Roo-lan Healthcare Center

F-F684, Quality of Care, related to the facility's failure to provide timely assessment and/or treatment by qualified personnel (nursing) when there was a delay in locating nursing staff due to lack of a working emergency response system determined to have began on [DATE REDACTED]. The facility removed the immediacy on [DATE REDACTED] with onsite verification from investigator by conducting staff observation of staff wearing walkie talkies for communication and interviews regarding re-education of all staff on emergency response plans which ensured an effective system was in place to safeguard, protect and prevent residents at risk for requiring an immediate response.

Findings included .

Facility Foreign Body Airway Obstruction Management (Chocking) policy, undated showed, timely intervention to relieve obstruction is imperative to offset complications.

Facility Emergency Operations Plan, undated, showed instructions for 'rapid response' to a situation that placed residents' health or safety at risk to activate overhead codes or facility emergency alert systems as appropriate

Resident 5 was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease, Chronic Obstructive Pulmonary Disease (breathing difficulty with cough, wheezing and often excess mucus), dementia, gastroesophageal reflux disease (condition in which stomach acid repeatedly flows back up into

the tube connecting the mouth and stomach), and dysphagia (swallowing difficulties). Resident 5's Minimum Data Set (MDS), an assessment tool, dated [DATE REDACTED], showed Resident 5 was rarely understood and had no behaviors.

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 505254 Department of Health & Human Services Printed: 09/12/2025 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 505254 B. Wing 08/19/2024

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

Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503

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 Review of Resident 5's POLST (Physician Orders for Life Sustaining Treatment), dated [DATE REDACTED], showed resident was a (DNAR), Do Not Attempt Resuscitation, allow natural death. The POLST showed choosing Level of Harm - Immediate DNAR would include appropriate comfort measure and may include a range of treatments including use of jeopardy to resident health or oxygen, oral suctioning and manual treatment of airway obstruction. safety Resident 5's nutritional assessment, dated [DATE REDACTED], showed the resident was receiving a regular diet with Residents Affected - Few pureed texture and honey thick liquids, had difficulty chewing and difficulty swallowing with a recent aspiration incident.

Resident 5's Speech Language Pathologist (SLP) evaluation and treatment, dated [DATE REDACTED], showed the resident had chronic, severe oropharyngeal dysphagia (swallowing problem occurring in the mouth and or throat). Staff reported coughing with puree intake when puree was separated, and a thin layer of liquid was present.

Resident 5's care plan, dated [DATE REDACTED], showed Resident 5 was at high risk of aspiration and was dependent

on staff for assistance with meals with a documented intervention to, ensure sitting upright for all meals and fluid intake.

During an interview on [DATE REDACTED] at 4:35 PM, Staff F, Certified Nurse Aid (CNA) provided their recollection of

the timeline of events on [DATE REDACTED] as follows:

Staff E, CNA came out of Resident 5's room and told Staff F Resident 5 was vomiting and to get a nurse.

Staff E came out in the hall again and asked Staff F what to do and said, it was getting bad

Staff F told Staff E to put the head of the bed up and get a basin.

Staff F said she could not find the nurse, she was on break or something

Staff F said she had a walkie talkie for communication but did not use it.

Staff F said she texted the assigned nurse, Staff D, Registered Nurse, that Resident 5 was vomiting.

Staff F said she went to look for a nurse and found Staff C, Staff C responded to the resident's room with a code cart.

Staff F said a nurse attempted to suction the resident's mouth, but the resident was already gray in color.

Staff F said Staff D returned from break and pronounced the resident's death.

Staff F said it may have taken eight or nine minutes for the nurse to come into the room, which occured at approximately 12:40 AM, making the time the resident started struggling about 12:31 PM.

During an interview on [DATE REDACTED] at 6:25 PM, Staff E provided their recollection of the timeline of events on [DATE REDACTED] as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 505254 Department of Health & Human Services Printed: 09/12/2025 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 505254 B. Wing 08/19/2024

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

Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503

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

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

F 0684 Resident 5 had been assisted with the lunch meal in the dining room by another staff member and was assisted back to bed and resting on his side. Level of Harm - Immediate jeopardy to resident health or Staff E said he was assisting Resident 5's roommate with the lunch meal and heard Resident 5 coughing. safety Staff E said the resident started vomiting while lying down. Residents Affected - Few Staff E said they went into the hallway and told Staff F Resident 5 had vomited and to find a nurse.

Staff E said they raised the head of the bed when the resident vomited and left the resident to go into the hallway and asked Staff F to find a nurse again.

Staff E said Resident 5 vomited three times.

Staff E said his walkie talkie used for communication was not charged and not functioning.

Staff E said Resident 5's skin color changed and appeared bluish around the mouth and Resident 5 wasn't breathing normally.

Staff E said the nurse came into Resident 5's room to assist but the resident had expired.

On [DATE REDACTED] at 2:55 PM, Staff C, Resident Care Manager (RCM) said Resident 5 had been on aspiration precautions and on [DATE REDACTED] Staff F, CNA came to their office and said Resident 5 was vomiting profusely.

The RCM said she retrieved the code cart with suction and immediately went to Resident 5's room, arriving at approximately 12:40 PM. Staff C said she radioed for a RCM to respond to Resident 5's room. Staff C said Resident 5 was seated at 90 degrees in bed and had vomit on the resident's shirt and blanket and Staff E was at bedside. Staff C said she attempted to suction the resident's mouth but could tell [Resident 5] was already gone and yellow in color. Staff C said the assigned nurse, Staff D, came in and assessed for signs of life and called time of death. Staff C said she was not sure why the CNAs did not use the walkie talkies as

they were issued on hire and were part of their uniform. Staff C confirmed when there was a change in a resident's respiratory status or bluish color around the residents mouth it was emergent and needed immediate response. Staff C said there was a delay in responding to the resident vomiting and was unsure of how much time elapsed before a nurse responded. Staff C said the CNA should have stayed with the resident and used the walkie to call for immediate response from a nurse, stating, this is why walkie talkies are needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 505254 Department of Health & Human Services Printed: 09/12/2025 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 505254 B. Wing 08/19/2024

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

Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503

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 On [DATE REDACTED] at 9:55 AM, Staff D said she was the assigned nurse for Resident 5 on [DATE REDACTED]. Staff D said she saw Resident 5 before lunch and the resident had been assisted with his meal in the dining room and was Level of Harm - Immediate brought back to his room and laid down after lunch. Staff D said she went on her lunch break and received a jeopardy to resident health or text message from Staff F, CNA that a resident was vomiting. The nurse said she didn't know it was an safety emergency and came back from her break when she saw the message. Staff D said she saw Staff C going down the hall with the code cart and Staff D followed and went into Resident 5's room. Staff D said she saw Residents Affected - Few Resident 5 was in bed with the head of the bed elevated with vomit on the resident's shoulder and two RCMs were at the resident's bedside and had suctioned the resident's mouth. Staff D said Resident 5 was nonresponsive and had no signs of life. Staff D said Resident 5 had DNR documentation, so staff did not resuscitate the resident. Staff D said the facility had implemented walkie talkies for communication to be used by all staff, but some staff wouldn't wear them and agency staff weren't issued one.

At 10:50 AM, Staff J, agency CNA was observed in the resident care area. The CNA did not have a walkie talkie radio. Staff J said they work for an agency and had worked at this facility for approximately two weeks and had not been issued a radio.

At 11:00 AM, Staff K, agency RN was observed in the resident care area. The RN did not have a walkie talkie radio. The RN said they were not issued a radio.

At 11:01 AM, Staff H, agency CNA was observed in the resident care area. The CNA did not have a walkie talkie radio. Staff H said they worked for an agency and were not issued a radio for communication.

At 11:06 AM, Staff I, CNA was observed in the resident care area. The CNA did not have a walkie talkie radio. Staff I said, That's on me, I forgot to grab one.

On [DATE REDACTED] at 3:15 PM, Staff A, Administrator, acknowledged Resident 5 was at risk for aspiration and was assessed on [DATE REDACTED] by a Dietician which indicated the resident had problems with swallowing and choking and that the resident was vomiting and had a change in their breathing and discoloration around their mouth and there was a delay in nursing emergency response and the resident expired at the facility. Staff A said the facility did not have the ability to overhead page from resident rooms and that walkie talkies were the method intended to be used and were not used as expected.

Reference WAC [DATE REDACTED](1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 505254 Department of Health & Human Services Printed: 09/12/2025 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 505254 B. Wing 08/19/2024

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

Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503

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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49451 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow recommended procedures for transportation and the resident sustained a fracture and laceration requiring hospitalization and surgery. This failure placed residents at risk for injury and a diminished quality of life.

Findings included .

Review of the undated facility policy, titled Recommended Safe Procedure for Transporting People who use Wheelchairs showed when loading and unloading passengers in a side loading van, the resident should be facing away from the vehicle. The policy reference emergency safety procedures and identified staff should immediately call 911 if a person in a wheelchair (w/c) was injured or if there was any question of an injury.

Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including End Stage Renal Disease (ESRD), subdural hematoma (serious condition where blood collects between the skull and surface of the brain), heart failure and anemia.

Resident 1's admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2024, showed Resident 1 had cognitive impairment, exhibited no behaviors, required use of a w/c, required substantial staff assistance for toileting, dressing, personal hygiene and dependent for chair to bed transfer.

Resident 1's nursing note, dated 07/04/2024, showed Resident 1 returned from dialysis in the facility bus and Staff G, Maintenance Director, who had transported the resident, reported Resident 1 had injured their left big toe while on the lift of the transport bus and that it was bleeding. The nursing note showed Resident 1 was not showing any signs of pain and denied pain. Resident 1 had loss of feeling in bilateral lower extremities and was unable to recognize their foot had slipped off the foot pedal while being lifted up into the bus from dialysis. First aid was initiated to left toe to stop the bleeding and then Resident 1 was transported to the hospital by Staff G and Staff A, Administrator. Resident 1 was admitted to hospital for further treatment.

Resident 1's hospital record showed the resident was admitted to the hospital on 07/03/2024 for a left big toe crush injury and required surgery to amputate the left big toe. An x-ray report, dated 07/03/2024, showed a suspected occult fracture (broken bone not easily seen on x-ray).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 505254 Department of Health & Human Services Printed: 09/12/2025 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 505254 B. Wing 08/19/2024

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

Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503

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 08/06/2024 at 2:00 PM, the facility bus was observed with Staff G, Maintenance Director and Staff G demonstrated use of the w/c lift. Staff G said Resident 1 was in a w/c and was very tall and weak after the Level of Harm - Actual harm dialysis treatment. Staff G said he placed the resident's feet on the footrest and both feet kept popping out as

the resident consistently slid down in the w/c seat. The maintenance director said he pushed the resident's Residents Affected - Few w/c onto the ramp (face first) and proceeded to use the button on the right side of the ramp to lift the ramp with the w/c. Staff G said he couldn't fully see the resident's feet and as the lift was going up the ramp came down onto the resident's toe. Staff G said when the w/c was lifted to the top, Staff G got back into the bus and pulled the resident's w/c off the lift and into the bus. Staff G said he saw the resident's sock and realized

the resident's foot was injured and released his foot. Staff G said he was unaware the resident's toe got caught as the resident had poor sensation and did not call out or indicate the foot was caught. Staff G then transported the resident back to the facility, where the resident's foot was assessed by nursing and then Staff G and Staff A transported the resident to the hospital. Staff G said the facility had two staff go on the bus with

the resident the previous two times the resident was transported to and from dialysis. Staff G said on this occasion to/from dialysis, we were short staffed, and I volunteered to pick him up on this day by myself. I wished I had not.

On 08/13/2024 at 3:15 PM, Staff A, said Resident 1 was weak after dialysis and Staff G should have asked for help and not transported the resident by himself. Staff A acknowledged the resident was injured during

the transfer process and the resident required evaluation and treatment at the hospital.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 505254