Health Inspection

Life Care Center Of Federal Way

Inspection Date: March 18, 2025

Total Violations 2

Facility ID 505188

Location FEDERAL WAY, WA

Inspection Findings

F-Tag F658

Harm Level: Minimal harm or disorder.

Residents Affected: Few

F-F658 - Services Provided Meet Professional Standards.

REFERENCE: WAC 388-97-1060(3)(g), -0260.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress Level of Harm - Minimal harm or disorder. potential for actual harm 50511 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 80) reviewed for mood and behavior was evaluated for potential mental health services to address demonstrated ongoing behaviors and failed to notify the provider of changes in behavior. This failure placed Resident 80 at risk for untreated mental health issues and other negative health issues.

Findings included .

According to the 01/28/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 80 had diagnoses including depression, a cognitive communication deficit, and failure to thrive and received an antidepressant medication.

Review of the 02/04/2025 Antidepressant Care Plan (CP) showed staff were to report changes in behavior and mood.

Review of a 01/24/2025 physician order showed staff were to monitor Resident 80's exhibited behavior including verbal abuse. Staff were to redirect the resident and provide one-on-one services and chart in the progress notes.

Review of the progress notes showed nursing staff documented on 03/04/2025, 03/09/2025 and 03/11/2025 that Resident 80 demonstrated refusals of care.

Review of March 2025 care staff task sheet showed on 03/09/2025, 03/11/2025, 03/12/2025, 03/15/2025 Resident 80 was agitated. On 03/01/2025, 03/04/2025, 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/14/2025 and 03/15/2025, staff documented Resident 80 refused to eat.

Record reviewed showed no evidence the facility assessed Resident 80's refusals of care, agitation, and refusals to eat, or notified the provider of behavior changes.

In an interview on 03/11/2025 at 2:40 PM Resident 80 stated the facility would not let their dog visit anymore and stated they were upset with the facility. Resident 80 stated even though they were hungry they did not want to eat.

Observation on 03/13/2025 at 10:39 AM showed Resident 80 lying in their bed, the room was dark, and the lights were off. Resident 80 stated I am not doing very good but declined to say what was bothering them.

In an interview on 03/18/2025 at 10:02 AM, Staff E (Social Services Assistant) stated if they knew about Resident 80's refusals they would have called the family to report the refusals of care and work on a plan to correct the behaviors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0742 In an interview on 03/18/25 at 10:53 AM Staff H (Unit Care Manager) stated Resident 80 could become aggressive and would refuse to eat. Staff H stated Resident 80 often refused care and stated they could not Level of Harm - Minimal harm or force services on residents. Staff H stated they expected staff to report refusals of care and after that, the potential for actual harm Director of Nursing and the social worker would meet to discuss refusals. Staff H stated staff should notify

the provider and if applicable, should make a referral for hospice care, but this did not happen. Residents Affected - Few

In an interview on 03/18/2025 at 12:19 PM Staff B (Director of Nursing) stated for Resident 80's refusals of care, staff should reapproach and help to change the resident's mind. Staff B stated staff should document refusals. Staff B stated the facility should have notified the doctor that Resident 80 refused medications, treatments, and care. Staff B stated Resident 80 had the right to refuse care, but their doctor needed to be notified as it could impact their overall care.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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** 50511 Residents Affected - Few Based on observation, interview, and record review the facility failed to: ensure medication refrigerator temperatures were monitored for 1 of 2 medication rooms (100/200 Unit); ensure expired medications and biologicals were disposed of appropriately for 1 of 2 medication rooms (300/400 Unit); and ensure medications and biologicals were secured for 1 of 6 Residents (Resident 31) reviewed for medication storage. These failures placed residents at risk for receiving the wrong medications, expired medications, and other negative health outcomes.

Findings included .

According to the revised 09/13/2024 Medication Storage in Refrigerator/Freezer policy the facility would ensure all medications and biological were stored in the appropriate temperatures. Safe temperatures for refrigeration were between the range of 36 degrees to 46 degrees Fahrenheit.

Observation on 03/13/2025 at 2:33 PM of 100/200-unit medication room showed the medication refrigerator temperature was at 49 degrees, above the recommended temperature range. There was no refrigerator temperature log to show staff monitored the refrigerator temperatures routinely.

In an interview on 03/13/2025 at 2:35 PM Staff I (Infection Preventionist) observed the medication refrigerator and stated it was used to store staff vaccinations. Staff I stated the temperature of 49 degrees was too high to store medications effectively. Staff I was not sure who was responsible for checking the temperatures of the medication refrigerator.

In an in interview on 03/18/2025 at 12:35 PM Staff B (Director of Nursing) stated they did not know who checked the medication room refrigerator temperatures but should be checked for optimal efficiencies of medications.

In an interview on 03/18/2025 at 12:56 PM Staff A (Regional VP) stated they did not know who checked the medication refrigerator temperatures but expected the nurses to check this daily since they are the only ones who had the keys. Staff A stated this was important as medications could go bad quickly and would be unsafe.

Observation on 03/13/2025 at 12:14 PM of the medication room for the 300/400 units showed an expired antibiotic medication was found in the medication refrigerator with a use-by date of 03/06/2025. Also observed was a bottle of a suspension powder used to treat high levels of potassium which expired in 2023 for a resident who discharged in May 2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 In an interview on 03/13/2025 at 12:20 PM Staff H (Unit Care Coordinator) stated there should not be any expired medications in the medication room. Staff H stated they were responsible for getting rid of expired Level of Harm - Minimal harm or medications but did not. potential for actual harm <Resident 31> Residents Affected - Few According to a 02/18/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 31 could make themselves understood and understood others in conversation. The MDS showed Resident 31 had a cognitive communication deficit and a diagnosis of non-Alzheimer's dementia.

Observation on 03/11/2025 at 9:09 AM showed a bottle of medicated power used for skin rashes with another resident's name placed on Resident 31's nightstand.

In an interview on 3/11/2025 at 9:42 AM Staff X (Licensed Practical Nurse) stated they did not know why the bottle of powdered medication was in Resident 31's room and stated it should not be there for Resident 31's safety.

In an interview on 03/18/2025 at 10:38 AM Staff H stated the staff should not leave medications in any resident's room. Staff H stated Resident 31 had confusion and it was not safe to leave medications in their room for any reason.

REFERENCE: WAC 388-97-1300(2).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 42203

Residents Affected - Some Based on interview and record review, the facility failed to ensure the Dietary Manager (Staff J) had the required qualifications to perform their duties for 1 of 1 facility kitchens. The failure to ensure a Dietary Manager without the required certification had fulltime support from a Registered Dietician (RD) placed all residents at risk of receiving a menu prepared by staff without the required competencies and skills to provide food and nutrition services.

Findings included .

During kitchen rounds on 03/11/25 Staff J at 8:35 AM (Incoming Dietary Director) provided access to the kitchen and stated they were in charge.

In an interview on 03/18/2025 at 11:14 AM Staff J stated they did not complete the required dietary manager training. Staff J stated the previous Dietary Director left sooner than anticipated. Staff J stated the facility's Registered Dietician (RD) did not work a fulltime schedule at the facility.

In an interview on 03/18/2025 at 12:01 PM Staff Q (RD) stated they were also the dietician for a sister facility. Staff Q stated they worked at the facility on Tuesdays and Thursdays, indicating they did not work in the facility fulltime as required when the dietary manager did not have the necessary certification.

REFERENCE: WAC 388-97-1160 (1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 47836

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure confidentiality of resident records was maintained for 1 of 4 medication carts (100 hall medication cart) reviewed. This failure placed residents at risk for a violation of their rights to privacy.

Findings included .

According to a facility policy titled, Resident Rights, revised 09/10/2024, the facility must protect and promote

the rights of the residents. The policy showed residents had the right to privacy and confidentiality of their medical information.

<100 hall medication cart>

In an observation and interview on 03/11/2025 at 12:33 PM Staff O (Licensed Practical Nurse) walked away from their medication cart with a list of all residents on 100 hall with their health information unsecured and in view. Staff O stated they were expected to maintain confidentiality of all resident information but did not. Staff O stated it was important to maintain confidentiality of resident information for their rights.

In an observation and interview on 03/12/2025 at 12:33 PM Staff P (Registered Nurse) walked away from their medication cart with a list of all residents on 100 hall with their health information unsecured and in view. Staff P stated they were expected to protect resident information and not leave in sight for others to view but they forgot. Staff P stated it was important to protect resident information for their rights.

In an interview on 03/17/2025 at 11:50 AM Staff B (Director of Nursing) stated they expected staff to secure all resident information before walking away from it. Staff B stated it was important to maintain confidentiality of resident information for their right to privacy.

REFERENCE: WAC 388-97-1720(1)(c), -0360(1-3).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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

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

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 50511

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff and failed to implement and develop a coordinated Care Plan (CP) for 1 of 2 residents (Resident 25) reviewed for hospice services. The failure to implement a system by which consistent communication between the facility and hospice staff occurred placed residents at risk for not for receiving necessary care and services, avoidable discomfort, and other negative health outcomes.

Findings included .

According to facility's revised 11/19/2024 Hospice policy, the facility would ensure the resident's CP included

the most recent hospice plan of care and a description of services provided by the facility to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing. The facility must designate a member of the team to ensure the resident received quality care in collaboration with the facility staff and the hospice staff.

According to a 02/19/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 25 had diagnoses including Multiple Sclerosis (MS - a chronic neurological condition) and muscle weakness and received hospice care services.

Record review showed the 12/05/2024 Hospice CP include a goal for a facility representative to coordinate care with the hospice services. The CP included interventions for staff to adjust the provision of Activities of Daily Living (ADL - dressing, grooming, bathing, eating etc.) to compensate for Resident 25's changing abilities, and to encourage participation to the extent the resident wished. The CP did not show how staff were to work with the hospice services team to coordinate care or to report changes in care regarding Resident 25' wellbeing.

Review of Resident 25's Kardex (nursing aides' instruction sheet) did not show what care was to be provided by the facility and what care by hospice services.

Review of Resident 25's medical record did not show documentation of the hospice plan of care and did not include documentation or notes from hospice visits to Resident 25.

Review of the hospice binder at the nurse's station on 03/11/2025 at 10:50 AM showed the binder contained

the demographics page of Resident 25's hospice admission. The binder did not contain a coordinated CP, instructions for care, or visit notes from the hospice team.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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

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

F 0849 In an interview on 03/14/2025 at 10:24 AM Staff G (Licensed Practical Nurse) stated the facility nurses provided wound treatment to Resident 25 when the hospice nurse did not come in to provide wound Level of Harm - Minimal harm or treatments. Staff G was not able to recall what time and when the hospice nurse usually came to the facility potential for actual harm so they could know whether to provide treatment or not.

Residents Affected - Few In an interview on 03/17/2025 at 9:53 AM Staff AA (Registered Nurse) stated they could not give Resident 25 too much pain medication because Resident 25 was on hospice, and hospice managed Resident 25's pain instead of the facility.

In an interview on 03/18/2025 at 10:19 AM Staff S (Certified Nursing Assistant) stated did not receive training

on hospice care. Staff S stated they referred to the hospice book at the nurse's station and the Kardex regarding hospice care needed for Resident 25 but was unsure where the hospice binder was at that time.

In an interview on 03/14/2025 at 1:20 PM, Staff H (Unit Care Coordinator) stated it was important to integrate hospice services into Resident 25's CP. Staff H stated it was important that hospice services placed documentation in the hospice binder, but they did not. Staff H stated they always asked the hospice nurse for

a verbal report but was not sure if hospice coordinated with floor nurses when Staff H was not in the facility. Staff H stated Resident 25's hospice service did not document directly into Resident 25's medical record and

the facility had to access the hospice services medical record system, but that system was not currently accessible to the facility.

In an interview on 03/18/2025 at 12:02 PM Staff B (Director of Nursing - DON) stated it was important to coordinate care with hospice care, to review the care plans, and to determine the resident's preferences. Staff B stated the DON, and the unit care coordinators should coordinate services with the hospice team and hospice should provide the facility with visit notes. Staff B stated they were unsure where the hospice notes were kept but if notes were left by hospice services, they should be scanned into the resident's medical

record but were not.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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** 47836 potential for actual harm Based on observation, interview, and record review the facility failed to appropriately store resident Residents Affected - Few respiratory equipment for 1 of 3 sampled resident (Resident 69) reviewed for respiratory care, follow physician orders for Transmission Based Precautions (TBP) for 1 of 2 residents (Resident 84) reviewed for antibiotic use, and appropriately use Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 1 of 3 residents (Residents 25) reviewed for infection control and one facility staff. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment.

Findings included .

According to the facility's 06/13/2024 Infection Prevention and Control Program policy the facility must establish and maintain an effective infection control program. The policy showed the facility would implement appropriate TBP and PPE use when required.

According to a 02/11/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 69 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 69 had no respiratory infections.

Review of Resident 69's health records showed they were transferred to an acute care hospital for a respiratory illness on 02/24/2025. Resident 69's health records showed a 02/28/2025 physician order for a respiratory medication to be administered via Small Volume Nebulizer (SVN - a machine that creates as mist out of liquid medication for inhalation) machine.

In an observation and interview on 03/11/2025 at 10:07 AM Resident 69's representative stated the staff stored the residents SVN machine on their roommate's nightstand. Observation at this time and on 03/12/2025 at 10:15 AM, 03/13/2025 at 9:23 AM, 03/14/2025 at 10:05 AM, and 03/17/2025 at 10:41 AM showed Resident 69's SVN machine on the roommate's nightstand.

In an interview on 03/17/2025 at 8:28 AM Staff F (Unit Care Coordinator) reviewed Resident 69's health records and stated the SVN machine was for Resident 69 and the SVN machine should be stored in Resident 69's area of the room, not in the roommates' side. Staff F stated it was important to keep each resident's equipment in their own area of the room for infection prevention.

In an interview on 03/18/2025 at 8:57 am Staff B (Director of Nursing) stated they expected the SVN machine be stored in Resident 69's area of the room. Staff B stated this was important for infection control and residents' rights to their space.

42203

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 <TBP Implementation>

Level of Harm - Minimal harm or <Resident 84> potential for actual harm According to the 02/21/2025 Admission MDS Resident 84 had a Multidrug-resistant Organism (MDRO - a Residents Affected - Few difficult to treat infectious organism) infection and surgical wounds. The MDS showed Resident 84 used an antibiotic medication.

According to a 02/17/2025 physician's order Resident 84 required contact precautions (a type of TBP requiring anyone who entered the room to utilize specified Person Protective Equipment (PPE) before entry) related to their MDRO infection.

Observation on 03/12/25 at 12:28 PM showed Enhanced Barrier Precautions (a system of PPE usage required for certain conditions that only required facility staff to use PPE when close contact with the resident was anticipated) were in place instead of the contact precautions ordered.

In an interview on 03/18/2025 at 1:07 PM Staff B stated the sign on the door should reflect the order but did not.

50511

According to the 02/19/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 25 had a neurological condition that affected their muscles and had skin pressure injuries on their lower back.

Review of the revised 10/29/2024 Moisture Acquired Skin Damage (MASD) CP, Resident 25 had pressure wound areas to their lower back and right hip. Staff were directed to use EBP when providing care that included the use of gowns, gloves, and masks.

Observation on 03/12/2025 at 10:12 AM showed no EBP signage on the door to Resident 25's room to direct staff to use EBP while providing care. Staff R (CNA) and Staff S (CNA) were observed assisting Resident 25 to turn and provided incontinence care. Neither Staff R or Staff S wore protective gowns while providing care to the wound areas. The pressure area on Resident 25's lower back had broken red skin and bled. The other two wounds on the lower hip areas had intact skin and was red and white in appearance. Staff R left the room with their gloves still on and walked down the hallway to call the nurse.

Observation on 03/12/2025 at 10:23 AM showed Staff R provided incontinence care to Resident 25 who was

in bed 3. Staff R left Resident 25 to get more incontinent supplies from their closet located in the front of the room while passing residents in bed 1 and bed 2 to obtain supplies.Staff R did not remove their soiled gloves or sanitize their hands before obtaining new supplies.

In an interview on 03/12/2025 at 10:33 AM Staff R stated the room was not labeled as an EBP room and

they only needed to wear gloves while providing care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 <Housekeeping >

Level of Harm - Minimal harm or In an observation on 03/13/2025 at 10:42 AM, room [ROOM NUMBER] had signage on the door that showed potential for actual harm EBP precautions for the room. Staff T (Housekeeping Assistant) was observed to finish cleaning room [ROOM NUMBER]. Staff T removed their EBP gown outside of the room and placed the gown on the bottom Residents Affected - Few of their housekeeping cart instead of disposing of the gown inside the room in the designated soiled garbage bin.

In an observation on 03/14/2025 at 11:26 AM Staff T stepped out of room [ROOM NUMBER] and removed their soiled gown outside of the room instead of inside of the room where the garbage bin was located.

In an interview on 03/14/2025 at 2:08 PM Staff I (Infection Preventionist) stated staff were to sanitize their hands before going in and going out of EBP rooms. Staff I stated all residents with indwelling devices, wounds, or requiring dressing changes should have EBP signage on the door to notify staff to use EBP. Staff I stated this was important to prevent the spread of infection. Staff I stated Resident 25 should have EBP signage because of their pressure wounds but did not. Staff I stated staff should remove gowns and gloves

before coming out of the room. Staff I stated staff were trained on this but needed additional training.

In an interview on 03/18/2025 at 9:52 AM Staff T stated they knew to wear a gown and mask while in an EBP room and should have taken gown off in the room and not in the hallway.

In an interview on 03/18/2025 at 12:14 PM Staff H (RN Unit Care Manager) stated staff were expected to use PPE when they saw bodily fluids or blood. Staff H stated the EBP sign should specify what staff need to wear and when it was needed and should be posted on the Resident 25's door but was not.

In an interview on 03/18/25 at 12:14 PM, Staff B (Director of Nursing) stated they would expect EBP signage

on the door to direct staff when to use PPE and staff should know when to use personal protective equipment (PPE-gloves, masks, gowns) during care.

REFERENCE: WAC 388-97-1320 (1)(a)(c), (2)(a)(c), (4),(5)(b)(c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 47836 potential for actual harm Based on interview and record review, the facility failed to provide education for the influenza vaccination Residents Affected - Some and administer a pneumococcal (pneumonia) vaccination within the recommended timeframe for 4 (Residents 8,14, 13, & 64) of 5 residents reviewed for vaccinations. This failure placed residents at risk of experiencing complications, not being able to make an informed decision, and contracting pneumonia, with its associated complications.

Findings included .

According to a facility policy titled, Pneumococcal Vaccine Policy for Residents, revised 01/28/2025, each resident would be offered the pneumococcal vaccine. The policy showed there would be documentation in resident health records of historical pneumococcal vaccination. The policy showed the facility would readdress refusals annually and show documentation of doing so. The policy showed education would be provided to the residents regarding the benefits and potential side effects and consent would be obtained.

According to the facility policy titled, Influenza Vaccine Policy for Residents, revised 01/28/2025, the facility would provide education regarding the risks and potential benefits of the Influenza vaccine prior to administration. The policy showed each resident would be offered the vaccine annually between October 31st through March 31st. The policy showed resident records would have documentation supporting the resident received education regarding the risks and benefits of the vaccine, consent or declination, and administration of the vaccine.

Review of Resident 8's health records showed they received the influenza vaccination on 10/14/2024. Resident 8's health records showed no documentation that education was provided for the influenza vaccine prior to administration. Resident 8's health records showed no documentation of the pneumococcal vaccination being offered or their historical immunization status.

Review of Resident 14's health records showed they received the influenza vaccination on 10/14/2024. Resident 14's health records showed no documentation that education was provided for the influenza vaccine prior to administration. Resident 14's health records showed no documentation of the pneumococcal vaccination being offered or their historical immunization status.

Review of Resident 13's health records showed they received the influenza vaccination on 10/14/2024. Resident 13's health records showed no documentation that education was provided for the influenza vaccine prior to administration. Resident 13's health records showed no documentation of the pneumococcal vaccination being offered or their historical immunization status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0883 <Resident 64>

Level of Harm - Minimal harm or Review of Resident 64's health records showed no documentation of the influenza or pneumococcal vaccine potential for actual harm being offered for the 2024-2025 season. Resident 64's health records showed no documentation of historical immunization status. Residents Affected - Some

In an interview on 03/14/2025 at 11:05 AM Staff I (Infection Preventionist) stated they did not have documentation of education or consent for the influenza vaccines for Residents 8, 14, 13, or 64 for the 2024-2025 season. Staff I stated they were expected to obtain a copy of each resident's immunization records from the department of health and scan into the residents health records but did not for Residents 8, 14, 13, or 64. Staff I stated it was important to educate residents and obtain consent prior to administration of vaccines to ensure they were aware of the risks and benefits of the vaccine. Staff I stated it was important to obtain residents vaccination status from the department of health upon admit to the facility to ensure they were up to date with the recommended vaccinations and decrease the chances of them acquiring a communicable disease.

REFERENCE: WAC 388-97-1340(2).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 47836

Residents Affected - Some Based on record review and interview, the facility failed to provide education on the benefits and potential side effects of the Covid-19 (C19) vaccination for 4 of 5 sampled residents (Resident 8, 14, 13, & 64) and provide education on the benefits and potential side effects of the C19 vaccination for 1 of 1 sampled staff (Staff U - Restorative Aide) reviewed for vaccinations. This failure placed residents, their representatives, and staff at risk of not being given the opportunity to make an informed decision regarding their medical care, potential complications of a communicable disease, and a decreased quality of life.

Findings included .

According to a facility policy titled, Covid-19 (SARS-CoV-2) Vaccination Program Policy for Associates, revised 11/27/2024, showed the facility would provide education regarding the benefits and potential side effects associated with the C19 vaccine and offer the vaccine unless it was medically contraindicated, or staff member had already been immunized. The policy showed the facility would maintain a copy of the education material provided to each staff member.

According to facility policy titled, Covid-19 (SARS-CoV-2) Vaccination Program Policy for Residents, revised 11/27/2024, showed the facility would offer all residents the C19 vaccine. The policy showed the facility would educate residents or their representatives regarding the benefits and potential side effects associated with the C19 vaccine. The policy showed the resident records would include documentation that the resident was provided education regarding the benefits and potential risks associated with the C19 vaccine and documentation of the resident's consent or declination. The policy showed the facility would offer and educate all residents on the C19 vaccine each time the C19 vaccine supplies were available to the facility.

Review of Resident 8's health records showed a 10/14/2025 Infection progress note the resident received

the C19 vaccination. Resident 8's health records did not show education was provided on the benefits and potential side effects of the C19 vaccination.

Review of Resident 14's health records showed a 10/14/2025 Infection progress note the resident received

the C19 vaccination. Resident 14's health records did not show education was provided on the benefits and potential side effects of the C19 vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0887 Review of Resident 13's health records showed a 10/14/2025 Infection progress note the resident received

the C19 vaccination. Resident 13's health records did not show education was provided on the benefits and Level of Harm - Minimal harm or potential side effects of the C19 vaccination. potential for actual harm <Resident 64> Residents Affected - Some

Review of Resident 64's health records did not show they were offered the C19 vaccine for the 2024-2025 C19 booster vaccine. Resident 64's health records did not show education was provided on the benefits and potential side effects of the C19 vaccination for the 2024-2025 vaccine booster.

In an interview on 03/14/2025 at 11:05 AM Staff I (Infection Preventionist) stated they did not educate Staff U or any staff on the C19 vaccination risks and benefits. Staff I stated they did not know they were required to educate all staff and residents on the C19 vaccine and retain documentation of doing so. Staff I stated they were expected to pull all residents immunization records from the health department and save in the resident's records to document which vaccinations the resident received but they did not. Staff I reviewed Residents 8, 14, 13, and 64's health records for the 2024-2025 C19 vaccination education of the benefits and potential side effects of the vaccine. Staff I stated they did not have documentation of education for the C19 vaccine for Residents 8, 13, 14, or 64 but understood the importance of having it in the resident's records.

In an interview on 03/17/2025 at 11:50 AM Staff B (Director of Nursing) stated they expected Staff I to educate all staff and residents on the risks and benefits for the C19 vaccination. Staff B stated they expected Staff I to retain documentation of the education for all employees and residents.

REFERENCE: WAC 388-97-0200(2), -0300(3)(a).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or 42203 potential for actual harm Based on observation, interview, and record review the facility failed to ensure qualified nursing staff were Residents Affected - Few provided training and specialized training for 4 of 5 staff members (Staff I [Infection Preventionist], Staff K [Licensed Practical Nurse], Staff CC [Certified Nursing Assistant - CNA] and Staff S [CNA] sampled for staff training. These failures placed residents at risk for unmet care needs and a diminished quality of life.

Findings included .

Review of the undated Facility Assessment showed staff were to be trained upon hire, annually, and as needed in the areas of communication, resident rights-ensuring staff were educated on residents rights and to properly care for its residents, abuse and neglect, infection control, person centered care, resident changes in condition, cultural competency, and quality assurance and performance improvement.

Review of staff training records did not show documentation (Staff I, Staff K & Staff CC) received training upon hire or annual training of facility assessment trainings.

In an interview on 03/17/2025 at 12:18 PM Staff DD (Staffing Coordinator) stated the facility did not have a Staff Development Coordinator to keep track of staff trainings. Staff DD stated they relied on staff to come to them when they needed to do their trainings. Staff DD stated the trainings were made available to the staff through their online health training site and provided the general curriculum of the table of contents of the facility's online trainings. Staff DD stated they thought the Director of Nursing kept copies of the training records but was not sure.

Review of the facility's Annual General Curriculum table of contents from their online health training vendor showed there were no specialized training curriculum available for dementia care, behavioral health, or hospice care.

In an interview on 03/17/2025 at 1:42 PM Staff C (Regional Director of Clinical Services) stated the facility should have completed all the required trainings for Staff I, Staff K, and Staff CC but did not.

In an interview on 03/18/2025 at 10:19 AM Staff S (CNA) stated they did not receive training on hospice care.

In an interview on 03/18/2025 at 10:38 AM Staff H (Unit Care Coordinator) stated they did not know if staff were trained on hospice care and did not have any proof that this training was provided by the facility. Staff H stated training on hospice was important as the facility had many residents receiving hospice care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0940 In an interview on 03/18/2025 at 12:16 PM Staff B (Director of Nursing) stated they did not know about specialized training on hospice care and did not think the facility provided this. Level of Harm - Minimal harm or potential for actual harm REFERENCE: WAC 388-97-1680(1)(2)(a)(b)(ii)(c).

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 50511

Residents Affected - Some Based on interview and record review, the facility failed to implement a system to ensure 1 of 1 (Staff CC) nursing aides reviewed for training received the required training for continued competency of no less than 12 hours per year. The failure to implement a system to provide mandatory training on dementia management, abuse prevention, and other specialized resident needs placed residents at risk for abuse, neglect, emotional distress, and physical injury.

Findings included .

In an interview and record review on 03/17/2025 at 1:42 PM, Staff C (Regional Director of Clinical Services) reviewed the personnel file for Staff CC and found no training documents related to abuse, neglect, exploitation, infection control, communication, resident rights, or cultural competency after Staff CC's hire date of 08/05/2024. Staff C stated the facility currently had no staff development coordinator who tracked nursing assistants continuing education and annual training requirements for mandatory topics or the topics related to resident population's special needs.

REFERENCE: WAC 388-97-1680(2)(a-c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 58 505188

F-Tag F700

Harm Level: Minimal harm or

Residents Affected: Some Based on observation, interview, and record review the facility failed to facilitate quarterly care conferences

F-F700 - Bedrails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47836 potential for actual harm Based on observation, interview, and record review the facility failed to provide necessary care and services Residents Affected - Few for 1 of 1 resident (Resident 77) reviewed for communication. Failure to provide communication assistance for residents where English was a second language placed residents at risk of miscommunication, unmet care needs, and quality of care.

Findings included .

According to a facility policy titled, Language Access Services and Effective Communication, revised 01/07/2025, the facility would ensure residents, where English was not their primary language, would have access to interpreters/translators and other aides needed without cost.

According to an 11/05/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 77 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 77's preferred language was their primary language.

The assessment showed Resident 77 needed an interpreter to communicate with the doctor and health care staff.

Review of an 11/08/2024 communication problem related to language barrier . Care Plan (CP) Resident 77 spoke limited English, and their primary language was birth language. The CP showed staff would observe for effectiveness of assistive devices for communication. The CP showed the translators phone number would be posted in Resident 77's room. The CP showed staff were to provide translation services to communicate with Resident 77 so the resident would be able to make their basic needs known.

Observation and interview on 03/11/2025 at 1:53 PM Resident 77 stated their primary language was not English. Resident 77 stated they would ask staff for help sometimes and when the staff didn't understand them, they would walk away and not respond to their request. Resident 77 stated they were unaware of translation assistance or devices to assist them in communication with staff. Observation at this time showed no communication assistive devices in Resident 77's room and no translator services phone number posted for the resident. Resident 77 opened all drawers in room to show they had not received any communication assistive devices.

In an interview on 03/17/2025 at 8:28 AM Staff F (Unit Care Coordinator) stated they had not provided Resident 77 with communication boards or the translators phone number as the CP instructed but should have. Staff F stated it was important to provide residents communication assistive devices when English was

a second language to ensure they could make themselves understood and understand others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0676 In an interview on 03/18/2025 at 8:57 AM Staff B (Director of Nursing) stated they expected staff to provide communication boards with pictures related to basic needs to residents when English was not their primary Level of Harm - Minimal harm or language. Staff B stated they expected staff to provide the translation services phone number to residents potential for actual harm that needed those services for communication. Staff B stated it was important to ensure good communication between the resident and staff to guide their care and ensure they're meeting the residents needs. Residents Affected - Few REFERENCE: WAC 388-97-1060(2)(a)(v).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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** 42203 potential for actual harm Based on observation, interview, and record review the facility failed to provide assistance with Activities of Residents Affected - Few Daily Living (ADL - bathing etc.) to residents dependent on staff assistance for 1 (Resident 139) of 5 residents reviewed for ADL. The failure to provide bathing assistance to residents placed residents at risk for poor hygiene, skin breakdown, and feelings of diminished self-worth.

According to the facility's 09/10/2024 ADL policy showed residents unable to perform their own ADL would receive the necessary assistance to maintain good grooming, and personal hygiene.

According to the 03/04/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 139 required substantial/maximal assistance with bathing and had a moderate memory impairment. The MDS showed Resident 139 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 139 had a highly transmissible gastrointestinal infection that required isolation.

According to the 02/27/2025 bathing preferences form Resident 139 preferred a bed bath in the morning twice a week. The form indicated Resident 139 required maximal assistance with bathing.

Review of the 02/27/2025 ADL Assistance . Care Plan (CP) included a goal for Resident 139 to return to their former level of comfort. This CP included no directions addressing Resident 139's bathing needs. There was no other CP addressing Resident 139's need for bathing assistance.

Review of the bathing records showed from the date of admission, 02/27/2025 through 03/17/2025 (18 days) Resident 139 received only one bed bath on 03/08/2025 with only one documented refusal of bathing on 03/07/2025.

In an interview on 03/12/2025 at 10:29 AM Resident 139 stated they wanted assistance with bathing. Resident 139 showed their fingernails were long and soiled and stated they needed help to trim them.

In an interview on 03/17/2025 at 2:23 PM Staff X (LPN) stated it was important to provide bathing assistance to residents who needed assistance. Staff X reviewed the bathing records and stated Resident 139 did not receive the bathing assistance they required but should have.

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 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0678 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42203

Residents Affected - Few Based on observation, interview, and record review the facility failed to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were implemented for 2 of 22 sample residents (Residents 32 & 16) and one supplemental resident (Resident 60), related to lifesaving treatment orders. The failure to follow the POLST instructions for Cardiopulmonary Resuscitation (CPR) (Resident 32) or ensure

the POLST was readily available (Residents 16 & 60) placed residents at risk for receiving unwanted CPR, avoidable trauma, and other negative health outcomes.

Findings included .

According to the facility's [DATE REDACTED] CPR policy, when a resident admitted to the facility, staff would verify if the resident had any Advanced Directives (legal documents that provide instructions for medical care when a resident cannot communicate their own wishes) and if not, verify if the resident did not wish to receive CPR.

The policy showed if the resident did not want CPR, a physician's order would be obtained (this information would be documented on a POLST form).

According to the facility's [DATE REDACTED] Advanced Directives and Advanced Care Planning policy, all residents would receive lifesaving treatment unless they had Do Not Resuscitate (DNR) documentation in place, in which case the DNR directive would be honored. The policy showed a physician's order would be obtained reflecting the DNR status. The policy showed the Director of Nursing (DON) would establish a system to inform all direct care staff of residents' DNR status.

According to the [DATE REDACTED] Significant Change Minimum Data Set (MDS - an assessment tool) Resident 32 had diagnoses including cancer, multiple heart conditions, high blood pressure, stage-3 kidney disease, diabetes mellitus (a condition making blood sugar regulation more difficult), high cholesterol, and Chronic Obstructive Pulmonary Disease (lung disease). The MDS showed Resident 32 experienced shortness of breath when lying down.

Observation on [DATE REDACTED] at 1:49 PM showed a staff member announced a Code Blue (medical emergency) for room [ROOM NUMBER] (Resident 32's room). At that time at the ,d+[DATE REDACTED] Unit nurse station Staff I (Infection Preventionist) was observed calling out from the nurse station toward room [ROOM NUMBER] to attempt resuscitation. At 01:50 PM a voice carried from room [ROOM NUMBER] stating it is bed 3. At that point Staff I yelled Gosh you guys, no CPR for bed 3 - selective treatment for BED 3! You have got to say which bed! At 1:58 PM the paramedics arrived at the facility and took over treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 0678 In an interview on [DATE REDACTED] at 1:48 PM Staff I stated they heard the housekeeper make the Code Blue alert for Resident 32. Staff I stated they heard the housekeeper say it was for room [ROOM NUMBER], bed 1. Staff I Level of Harm - Minimal harm or stated they looked at the POLST book (a binder held at the nurse station which was to include the POLST potential for actual harm forms of every resident for the 100 and 200 units) and called out 207, bed 1 - full code, selective treatment. Staff I stated shortly thereafter they overhead Code Blue ,d+[DATE REDACTED] at which point Staff I provided the Residents Affected - Few correct information for Resident 32. Staff I stated by that point CPR was already initiated which meant it was necessary to continue until the paramedics took over treatment.

In an interview on [DATE REDACTED] at 8:46 AM with Staff B (Interim Director of Nursing) and Staff C (Regional Director of Clinical Services) Staff B explained Resident 32 was found unresponsive by a facility volunteer who alerted Staff K (Licensed Practical Nurse) who immediately went to Staff I's office for help. Staff B stated Staff I reviewed the POLST and said full code which was not correct for Resident 32. Staff B confirmed three other nurses went to room [ROOM NUMBER] and started CPR and continued until the paramedics arrived. Staff B stated staff should have properly identified the resident and referred to the correct POLST but did not. Staff C stated the facility identified the root cause of the miscommunication was the fact the POLST book was organized by room, rather than by resident name.

According to the [DATE REDACTED] Admission MDS Resident 16 had intact memory. The MDS showed Resident 16 had diagnoses including anemia and a right femur (thigh bone) fracture.

Review of the POLST book on [DATE REDACTED] at 10:03 AM showed no POLST available for Resident 16. There was also no POLST in Resident 16's chart. In an interview at that time Staff C confirmed there was no POLST in

the book and stated it may be in Resident 16's chart or with the medical records department.

In an interview on [DATE REDACTED] at 10:05 AM Staff L confirmed they did not have a POLST for Resident 16's POLST.

In an interview on [DATE REDACTED] at 11:22 AM Staff B stated they were unable to find Resident 16's POLST and it was necessary for Resident 16 to complete a new POLST form. Staff B confirmed the POLST book was the first place nurses would look for a POLST.

Review of the POLST book on [DATE REDACTED] at 11:18 AM showed there was no POLST for Resident 60 in the POLST book. In an interview at that time Staff B took note that the POLST was not in the POLST book.

REFERENCE: WAC [DATE REDACTED] (1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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** 47836 potential for actual harm Based on record review and interview the facility failed to ensure 3 of 3 residents (Resident 8, 13, & 64) Residents Affected - Few reviewed for Edema (fluid retention in the body) received the necessary care and services they required in accordance with professional standards of practice. The facility failure to assess and monitor residents with edema placed residents at risk for complications, worsening conditions, and a diminished quality of life.

Findings included .

According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 reentered the facility on 08/08/2024. The MDS showed Resident 8 had diagnoses of, but not limited to, heart failure with edema. The MDS showed Resident 8 received diuretic medication during the assessment period.

Review of an 11/02/2023 diuretic therapy Care Plan (CP) showed Resident 8 received diuretic medication for edema.

Review of Resident 8's health records showed a 08/08/2024 physician's order for a diuretic medication given daily for edema. Resident 8's health records showed no physician's order to assess and monitor edema.

In an interview on 03/17/2025 at 8:28 AM Staff F (Unit Care Coordinator) reviewed Resident 8's health records and stated they did not have documentation of monitoring the resident's edema, but it should be monitored every shift. Staff F stated it was important to monitor edema every shift to best manage heart failure with edema and prevent them from fluid overload.

According to a 10/18/2024 Annual MDS Resident 13 reentered the facility on 05/17/2022. The MDS showed Resident 13 had diagnoses of, but not limited to, heart failure with edema and kidney failure. The MDS showed Resident 13 received diuretic medication during the assessment period.

Review of an 09/13/2022 hypertension (high blood pressure) CP showed the facility would notify the doctor of edema.

Review of Resident 13's health records showed a 10/21/2024 physician order for a diuretic medication given daily for edema. Resident 13's health records showed a 01/11/2023 physician order to monitor the resident's weight monthly. These records showed the facility only weighed Resident 13 10 times out of 27 opportunities since the 01/11/2023 monthly weight order. Resident 13's health records showed no physician order to assess and monitor their edema.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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

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

F 0684 In an interview on 03/17/2025 at 8:28 AM Staff F reviewed Resident 13's health records and stated they did not have documentation of monitoring the resident's edema, but it should be monitored every shift. Staff F Level of Harm - Minimal harm or reviewed Resident 13's weight monitoring and stated they were not monitoring the resident's weight per potential for actual harm physician orders but should have. Staff F stated it was important to monitor edema every shift to best manage heart failure with edema and prevent them from fluid overload. Staff F stated it was important to Residents Affected - Few monitor a resident weight more frequently with weight changes and while taking diuretic medications to ensure the edema is getting better also that they are not diuresing (removing fluid from the body) too much fluid from the resident causing them to become dehydrated.

According to a 12/13/2024 Annual MDS Resident 64 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 64 had no memory impairment.

Observation and interview on 03/12/2025 at 10:18 AM Showed Resident 64 with bilateral lower extremity edema. At this time Resident 64 stated their weight has been slowly increasing since they admitted to the facility due to retaining water.

Review of Resident 64's health records showed a 02/14/2025 physician order for a diuretic medication given daily for edema. Resident 64's health records showed no physician order to assess and monitor their edema.

In an interview on 03/17/2025 at 8:28 AM Staff F reviewed Resident 64's health records and stated they did not have documentation of monitoring the resident's edema, but it should be monitored every shift. Staff F stated it was important to monitor edema every shift to best manage the edema and prevent them from fluid overload.

In an interview on 03/18/2025 at 8:57 AM Staff B (Director of Nursing) stated they expected staff to monitor and document edema every shift. Staff B stated they expected staff to monitor weight for residents with edema more frequently and/or as per physician orders. Staff F stated if a resident refused to have their weight monitored, they expected staff to document the refusal.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42203

Residents Affected - Some Based on observation, interview, and record review the facility failed to provide an environment free of accident hazards for 2 of 4 units (Units 100 & 200), ensure wheelchairs were assessed for safety prior to use for 1 of 9 residents (Resident 63) reviewed for positioning/mobility, and failed to ensure sharps and chemicals were stored safely for 1 of 4 shower rooms (100 Hall Shower Room) reviewed. The failure to ensure hot water was maintained within safe limits, wheelchairs were assessed for safety prior to use, and shower rooms were free of hazards placed residents at risk for burns, exposure to sharps and chemicals, wheelchair accidents, and other negative health outcomes.

Findings included .

According to the facility's 01/21/2025 Hot Water Temperature Inspection Policy, the facility would monitor temperatures weekly. The policy showed hot water temperatures could reach hazardous temperatures in hand sinks, showers, and tubs accessible to residents, and many residents in long-term care facilities had conditions that increased risk for burns. The policy showed a hot water temperature of 120 degrees Fahrenheit (F) could cause a third-degree burn with five minutes of exposure, a temperature of 124 F could cause a third degree burn with three minutes of exposure, and a temperature of 127 F could cause a third degree burn with one minute of exposure.

According to a facility policy titled, Storage of Chemicals, revised 06/17/2024, the residents environment would remain free of accident hazards. The policy showed each resident would receive supervision around chemicals to prevent accidents. The policy showed chemicals not in use would be stored out of reach of residents.

Observation of hot water temperatures on the 200 unit on 03/11/2025 showed: at 10:09 AM the hot water temperature in room [ROOM NUMBER] was measured at 124.1 F; at 10:11 AM the hot water temperature in room [ROOM NUMBER] was measured at 120 F; at 11:08 AM the hot water temperature in room [ROOM NUMBER] was measured at 121.7 F; at 11:13 AM the hot water temperature in room [ROOM NUMBER] was measured at 120.7 F; at 12:29 PM the sink in the 100/200 Unit shower room's hot water temperature was measured at 125.1 F.

Observation of the 100 unit on 03/11/2025 between 11:00 AM and 11:15 AM showed: the temperature in room [ROOM NUMBER] was measured at 122.7 F; the temperature in room [ROOM NUMBER] was measured at 122.3 F; the temperature in room [ROOM NUMBER] was measured at 122.5 F; the temperature

in room [ROOM NUMBER] was measured at 117.3 F; the temperature in room [ROOM NUMBER] was measured at 118.9 F; the temperature in room [ROOM NUMBER] was measured at 115.3 F.

In an interview on 03/11/2025 at 11:25 AM Staff Y (Maintenance Director) stated they monitored water temperatures weekly. Staff Y said the facility aimed to maintain water temperatures below 120 F for resident safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 03/12/2025 at 11:10 AM Staff Z (Maintenance Assistant) stated this morning the facility identified a failed component in the hot water line that caused temperatures to rise above the safe limit and Level of Harm - Minimal harm or required repair. potential for actual harm <Wheelchair Assessment> Residents Affected - Some <Resident 63>

According to the 01/22/25 Annual Minimum Data Set (MDS - an assessment tool) Resident 63 had intact memory and diagnoses including heart failure, weakness, and a history of traumatic fracture. The MDS showed Resident 63 used a manual wheelchair.

In an interview on 03/11/2025 at 10:55 AM Resident 63 stated they were awaiting training for their new wheelchair. Resident 63 was observed to be in a tilt-in-space wheelchair (a specialized wheelchair that could adjust the positioning of a resident from upright to tilted back and could not be adjusted by the user of the chair.)

Record review showed the 02/21/2024 Resident at risk for falls . Care Plan (CP) Resident 63 included a 02/26/2024 intervention for a DEVICE: TILT-N-SPACE [wheelchair] while out of bed to assist with proper positioning, pressure relief and comfort. There were no other directions in Resident 63's CP regarding the purpose or proper use of the tilt-in-space wheelchair.

Record showed no evidence the Resident 63's tilt-in-space wheelchair use was assessed for safe use by the resident.

In an interview on 03/14/2025 at 2:13 PM Staff BB (Senior Director of Rehab Services) stated the therapy department completed wheelchair safety assessments for residents. Staff BB stated wheelchairs were reassessed by the therapy department on a quarterly basis.

In an interview on 03/18/2025 at 10:17 AM Staff BB stated Resident 63 was provided the tilt-in-space wheelchair from the facility's pool of wheelchairs because it was the wheelchair that best suited the resident's longer frame. Staff BB stated because the chair was not provided for the purposes of tilting the resident, they did not complete a safety assessment for Resident 63. At that time Staff BB produced a therapy discharge summary showing Resident 63 was provided the tilt-in-space wheelchair as a placeholder. The discharge summary showed the wheelchair just happens to be tilt-in-space . and was signed as completed on 03/14/2025 at 3:34 PM.

In an interview on 03/18/2025 at 10:30 AM Staff B (Director of Nursing) stated their expectation was that any wheelchair, including a tilt-in-space wheelchair, should be assessed for safety periodically.

47836

<100 Hall Shower Room>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 Observation and interview on 03/11/2025 at 12:07 PM showed Staff M (Certified Nursing Assistant) exit the shower room leaving a resident unattended in the shower room. Observation at this time showed a cabinet in Level of Harm - Minimal harm or the shower room wide open with razors accessible and a bottle of disinfectant cleaner sitting on the half wall potential for actual harm of the shower within reach of the resident. Staff M returned to the shower room at 12:09 PM and stated they were not supposed to leave residents unattended in the shower room. Staff M stated the chemical cleaner, Residents Affected - Some and razors should have been locked up and not accessible to residents for their safety. Staff M stated they were never given a key to the cabinet and were never informed of where one was to ensure it was kept locked.

In an interview on 03/17/2025 at 11:50 AM Staff B (Director of Nursing) stated they expected disinfectants and razors to be stored behind locked doors, out of reach to residents. Staff B stated it was important that chemicals and sharps were stored properly behind locked doors for resident safety.

REFERENCE WAC: 388-97-1060 (3)(g), -3320.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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** 47836 potential for actual harm Based on observation and interview the facility failed to ensure fresh water was offered for 5 of 5 residents Residents Affected - Few (Residents 8, 14, 13, 69, & 64) reviewed for hydration. Failure to offer fresh water daily placed residents at risk of dehydration, potential risk for medical complications, and decreased quality of life.

Findings included

According to a facility policy titled, Hydration and Nutrition, revised 09/10/2024, each resident would be offered fluids to maintain proper hydration. The policy showed fluids would always be available to residents and a hydration cart may be utilized.

According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 reentered the facility on 08/08/2024. The MDS showed Resident 8 had no memory impairment.

In an observation and interview on 03/12/2025 at 1:30 PM Resident 8's water pitcher was empty. At this time Resident 8 stated the staff do not offer fresh water and they only get it if they ask. Observations on 03/13/2025 at 10:16 AM, 03/14/2025 at 2:17 PM, 03/17/2025 at 8:28 AM, and 03/18/2025 at 8:39 AM showed Resident 8 without fresh water available.

According to a 01/23/2025 Annual MDS Resident 14 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 14 had moderate memory impairment.

In an observation and interview on 03/12/2025 at 9:18 AM Resident 14's water pitcher was empty. At this time Resident 14 stated the staff do not offer fresh water and they only get it if they ask. Observations on 03/13/2025 at 10:40 AM, 03/14/2025 at 9:02 AM, and 03/18/2025 at 8:40 AM showed Resident 14 without fresh water available at bedside.

According to a 10/18/2024 Annual MDS Resident 13 reentered the facility on 05/17/2022. The MDS showed Resident 13 had diagnoses of, but not limited to, heart failure with edema and kidney failure.

In an observation and interview on 03/12/2025 at 12:56 PM Resident 13's water pitcher was empty. Resident 13 stated the staff do not offer fresh water and they only get it if they ask. Observations on 03/13/2025 at 9:26 AM, 03/14/2025 at 1:25 PM, and 03/18/2025 at 8:47 AM showed Resident 13 without fresh water available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 a 02/11/2025 Admission MDS Resident 69 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 69 had moderate memory impairment. The MDS showed Resident 69's representative participated Level of Harm - Minimal harm or in the assessment. potential for actual harm

In an observation and interview on 03/11/2025 at 10:02 AM Resident 69's water pitcher was empty. Resident Residents Affected - Few 69's family member stated the resident was on thickened fluids and staff do not offer fresh water. Resident 69's representative stated they only get fluids on meal their trays. Observations on 03/12/2025 at 9:27 AM, 03/13/2025 at 1:12 PM, 03/14/2025 at 9:07 AM, and 03/18/2025 at 8:42 AM showed Resident 69 without fresh water available.

According to a 12/13/2024 Annual MDS Resident 64 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 64 had no memory impairment.

In an observation and interview on 03/12/2025 at 9:29 AM Resident 64's water pitcher was empty. At this time Resident 64 stated the staff do not offer fresh water and they only get something to drink if they ask.

Observations on 03/13/2025 at 10:30 AM, 03/14/2025 at 1:45 PM, and 03/18/2025 at 8:45 AM showed Resident 64 without fresh water available.

In an interview on 03/11/2025 at 12:07 Staff M (Certified Nursing Assistant) stated they would bring residents fresh water if they asked otherwise, they received fluids on their meal trays.

In an interview on 03/17/2025 at 8:28 AM Staff F (Unit Care Coordinator) stated they expected staff to offer and provide fresh water pitchers every shift. Staff F stated resident should not have to ask for fluids and staff should automatically offer at the beginning of their shift or per resident preference. Staff F stated it was important for staff to automatically offer fluids to residents because some residents could not ask or may forget to ask for fresh water. Staff F stated it was important to offer and provide fluids to residents to ensure

they stay hydrated.

In an interview on 03/18/2025 at 8:57 AM Staff B (Director of Nursing) stated they expected staff to offer fresh water to residents as part of their care each shift. Staff B stated it was important to offer and provide fluids to residents to ensure they are staying hydrated.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 50511 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 of 4 residents (Resident 43) Residents Affected - Few reviewed for respiratory care, were provided the care they required, consistent with professional standards of practice. Failure to ensure oxygen delivery was provided according to physician ordered flow rates and failure to monitor oxygen equipment, placed residents at risk of respiratory discomfort, oxygen-related accidents, and a decreased quality of life.

Findings Included .

According to the revised 10/11/2024 Oxygen Administration Policy, the facility must ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice and

the person-centered care plan. Oxygen orders should be written for a specific flow rate required by the resident.

According to the 12/03/2024 Annual Minimum data set (MDS - an assessment tool) Resident 43 had a diagnosis of chronic obstructive pulmonary disease (COPD) and required oxygen therapy.

According to the 12/03/2024 COPD care plan (CP), staff were directed to administer oxygen at a setting of 2 Liters Per Minute (LPM) continuously.

Record review showed 08/20/2024 physician's order for oxygen at 2 LPM continuously through nasal cannula (NC).

Observations on 03/11/2025 at 10:55 AM, 03/11/2025 at 2:23 PM, 03/13/2025 at 10:53 AM and 03/14/2025 at 9:23 AM, showed Resident 43's oxygen flow rate set at 3 LPM via NC.

Observation and interview on 03/13/2025 at 10:53 AM showed the other end of the oxygen tubing placed in Resident 43's nose was lying on the floor and not connected to the oxygen concentrator. Observation showed the oxygen flow rate was set to 3 LPM instead of 2 LPM. Staff G (Licensed Practical Nurse) verified

the tubing was on the floor and not connected to the concentrator and stated it should be connected.

In an observation and interview on 03/14/2025 at 10:35 AM Staff G verified the oxygen was set at 3 LPM instead of 2 LPM. Staff G was unsure of the oxygen order and stated they thought the order showed the oxygen should be set between 2 to 3 LPM and needed to check the medication orders. Staff G stated it was important for residents to get the right amount of oxygen so they could breathe better.

In an interview on 03/18/2025 at 10:50 AM Staff H (Unit Care Coordinator) stated staff should check oxygen levels, check to see oxygen tubing was connected, and check oxygen settings to determine if the correct rate was administered. Staff H stated it was important for residents to receive the right amount of oxygen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 03/18/2025 at 12:24 PM Staff B (Director of Nursing) stated oxygen should be administered according to the orders and nurses should round every shift for residents with oxygen to check Level of Harm - Minimal harm or for oxygen needs. Staff B stated it was important to follow the physician's orders for the resident's specific potential for actual harm rate determined by their health conditions.

Residents Affected - Few REFERENCE: WAC 388-97-1060 (3)(j)(vi).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 - Few Based on observation, interview, and record review the facility failed to obtain consent prior to implementing bed rails/bed against the wall for 2 of 3 residents (Resident 8 & 69) and complete a safety assessment for

the bed against the wall for 1 of 3 residents (Resident 69) reviewed for accident hazards. The failure to obtain consent and complete a safety assessment prior to implementing bed rails/bed against the wall placed residents at risk for injury, entrapment, and other negative health outcomes.

Findings included .

According to facility policy titled, Bed Rails - Safe and Effective Use of Bed Rails, revised 09/06/2024, the facility would review the risks and benefits of bed rail use with the resident/representative prior to installation, complete a safety assessment, and obtain the resident/representatives consent. The policy showed a comprehensive care plan would be developed for the use of bed rails within 48 hours of installation.

According to a 12/24/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 8 had no bed rails in use on their bed.

Review of Resident 8's health records showed a 01/23/2023 evaluation for the use of bilateral quarter bed rails to Resident 8's bed. Resident 8's health records showed no consent for the bilateral quarter bed rails.

An observation on 03/12/2025 at 2:08 PM showed bilateral quarter bed rails to Resident 8's bed.

In an interview on 03/17/2025 at 8:28 AM Staff F (Unit Care Coordinator) reviewed Resident 8's health records and stated Resident 8 had bed rails but consent was not obtained prior to them being installed to their bed. Staff F stated it was important to obtain consent from the resident prior to installing bed rails to their bed to ensure the resident wants the bed rails.

According to a 02/11/2025 Admission MDS Resident 69 admitted to the facility on [DATE REDACTED]. The MDS showed Resident 69 had no restraints in use on their bed.

Observation on 03/11/2025 at 10:20 AM showed Resident 77's left side of bed against the wall.

Review of Resident 69's health records on 03/17/2025 showed no safety assessment or consent for the bed against the wall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 58 505188 Department of Health & Human Services Printed: 09/04/2025 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 505188 B. Wing 03/18/2025

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

Life Care Center of Federal Way 1045 South 308th Street Federal Way, WA 98003

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 In an interview on 03/17/2025 at 8:28 AM Staff F reviewed Resident 77's health records and stated staff were expected to obtain consent and complete a safety assessment prior to placing a resident's bed against Level of Harm - Minimal harm or the wall but they did not. Staff F stated it was important to obtain consent and complete a safety assessment potential for actual harm for the bed against the wall to ensure injuries or entrapment would not happen to the resident.

Residents Affected - Few In an interview on 03/18/2025 at 8:57 AM Staff B (Director of Nursing) stated they expected staff to obtain consent and complete a safety assessment prior to installation of bed rails or placing a bed against the wall.

Refer to

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Life Care Center Of Federal Way

Inspection Findings

F-Tag F658

F-Tag F700

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