PM, they stated, I'm not doing good today, and that their pain level was at an 8 out of 10. The resident stated they told the staff and physician this date that they remain in constant pain.

Per record review of a 30-day look back at the nursing bed repositioning monitoring task, from 06/18/24 to 07/18/2024, required staff to document the level of assistance for bed rolling. The resident was dependent on

the staff to roll in bed every day, except for two days. There was no documentation of bed repositioning after 8:00pm for 13 days and before 7:00am for 15 days.

During an observation and interview on 07/18/2024 at 3:01 PM, Resident 294 was sitting upright in their wheelchair and showed intense facial grimacing and arched their head back pressing into the headrest of their wheelchair. The resident stated that his pain level was 9 out of 10 and stated, Sometimes it [pain medication] works and sometimes it doesn't. Resident 294 indicated that they would desire to be at least at a pain level of 4 out of 10.

During an interview on 07/18/24 at 4:10 PM, RN, Staff M, Registered Nurse, stated that Resident 294 constantly complained of pain. Staff M stated they consulted with the physician regarding changing the resident's prescription for Oxycodone to be a routine order instead of as needed. Staff M stated non-pharmacological interventions for pain included getting the resident a bariatric bed and air mattress and were not available within the facility until recently.

On 07/19/24 at 09:37 AM, an observation and interview were conducted with Resident 294. The resident was sitting in their wheelchair dozing off listening to music. They stated their pain level was 7 out of 10 and did not remember when they had last taken their pain medication. Resident 294 stated that the staff usually tells them when their pain medications are due.

During an interview on 07/22/2024 at 10:19 AM with Staff B, Director of Nursing Services and Infection Prevention, stated that the process for residents that have uncontrolled pain includes offering pain medications for control, monitoring changes in their medical condition, and conducting pain evaluations (including an assessment completed by the facility physician). Staff B stated they were aware that Resident 294 had a diagnosis of chronic pain, which is an indicator that their pain needs to be managed per the care plan. Staff B confirmed there was no documentation by the physician addressing Resident 294's pain. Staff B also confirmed nursing should have documented that Resident 294's pain was not being managed and notified the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0697 Per review of the Physician's Communication Book on 07/22/2024 at 10:44 AM, an undated entry documented after 07/20/2024 requested the provider to review Resident 294's pain. Level of Harm - Minimal harm or potential for actual harm Reference WAC 388-97-1060 (1)

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0728 Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Level of Harm - Minimal harm or potential for actual harm 46115

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure 2 of 3 nursing assistants (Staff V,W) met competency requirements defined under State Law, for license and certification. This failure placed residents at risk to receive care from incompetent and unlicensed staff.

Findings included:

Record review of employee files on 07/22/2024 documented Staff V was hired as a nursing assistant on 04/01/2024. Documentation in the file revealed that Staff V had a nursing assistant license that was pending.

Staff V was observed in the facility on 07/09/2024, 07/11/2024 and 07/16/2024 providing care and services to the residents.

Record review of employee files on 07/22/2024 documented Staff W was hired as a nursing assistant on 05/01/2024. Documentation in the file revealed that Staff W had a nursing assistant license that was pending.

Staff W was observed in the facility on 07/08/2024, 07/09/2024, 07/11/2024, 07/12/2024, and 07/13/2024 providing care and services to the residents.

In an interview on 07/22/2024 at 2:30 PM, Staff X, Administrator from a sister facility, stated staff must have

a nursing assistant certification before providing direct patient care.

Reference: WAC 388-97-1660 (3)(a)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Level of Harm - Minimal harm or potential for actual harm 46115

Residents Affected - Some Based on interviews and record review, the facility failed to ensure 5 of 8 sampled staff received mandated training on dementia and behavioral health. This failure placed the residents at risk for having unmet care needs and a diminished quality of life.

Findings included .

Review of competency training records for Staff W, Nursing Assistant, Staff BB, Cook, Staff JJ, Licensed Practical Nurse, Staff KK, Registered Nurse and Staff LL, Registered Nurse revealed they had not received any training on dementia and behaviors.

During an interview on 07/22/2024 at 3:54 PM, Staff C, Clinical Resource Nurse, stated dementia and behavior training was important so that staff could meet the needs of the residents and should be offered to new employees and annually thereafter.

Review of the 2024 Facility Assessment Tool provided by the facility documented training requirements included full time, part time and contracted staff.

No Associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or 50846 potential for actual harm Based on interview, observation and record review, the facility failed to provide medically related social Residents Affected - Few services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 3 residents (Resident 28) Failure to assist with discharge planning placed resident at risk for a decreased quality of life.

Findings included:

The resident admitted to the facility in May 2023. Review of the Minimum Data Set (MDS) assessment, dated 04/30/2024, revealed they did not have any cognitive impairment. The MDS indicated resident 28 had behaviors, the facility coded her behaviors did not significantly intrude on the privacy or activity of others, and that the behaviors did not significantly disrupt care or living environment. The MDS indicated she was independent with Activities of Daily Living (ADL's) to include, bed mobility, transfers, locomotion on/off unit, dressing, toilet use and personal hygiene.

On 07/08/2024 at 2:42pm, Resident 28 stated she would like to be living somewhere else. When asked if she was getting assistance with finding alternate placement, Resident 28 stated No.

On 07/10/24 at 10:00am, Resident 28, observed walking in the facility hallways independently. She dropped off her laundry in front of the facilities laundry room door, went to the kitchen, got the food she requested and walked back to her room.

On 07/11/2024 at 11:00am, Interview with Social Services, staff E, regarding discharge planning for Resident 28. Staff E stated, She does talk with her about discharging every day. She would like to discharge to the hotel. Resident has also requested to be discharged to the street. Functionally, she is independent with ADL's mental health issues interferes with her ability to live independently. Like an Adult family home she would be OK. I think she would be OK there. When asked for inquiries for alternate living arrangements, there was no documentation. When asked if the State Social Worker had been contacted to assist with discharge planning, Staff E, stated No, she had not talked with the State Social Worker about Resident 28's discharge. There was no level 2 PASRR completed to ascertain if specialized mental health services would be beneficial to ensure appropriate placement of Resident 28.

On 07/16/2024, at 4:15pm, staff II, nursing assistant, stated resident is independent with her ADL's, except for bathing.

On 07/16/2024 at 4:30pm, staff B, Director of Nursing, stated a Less restrictive environment, most definitely,

she has not pushed for going anywhere else. A group home would be a good place for her. She is independent with a lot of her cares in her room.

Reference WAC 388-97-0960(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 46115 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. The facility further failed to ensure narcotics were locked in a permanently affixed narcotic container in 1 of 1 medication storage room refrigerators. These failures placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications.

Findings included .

During an observation of the medication storage room on 07/15/2024 at 7:45 AM with Staff, AA, Registered Nurse (RN), the refrigerator contained influenza vaccines that had expired on 06/30/2024 and Tuberculin (used to check for tuberculosis) that was opened on 04/27/2024 and not discarded after 30 days as required.

The medication refrigerator held a white box, which was used to store narcotic medication, and was not locked as required.

During an interview on 07/22/2024 at 5:49 PM, Staff B, Director of Nursing, stated the vaccines and the Tuberculin should have been discarded as the effectiveness of the medications could have been altered. Staff B added the Ativan should have been in a locked container.

<Undated Insulin>

According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by

the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 F and 86 F for up to 28 days and continue to work.

During an audit of the 100-hall medication cart on 7/22/2024 at 4:28pm with Staff R, Medication Technician,

an insulin pen (an injection device used to deliver preloaded insulin into the body) was observed to have been opened and it was not dated with the date it was opened or the discard date. In a concurrent interview Staff R stated they did not know when the insulin pen had been opened.

In an interview on 07/22/2024 at 5:47 PM, Staff M, Registered Nurse (RN) stated insulin should be dated when opened and discarded after 30 days. They stated this was important because the insulin could be less effective after 30 days of being opened.

Reference: WAC 388-97-1300 (2), 2340

47728

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47728

Residents Affected - Many Based on observation and interview the facility failed to ensure food was labeled, dated and covered, and expired food was discarded on or before the expiration date for 1 of 1 kitchen reviewed. Additionally, the facility failed to ensure staff wore beard covering while preparing and serving food. These failures resulted in risk of food borne illness and diminished quality of life for all residents.

In an observation of the facility kitchen on [DATE REDACTED] at 8:50 AM the following foods were noted in the refrigerators/freezers that were expired and/or past the use by date:

-tortillas use by [DATE REDACTED]

-macaroni salad use by [DATE REDACTED]

-salsa use by [DATE REDACTED]

-strawberry yogurt with expiration date of [DATE REDACTED]

In addition, there were open packages of various berries that were not dated, uncovered celery in the refrigerator, and an open undated package of cooked eggs.

During an observation of the resident nourishment freezer/refrigerator on [DATE REDACTED] at 5:00 AM multiple open food packages were observed that were not labeled with a resident name and/or the date opened or use by date. In addition, the shelves in the refrigerator were dirty with debris on the bottom shelf, and standing liquid was present on the top shelf where food containers were placed. The seals on the freezer and refrigerator doors were both dirty with debris and spilled food/liquid.

In an observation on [DATE REDACTED] at 11:31 AM during lunch tray-line service, Staff BB, Cook, was serving food onto plates for residents and was not wearing a beard net. When asked, Staff BB, and Staff CC, Dietary Manager both stated they were told by the former dietician that Staff BB's beard was short enough that they did not need a beard net. Staff BB had a full beard approx. two inches long.

At 11:41AM on [DATE REDACTED], during lunch tray-line an observation was made of uncovered cottage cheese and pudding cups placed on lunch trays to be delivered to resident rooms.

During an interview on [DATE REDACTED] at 11:54 AM, Staff CC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 In an interview on [DATE REDACTED] at 1:14 PM Staff CC, Dietary Manager, stated the dietary manager was responsible for cleaning the resident's nourishment refrigerator and discarding expired food. Staff CC stated Level of Harm - Minimal harm or the nourishment refrigerator was cleaned once per week and checked Monday-Friday by the dietary potential for actual harm manager and checked on weekends by the weekend dietary aide. They stated the refrigerator/freezer should not have spilled food or debris in them because it was not sanitary. When asked why the cottage cheese and Residents Affected - Many pudding cups were not covered when placed on the meal trays, Staff CC stated they did not normally cover them and asked if they should. They then stated it was important to cover the food to prevent contamination. When asked how opened food should be stored Staff CC stated in a container with a lid, labeled with what

the item was, the date it was opened and the date it should be used by.

Reference: WAC [DATE REDACTED](3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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** 37544 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure personal protective Residents Affected - Many equipment (PPE) was implemented timely in accordance with the guidelines of the Centers for Disease Control (CDC) and the Local Health Department for the use of facial coverings after Resident 18 tested positive for COVID-19. This failure placed all residents and staff at risk for contracting COVID-19 (an acute respiratory illness caused by a virus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions). In addition, failure to ensure PPE was implemented for 2 of 4 sampled residents (Resident 13, 16) reviewed for Enhanced Barrier Precautions (EBP), failure to ensure resident 13's urinary catheter (a tube placed in the bladder to drain urine into a collection bag outside the body) was maintained in a sanitary manner, and failure to ensure hand hygiene was performed during the dining observation placed residents at risk for infection and diminished quality of life.

Findings included .

<Facial Coverings>

According to the 06/24/2024 CDC publication, Infection Control Guidance: SARS-CoV-2, a barrier face covering, such as a surgical mask, and/or an N95 respirator, a particle filtering device worn over the mouth and nose, was recommended to be worn by healthcare providers when there were suspected or confirmed cases of SAR-CoV-2 (COVID-19), when other respiratory infections symptoms such as runny nose, cough or sneeze were present, or when there had been close contact or a high risk exposure to someone infected with COVID-19.

In an interview on 07/17/2024 at 10:02 AM, Resident 41 stated their roommate, Resident 18, tested positive for COVID-19 at the hospital and tested negative here. Resident 41 stated the nursing staff would be testing them today.

On 07/17/2024 at 10:04 AM, Staff AA, Registered Nurse, stated they were informed Resident 18 tested positive yesterday at an outside doctor appointment. Staff AA stated they retested the resident when they returned to the facility, and the test was negative, the resident had no symptoms, and the facility was monitoring (test) the resident on days three and five.

On 07/17/2024 at 10:39 AM, a telephone call was placed to [NAME] County Public Health Department to inquire if the facility had notified them of Resident 18 testing positive for COVID-19 on 07/16/2024, while at

an outside doctor appointment. Collateral Contact (CC1), Communicable Disease Registered Nurse, stated

the facility had just had a COVID-19 outbreak recently, and they had not notified of any new positive cases. When asked what PPE and precautions the staff should be using, CC1 stated Resident 18 should be placed

in isolation, retested on days one, three, and five, staff needed to wear an N95 and PPE when providing care for Resident 18, surgical masks should be worn by all staff while in the building, and the resident's room mate needed to be monitored for symptoms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 07/17/2024 at 10:53 AM found Resident 18 had not been placed in isolation, no signage was present on the door to inform staff of any PPE that was needed, nor had a PPE cart been placed with Level of Harm - Minimal harm or supplies outside the resident's door. In addition, none of the staff in the building were wearing surgical potential for actual harm masks.

Residents Affected - Many In an interview on 07/17/2024 at 11:21, Staff B, Director of Nursing was asked about Resident 18's positive COVID status. Staff B stated because they did not know what type of test the clinic had done and the test done at the facility when the resident returned was negative, they considered the resident's COVID status as unknown. They were treating the resident as if they had been exposed, and Resident 18 would not be placed

on precautions until direction was received from the Health Department. When asked if the facility had notified the Health Department, Staff B stated no.

In an interview on 07/17/2024 at 11:56 AM, CC2, Charge Nurse Tri-State Same Day Procedure Unit, confirmed Resident 18 had tested positive for COVID-19 on 07/16/2024 while at the clinic and they had called the facility and informed Staff AA, Registered Nurse.

Observations on 07/17/2024 at 1:05 PM, 1:48 PM, and 3:16 PM showed staff were still not wearing surgical masks, nor had Resident 18 been placed on isolation, or precautions implemented.

In a follow-up interview on 07/17/2024 at 3:17 PM, CC1 stated the facility had notified them of Resident 18's positive COVID test, and the facility was told Resident 18 should be on isolation, retested on days one, three, and five, staff needed to wear an N95 and PPE when providing care for Resident 18, surgical masks should be worn by all staff while in the building, and the resident's roommate needed to be monitored for symptoms.

A follow-up observation on 07/17/2024 at 3:17 PM found Resident 18 had been placed on isolation, a PPE cart was at the room entrance, and a sign had been posted to inform staff of the PPE needed, but staff working the building were not wearing surgical masks.

On 07/18/2024 at 9:03 AM, observations showed staff were not wearing surgical masks while in the building.

On 07/18/2024 at 9:27 AM, a telephone call was received from CC3, Director [NAME] County Public Health Department, to clarify to the survey team that they had recommended the facility implement the use of surgical masks for their staff after Resident 18 tested positive on Monday.

Review of the email correspondence between CC3 and Staff B, showed on 07/18/2024, Staff B had communicated with the [NAME] County Health Department and at 9:57 AM, CC3 responded with the following Department of Health and CDC guidance related to Resident 18's positive COVID-19 status:

- Isolate the resident and have them wear a surgical mask.

- The resident needed to be retested at days one, three, and five, and with negative results was to be taken out of isolation.

- The proper state signage needed to be placed on the resident's door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 - For the resident's roommate, it was recommended that they wear a surgical mask. They do not need to be tested unless they develop symptoms. Level of Harm - Minimal harm or potential for actual harm - All staff entering the resident's room must wear an N95 mask and gloves.

Residents Affected - Many - It was a CDC recommendation that all staff in the building wear surgical masks as part of spread prevention.

In an observation on 07/18/2024 at 10:06 AM, staff working in the building were now wearing surgical masks, two days after Resident 18 tested positive for COVID-19.

46115

<Enhanced Barrier Precautions>

According to the 04/02/2024 Centers of Disease Control publication, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care areas and indicated for residents with urinary catheters.

On 07/11/2024 at 2:49 PM, Staff AA, Registered Nurse, observed Resident 13's colostomy bag and removed

the dependent loop from their catheter and was not wearing a gown.

On 07/11/2024 at 3:13 PM, Resident 13 did not have an enhanced barrier precautions sign on the door and did not have personal protective equipment (PPE) that was accessible near the room.

During an observation on 07/15/2024 at 9:51 AM, Staff Z, Nursing Assistant and Staff GG, Nursing Assistant entered room [ROOM NUMBER] to assist the resident with repositioning, neither of them had worn a gown.

In an interview on 07/16/2024 at 2:50 PM, Staff Z stated if a resident was on precautions there would be a sign on the outside of their door and a gown and gloves would needed to be worn during cares. Staff Z added that Resident 13 had wounds and a urinary catheter. Staff Z was unsure if they should have worn a gown to reposition and move the resident's catheter to the opposite side of the bed.

During an interview on 07/16/2024 at 2:54 PM, Staff C, Clinical Resource Nurse, stated Resident 13 should have had a sign on their door for enhanced barrier precautions and a gown should have been worn during cares. Staff C added this was important to prevent the potential for increased risk of bacterial infections related to open wounds and the urinary catheter.

In an interview on 07/18/2024 at 12:16 PM, Staff B, Director of Nursing, stated Resident 13 should have had enhanced barrier precautions in place and staff should have worn a gown when cares were provided.

<Resident 16>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 Per the 06/11/2024 assessment Resident 16 was cognitively intact, was incontinent of bowel and bladder, was dependent on staff for activities of daily living (ADLs) such as bathing, personal hygiene, and transfers, Level of Harm - Minimal harm or and had diagnoses including diabetes, and a pressure wound. potential for actual harm

During an observation on 07/15/2024 at 09:41 AM, Staff AA, Registered Nurse (RN) performed wound care Residents Affected - Many for Resident 22 on open wounds on the resident's buttocks and back of the left thigh. Staff AA was not wearing a gown while performing wound care.

On 7/15/2024 at 10:00 AM Resident 22 did not have an enhanced barrier precautions sign on the door and did not have personal protective equipment (PPE) that was accessible near the room.

In an interview on 07/18/2024 at 2:08 PM, Staff Q, Nursing Assistant, stated they had received Enhanced Barrier Precautions (EBP) education and EBP consisted of wearing a gown, gloves, and mask, and should have been implemented when a resident had a catheter, and/or open wounds.

During an interview on 07/18/2024 at 12:16 PM, Staff B, Director of Nursing, stated the expectation for a resident with a wound was to have EBP implemented and if staff was performing wound care they should have worn a gown, gloves, and mask to protect the resident and themself.

<Urinary Catheter>

According to the 05/27/2024 quarterly assessment, Resident 13 had diagnoses which included neurogenic bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) and was moderately cognitively intact and able to direct their care. The resident required total assistance for activities of daily living such as toileting and had a catheter.

During an observation on 07/08/2024 at 2:38 PM, Resident 13 was observed lying in bed, and their catheter was lying on the floor without a cover over it.

In an observation on 07/15/2024 at 4:26 AM, the resident was observed lying in bed, and their catheter was lying on the floor without a cover over it.

During an observation on 07/17/2024 at 8:53 AM, the resident was lying in bed and the catheter was on the bed, the same level as the bladder, which prevents the urine from draining into the collection bag and can cause a urinary tract infection.

During an interview on 07/16/2024 at 2:12 PM, Staff B, Director of Nursing, stated the catheter needed to be changed if it was on the floor.

In an interview on 07/17/2024 at 8:56 AM, Staff B confirmed the catheter was at the same level as the bladder and needed to be lowered.

47728

<Hand Hygiene>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 50 505251 Department of Health & Human Services Printed: 09/17/2025 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 505251 B. Wing 07/22/2024

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

Colfax of Cascadia, LLC 1150 West Fairview Road Colfax, WA 99111

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 Per the 07/09/2024 assessment Resident 22 was cognitively intact, was incontinent of bowel and bladder, was dependent on staff for activities of daily living (ADLs) such as bathing, toileting, and personal hygiene Level of Harm - Minimal harm or and had diagnoses including stroke, and hemiplegia (one-sided weakness or paralysis). potential for actual harm

During an observation of personal care on 07/22/2024 at 12:54 PM, Staff II, Nursing Assistant (NA), and Residents Affected - Many Staff Z, Medication Technician (MT), provided perineal care (cleaning of the genitals and anal area) for Resident 22. While Resident 22 was lying on their back on the bed, Staff II donned gloves and using a wet wipe performed perineal care then rolled the resident onto their left side. Staff Z then, wearing gloves and using wet wipes, proceeded to carry out the perineal care for the resident. Staff II, after removing their gloves and before performing hand hygiene, proceeded to touch their surgical mask, and Staff Z, after removing their gloves and before performing hand hygiene, proceeded to adjust the bed and place pillows under and around the resident

In an interview on 07/22/2024 at 1:07 PM, Staff II (NA) stated hand hygiene should have been done between glove changes and acknowledged they should have performed it after removing their gloves and before touching anything else to prevent infection.

During an interview on 07/22/24 at 1:39 PM, Staff Z, MT stated hand hygiene should be performed before putting on gloves, after removing gloves, and between gloves changes, to prevent the spread of bacteria.

They stated they should have performed hand hygiene after removing their gloves and before adjusting the resident's bed.

Reference (WAC): 388-97-1320 (2)(b),(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 50 505251