Providence Marianwood

F-F677- Activities of Daily Living (ADL) Care Provided for Dependent Residents.

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

51149

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 505418

F-F689. The facility removed the immediacy on 07/24/2024 after they immediately contacted the outside vendor to assess and/or repair the boiler, identified other high risk residents, placed temporary caution signs in resident room sinks and shower rooms to mix cold and hot water to reduce/eliminate the risk for burns/scalding, instituted audits to monitor the boiler gauge and all resident rooms- water temperature monitoring, updated the facility's rounding log, and provided education to the Facilities (Maintenance) Manager regarding the domestic water policy, and implemented a plan of correction to sustain ongoing compliance.

Findings included .

<Hot Water Temperature>

<Facility Policy>

The facility's Domestic Water Policy, revised 01/2019, showed the facility's domestic hot water would be checked monthly to ensure a hot water temperature of 105 to 115 F was maintained.

<Centers for Medicare and Medicaid Service (CMS) Hot Water Guidelines>

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 6 505418 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505418 B. Wing 08/01/2024

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

Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029

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 According to revised 02/03/2023 CMS guidelines: A third-degree burn would occur after five minutes of exposure to a hot water temperature of 120 F, after three minutes of exposure to a hot water temperature of Level of Harm - Immediate 124 F, after one minute of exposure to a hot water temperature of 127 F, and after 15 seconds of exposure jeopardy to resident health or to a hot water temperature of 133 F. safety

Observation on 07/23/2024 at 10:57 AM showed room [ROOM NUMBER] had two sinks, one labeled for Residents Affected - Some Resident 33, and the other for Resident 68 who shared the room. When temperatures were taken, the hot water from Resident 33's sink became hot very quickly after turning on the faucet and felt uncomfortable for hand washing. The temperature measured at that time was 127 F. At the same time, Resident 68's sink's hot water measured 125 F.

The following observations of hot water were made:

On 07/23/2024 at 10:59 AM, the hot water temperature in room [ROOM NUMBER] was observed at 129 F.

On 07/23/2024 at 11:00 AM, the hot water temperature in room [ROOM NUMBER] was observed at 124 F.

On 07/23/2024 at 11:01 AM, the hot water temperature in room [ROOM NUMBER] was observed at 126 F.

On 07/23/2024 at 11:05 AM, the hot water temperature in room [ROOM NUMBER] was 130 F in one sink and 131 F in the other sink.

On 07/23/2024 at 11:07 AM, the hot water temperature in room [ROOM NUMBER] was observed at 127 F.

On 07/23/2024 at 11:07 AM, the hot water temperature in room [ROOM NUMBER] was 127 F in one sink and 133 F in the other sink.

On 07/23/2024 at 11:10 AM, the hot water temperature in room [ROOM NUMBER] was observed at 127 F.

On 07/23/2024 at 11:20 AM, the hot water temperature in room [ROOM NUMBER] was observed at 132 F.

On 07/23/2024 at 11:24 AM, the hot water temperature in room [ROOM NUMBER] was observed at 132 F.

On 07/23/2024 at 11:45 AM, the hot water temperature in room [ROOM NUMBER] was 133 F in one sink and 134 F in the other sink.

On 07/23/2024 at 11:59 AM, the hot water temperature in room [ROOM NUMBER] was observed at 134 F.

On 07/23/2024 at 12:47 PM, the hot water temperature in room [ROOM NUMBER] was observed at 130 F.

In total, between 10:57 AM and 12:47 PM on 07/23/2024, surveyors observed unsafe water temperatures in multiple rooms on each of the facility's four units. None of the rooms observed had hot water at a safe temperature.

In an interview on 07/23/2024 at 1:40 PM, Staff C (Facilities Manager) stated they maintained a hot water temperature log. Staff C stated hot water should be no hotter than 120 F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 505418 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505418 B. Wing 08/01/2024

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

Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029

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 07/23/2024 at 1:47 PM, Staff C stated hot water temperatures were checked and logged monthly. Staff C stated they checked a couple rooms at the end of the building near the boiler because it Level of Harm - Immediate serve[d] the whole building. jeopardy to resident health or safety Observation on 07/23/2024 at 2:33 PM showed the facility had two boilers located in the maintenance shop.

A sign on the boilers indicated they were installed on 12/31/2020. In an interview at that time, Staff C stated if Residents Affected - Some they identified any problems with excessively hot water, they called a vendor for assistance to identify and repair the problem.

Review of the facility's 2024 Hot Water Temperature Log provided by Staff C on 07/23/2024 showed the hot water should be 110 DEG + or - 10 degrees which was not consistent with the facility's policy for hot water to remain in the 105-115 F range. The log showed, once a month from January through June 2024, Staff C documented two temperatures. For each month, one of those temperature measurements was taken in the maintenance room, and the second was taken in either the staff break room, the facility's main dining room, or rehabilitation gymnasium (gym). No temperatures measurements were made in resident rooms.

The 2024 Hot Water Temperature Log showed on 02/27/2024 the hot water was measured at 122 F in the gym, on 05/24/2024 at 121.5 F in the gym, and on 06/24/2024 at 122 F on 06/24/2024 in the maintenance room; all three temperatures were above the maximum temperature limit for hot water as required.

In an interview on 07/23/2024 at 2:51 PM, Staff C stated they contacted the vendor to fix the hot water system after identifying hot temperatures exceeded safe limits. Staff C stated they would provide documentation showing when they last contacted the vendor.

On 07/23/2024, Staff C provided a 04/11/2024 estimate from the vendor for repair of a failed flow switch.

This invoice was signed by Staff C on 04/15/2024. The vendor's signature was left blank. There was no indication that the work was paid for or completed.

Observation on 07/23/24 at 3:46 PM with Staff's C and D (Director of Rehabilitation Services) showed the hot water temperature in room [ROOM NUMBER] was at 128 F. Both staff stated the temperature reading was high. At that time, Staff C checked the readout of a digital thermometer measuring the temperature of the pipe where hot water flowed from the hot water tanks to the rest of the facility. This thermometer showed a temperature of 123.8 F.

<Resident 33>

According to the 04/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 33 had impaired memory and needed substantial to maximal assistance from staff for transfers and personal hygiene. The MDS showed Resident 33 had a stroke history and hemiplegia (one-sided partial paralysis) on their right side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 505418 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505418 B. Wing 08/01/2024

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

Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029

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 07/23/2024 at 10:42 AM, Resident 33 stated sometimes they had to wait a long time for

the bathroom. Resident 33 stated if staff did not come quickly enough to assist them, they got themselves up Level of Harm - Immediate to use the bathroom even though they knew they should wait for help as they could wait no longer. jeopardy to resident health or Observation at that time showed Resident 33's right hand had limited range of motion. Resident 33's fingers safety curled in toward the palm of the hand. Observation of the sink at 07/23/2024 at 10:57 AM showed the faucet had a left lever that controlled hot water and a right lever that controlled the cold water which could impact Residents Affected - Some the ability of a person with a right-hand impairment to adjust the hot water temperature with cold water.

In an interview on 07/24/2024 at 11:36 AM, Staff A (Administrator) stated it was important to ensure the hot water temperature in resident rooms were maintained within the safe temperature as required to prevent adverse outcome and resident injury including burns caused by scalding. Staff A stated Staff C knew the water flow switch needed repair last April 2024 based on the facility provided project proposal but did not address the situation appropriately.

In an interview on 07/24/2024 at 11:48 AM, in the presence of Staff A, Staff C confirmed they knew about the situation and stated they should have acted upon the identified water valve repair needed but did not.

43642

<Unsecured Chemicals>

<Unit A>

Observations on 07/23/2024 at 1:38 PM showed the shower room door on Unit A was unlocked. Inside the unlocked room was a cabinet with a key in the keyhole. The key was attached to the cabinet by a chain. The cabinet door could be opened without having to turn the key. Inside the cabinet was a spray bottle of disinfectant with a label that stated, DANGER, keep out of reach of children, and identified first aid steps if

the chemical was ingested.

In an interview on 07/25/2024 at 9:47 AM, Staff C stated the shower room door and chemicals should be locked and secured. Observations at this time showed the door was unlocked and was easily opened when checked. Staff C stated the door should be locked not only to provide privacy for residents, but to assure chemicals are secured to reduce risks of accidents.

46471

<Unit C>

Observation on 07/23/2024 at 10:28 AM showed the shower room door across room [ROOM NUMBER] had

a sign to keep doors locked at all times but the key combination lock was broken and the door was left unlocked; inside was unsecured chemicals including a gallon of bleach cleaning solution situated next to the toilet and a spray bottle of disinfectant solution hanging from the shower grab bar.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 505418 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505418 B. Wing 08/01/2024

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

Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029

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 On 07/23/2024 at 10:33 AM, Staff G (Certified Nursing Assistant - Shower Aide) came and stated they were getting the shower room ready for a resident. Staff G determined the key combination lock was broken/faulty Level of Harm - Immediate and the door was left unlocked. Staff G stated the maintenance department should be notified to have the jeopardy to resident health or door lock fixed right away. Staff G stated it was important to ensure the door was kept locked at all times so safety confused and wandering residents could not enter the room and accidentally ingest or apply any chemicals

on themselves that were left unsecured inside the shower room. Residents Affected - Some

In an interview on 07/23/2024 at 10:43 AM, Staff C confirmed the key combination lock to the shower room in Unit C needed to be repaired and stated the shower door must be kept locked at all times (as indicated by

the posted sign on the door) for resident safety.

50511

<Facility Policy>

According to the Fall Prevention and Response facility policy, revised 08/2023, the facility would reduce the risk of falls and injury resulting from falls by assessing and periodically reassessing each resident's risk for falling. The policy showed the potential risks associated with increased care needs and the environment and to implement interventions to address identified risks.

<Resident 64>

According to the 05/15/2024 Quarterly MDS, Resident 64 needed help with functional cognition, had visual impairment, was dependent on staff in wearing their footwear, and needed moderate assistance with dressing and transferring from bed, chair and toilet. The assessment showed Resident 64 admitted to the facility on [DATE REDACTED] and had two or more falls since their admission to the facility.

In an interview and observation on 07/23/24 at 1:48 PM, Resident 64 stated, I have no clothes; no shoes or socks and I only have slippers and my feet hurt when I walk. Resident 64's toenails were observed long enough to curl into bottom of foot and resident had brown suede slippers and no other shoes in the room.

On 07/23/2024 at 2:05 PM, Resident 64 stated, .every time I turn around, I am falling, and the toilet commode was loose, if I lean over too much, I might fall.

On 07/26/2024 at 8:39 AM, Resident 64 stated, I already got myself up, the staff don't really help me, and

they come in after the fact .

Observation on 07/30/2024 at 8:34 AM showed Resident 64's bed was tilted downwards to the right; the bed was unbalanced when moved and Residnt 64 stated the bed was broken.

On 07/31/2024 at 11:32 AM, the bed table was propped up against bathroom door, the walker was at the foot of the bed, and resident was seated at a chair in front of bed away from walker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 505418 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505418 B. Wing 08/01/2024

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

Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029

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 Record reviews of the 04/25/2024 facility fall event occurrence investigation report showed Resident 64 had

a fall by the room door; the 07/1/2024 investigation report showed Resident 64 sustained a fall near their Level of Harm - Immediate bed, and the 07/07/2024 investigation report showed another fall sustained by Resident 64 near the jeopardy to resident health or bathroom. The fall prevention interventions listed on the investigation reports included the application of two safety non-slip tape strips placed on the floor by the bedside and a signage was posted to remind resident to call for assistance before attempting to transfer. Residents Affected - Some

In an interview on 07/30/2024 at 8:37 AM, Staff J (Licensed Nurse) stated the bed looked broken and did not look normal. Staff J stated the care staff did not get a chance to see Resident 64 yet to notice their bed, and that the resident continually refused care so we [staff] do whatever we can.

In an interview on 07/30/2024 at 8:42 AM, Staff B (Director of Nursing) stated care staff still needed to encourage residents with dementia (who refused care) and must do whatever they could to help them. Staff B stated Resident 64's bed did not look normal, and the bed looked broken. Staff B observed Resident 64's long, uncut toenails and confirmed the resident needed podiatry services. Staff B stated staff should notify them when a resident had long nails and were refusing care, as foot care was important to prevent skin injury and accidents.

Refer to