Roo-lan Healthcare Center

F-F550-Resident Rights/Exercise of Rights. Previous survey deficiency dated 02/2019 (D), 08/2021 (E), 05/2023 (D) & 03/2024 (D) & 02/2025 (D).

Refer to

F-F561-Self-Determination. Previous survey deficiency dated 08/2021 (D), 05/2023 (D), 03/2024 (C) & 02/2025 (E).

Refer to

F-F578-Request/Refuse/Discontinue Treatment; Formulate Adv Dir. Previous survey deficiency dated 02/2019 (E), 08/2021 (E), 05/2023 (E) & 03/2024 (D).

Refer to

F-F585 Grievances

The governing body failed to ensure action or response was given to the resident council member concerns and to have a formal Grievance system in place.

Refer to

F-F604 Right to be Free from Restraints

The governing body failed to ensure assessments, orders, consent and care plans were in place for residents with bed rails.

Refer to

F-F625

Reference WAC 388-97-0120

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,

before transfer or discharge, including appeal rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46793

Residents Affected - Some Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 5 of 6 sampled resident (Residents 4, 11, 42, 57 & 58), failed to provide the Ombudsman notification for 6 of 6 sampled residents (Residents 3, 4, 11, 42, 57 & 58), and failed to update a resident representative for 1 of 6 sampled residents (Resident 11) reviewed for hospitalization .

This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.

Findings included .

The facility policy titled, Transfer and Discharge, dated 2023, documented the facility's transfer/discharge notice would be provided to the resident and the resident's representative in a language and manner in which they could understand. The notice would include all of the following at the time it is provided that facility would maintain evidence that the notice was sent to the Ombudsman.

<Transfer/discharge notice>

Resident 4 was admitted to the facility on [DATE REDACTED]. Resident 4 was transferred to the hospital on 11/23/2024.

The electronic health record (EHR) documented no Transfer/Discharge notification was provided to Resident 4.

Resident 11 was admitted to the facility on [DATE REDACTED]. Resident 11 was transferred to the hospital on 01/16/2025. The EHR documented no Transfer/Discharge notification was provided to Resident 11

Resident 42 was admitted to the facility on [DATE REDACTED]. Resident 42 was transferred to the hospital on 10/01/2024. The EHR documented no Transfer/Discharge notification was provided to Resident 42.

Resident 57 was admitted to the facility on [DATE REDACTED]. Resident 57 was transferred to the hospital on 01/17/2025. The EHR documented no Transfer/Discharge notification was provided to Resident 57.

Resident 58 was admitted to the facility on [DATE REDACTED]. Resident 58 was transferred to the hospital on 11/15/2024. The EHR documented no Transfer/Discharge notification was provided to Resident 58.

<Ombudsman Notification>

Resident 3 was admitted to the facility on [DATE REDACTED]. Resident 3 was transferred to the hospital on 10/04/2024.

The EHR documented no Ombudsman notification was provided.

Resident 4 was admitted to the facility on [DATE REDACTED]. Resident 4 was transferred to the hospital on 11/23/2024.

The EHR documented no Ombudsman notification was provided.

Resident 11 was admitted to the facility on [DATE REDACTED]. Resident 11 was transferred to the hospital on 01/16/2025. The EHR documented no Ombudsman notification was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0623 Resident 42 was admitted to the facility on [DATE REDACTED]. Resident 42 was transferred to the hospital on 10/01/2024. The EHR documented no Ombudsman notification was provided. Level of Harm - Minimal harm or potential for actual harm Resident 57 was admitted to the facility on [DATE REDACTED]. Resident 57 was transferred to the hospital on 01/17/2025. The EHR documented no Ombudsman notification was provided. Residents Affected - Some Resident 58 was admitted to the facility on [DATE REDACTED]. Resident 58 was transferred to the hospital on 11/15/2024. The EHR documented no Ombudsman notification was provided.

On 01/29/2025 at 9:01 AM, Staff A, Administrator, with Staff B, Director of Nursing Services present, said Transfer notification and Ombudsman notification had not been completed for residents. Staff A said the expectation was Transfer notification and Ombudsman notification would be completed moving forward.

50945

<Resident Representative Notification>

Resident 11 was admitted to the facility on [DATE REDACTED] and had diagnoses of post-traumatic stress disorder (PTSD, a mental health condition triggered by an extremely stressful or terrifying event), depression, and anxiety.

Review of the (EHR) showed Resident 11 was transferred and discharged to the hospital on 01/16/2025.

During an interview on 01/27/2025 at 4:29 PM, when asked about the circumstances surrounding Resident 11's discharge, Collateral Contact 1, Resident 11's medical and financial power of attorney (POA), said, when was he discharged ? Collateral Contact 1 said they were not notified Resident 11 had left the facility.

During an interview on 01/28/2025 at 10:19 AM, Collateral Contact 1 said the facility would not tell them where Resident 11 went.

At 10:28 AM, Collateral Contact 1 was given Resident 11's belongings on a cart (backpack, suitcase, mountain dew, red bull, root beer, filled Walmart totes, trash bag with items in it).

At 10:30 AM, Staff C, RCM, updated Collateral Contact 1 on where Resident 11 had gone.

During an interview on 02/05/2025 at 2:08 PM, Staff B, DNS, said their expectation was that the RCM or someone would notify the POA or emergency contact when a resident discharged . When asked why the facility did not send belongings with Resident 11, Staff B said it was emergent and that usually the family would come to pick them up. When asked about Resident 11's POA, Staff B said yes, the POA should have been contacted to pick up Resident 11's belongings.

WAC 388-97- 0120 (2)(a-d)

37044

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0623 42960

Level of Harm - Minimal harm or 50488 potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37044

Residents Affected - Some Based on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 4 of 6 sampled residents (Resident 4, 11, 42 & 57) reviewed for hospitalization .

This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in

the hospital.

Findings included .

The facility policy, titled, Bed hold Notice Upon Transfer, dated 2023, documented, 1. Before a resident is transferred to the house or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies . 2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies, as stipulated

in the State's plan . 5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.

1) Resident 4 was admitted to the facility on [DATE REDACTED]. Resident 4 was transferred to the hospital on 11/23/2024. The electronic health record (EHR) documented no bed hold notification was provided to Resident 4.

2) Resident 11 was admitted to the facility on [DATE REDACTED]. Resident 11 was transferred to the hospital on 01/16/2025. The EHR documented no bed hold notification was provided to Resident 11

3) Resident 42 was admitted to the facility on [DATE REDACTED]. Resident 42 was transferred to the hospital on 10/01/2024. The EHR documented no bed hold notification was provided to Resident 42.

4) Resident 57 was admitted to the facility on [DATE REDACTED]. Resident 57 was transferred to the hospital on 01/17/2025. The EHR documented no bed hold notification was provided to Resident 57.

On 01/29/2025 at 11:09 AM, in a joint interview with Staff A, Administrator, and Staff B, Director of Nursing Services, Staff B said when a resident leaves the facility a bed hold should be offered to the resident. If the resident, wants a bed hold, the facility has the resident sign the bed hold notice. If the resident does not want

a bed hold, they do not provide a copy of the bed hold. When asked if Resident 4, 11, 42 & 57 should have received a bed hold notification, Staff B said yes.

WAC 388-97-0120 (4)

42960

50488

50945

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945 potential for actual harm Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessments Residents Affected - Some (MDS) were complete and accurate for 9 of 23 sampled residents (Residents 27, 11, 12, 42, 1, 65, 16, 32 & 57). This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life.

Findings included .

Review of the October 2024 Resident Assessment Instrument (RAI, a manual that provides instruction on how to accurately code a MDS assessment) showed the following criteria must be met to code restorative services on the MDS:

a) Measurable and objective interventions must be documented in the care plan.

b) Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record, which should include reassessment of progress, goal, and duration/frequency of the program(s).

c) Range of motion (ROM) exercise programs must be individualized to the resident's needs, planned, monitored, evaluated and documented in the resident's medical record.

1) Resident 27 was admitted to the facility on [DATE REDACTED] with diagnoses of dementia and anxiety. Review of the Quarterly MDS, dated [DATE REDACTED], showed Resident 27 had severe cognitive impairment, and was taking an antipsychotic (decreases symptoms of a loss of contact with reality) medication. Resident 27's MDS had their last gradual dose reduction (GDR, a requirement of facilities to try to lower behavioral health drug doses) listed as 07/01/2024.

A review of the Electronic Health Record (EHR) did not support the GDR date of 07/01/2024. Resident 27 was taking a medication called Seroquel (an antipsychotic), which, on 07/02/2024, the doses for morning and nighttime on the Medication Administration Record (MAR) were seen to have been swapped (this would not count as a GDR as the 24-hour dose remained the same).

During an interview on 02/03/2025 at 12:52 PM, Staff G, MDS Director, said they should not have coded the GDR for 07/01/2024 and this date was incorrect.

During an interview on 02/04/2025 at 11:26 AM, Staff B, Director of Nursing Services (DNS), said it did not meet expectation, that the MDS for Resident 27 was coded inaccurately for the last GDR date.

2) Resident 11 was admitted to the facility on [DATE REDACTED] with diagnoses of post-traumatic stress disorder (PTSD, a mental health condition triggered by an extremely stressful or terrifying event), depression, and anxiety. The Admission MDS, dated [DATE REDACTED], showed Resident 11 did not have a Level II Preadmission Screening and Resident Review (PASRR) process completed. The EHR showed Resident 11 had a Level II PASRR uploaded in their record, dated 03/03/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0641 During an interview on 02/03/2025 at 1:01 PM, when asked if the Level II PASRR for Resident 11 should been included on the MDS, Staff G, MDS Director, said yes. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/04/2025 at 11:37AM, Staff B, DNS, said it did not meet expectations that Resident 11 did not have their Level II PASRR reflected on their MDS. Residents Affected - Some 37044

3) Resident 12 admitted to the facility on [DATE REDACTED] with orders for: venlafaxine (an antidepressant) for depression, mirtazapine (an antidepressant) for depression with decreased appetite, and buspirone (antianxiety medication.) The diagnosis for the use of buspirone was left blank.

The 12/30/2024 Psychotropic Medication Therapy consent form for the use of buspirone, documented it was used to treat anxiety with a goal of decreasing anxiety symptoms.

Review of the Admission MDS, dated [DATE REDACTED], showed the resident was cognitively intact, had an active diagnosis of depression, no diagnosis of anxiety, but required the use of antidepressant and antianxiety medication.

On 01/28/2025 at 3:09 PM, Staff DD, Social Service Director, confirmed Resident 12's diagnosis for the use of buspirone was anxiety disorder and anxiety should have been coded as an active diagnosis on the Admission MDS.

4) Resident 42's Quarterly MDS, dated [DATE REDACTED], showed they received a restorative passive Range of Motion (ROM) program once and a bed mobility program twice during the assessment period. The 10/14/2024 Quarterly MDS showed they received a restorative passive ROM program and a bed mobility program five times each during the assessment period

A restorative nursing care plan, initiated 12/01/2024, showed the resident was to participate in a passive ROM restorative nursing program (RNP) five to seven days a week to maintain upper extremity (UEs) strength, and an active ROM program five to seven days a week to maintain lower extremity (LEs) strength.

The programs failed to identify what UE and LE joints would be ranged, through what planes of motion (e.g. flexion, extension, abduction, adduction, internal/external rotation) or how many sets/repetitions would be performed. The care plan did not identify a measurable objective, and the interventions were not personalized to Resident 42's needs. Additionally, there was not a bed mobility restorative program identified

on the care plan.

On 02/05/2025 at 11:56 PM, Staff G, MDS Director, said Resident 42's 10/14/2024 and 01/12/2025 quarterly MDS' needed to be corrected. Staff G acknowledged the resident was not on a bed mobility restorative /functional maintenance program and the passive ROM program did not identify a measurable objection or have interventions that were personalized to Resident 42's needs.

42960

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0641 5) A review of the Quarterly MDS, dated [DATE REDACTED], shows Resident 1 was admitted to the facility on [DATE REDACTED], with a diagnosis of a cerebral infarction (a condition where blood flow to the brain is interrupted, causing Level of Harm - Minimal harm or brain tissue to die) affecting their right dominant side. The MDS also showed Resident 1 was on a restorative potential for actual harm nursing program documenting passive range of motion for five days and dressing and/or grooming for five days in the last seven calendar days for at least 15 minutes. Residents Affected - Some

On 02/05/2025 at 11:56 AM, Staff G, Licensed Practical Nurse (LPN)/MDS Director, acknowledged the information that was coded for restorative, on the most recent MDS, should not have been collected.

6) A review of the Quarterly MDS, dated [DATE REDACTED], showed Resident 65 was admitted to the facility on [DATE REDACTED] with a diagnosis of cerebral infarction (stroke) affecting left non-dominant side. The MDS also showed Resident 65 was on a restorative nursing program documenting passive range of motion for six days in the last seven calendar days for at least 15 minutes.

On 02/05/2025 at 11:56AM, Staff G, LPN/MDS Director, acknowledged the information that was coded for restorative, on the most recent MDS, should not have been collected.

50488

7) Resident 16 admitted to the facility on [DATE REDACTED] and was receiving dialysis. The MDS, dated [DATE REDACTED], showed Resident 16 had a significant change and was no longer receiving dialysis but was receiving hospice services. The Quarterly MDS, dated [DATE REDACTED], had dialysis marked and hospice was not marked.

On 01/28/2025 at 10:26 AM, Staff G LPN/MDS Director, said that they had marked the MDS incorrectly and would submit a modification.

8) Resident 32 was admitted to the facility on [DATE REDACTED] with hospice services. The Quarterly MDS, dated [DATE REDACTED], showed Resident 32 was moderately cognitvely impaired and needed substantial assistance for most Activities of Daily Living (ADLs).

A review of hospice records showed Resident 32 graduated from their services on 04/12/2024. The Significant Change MDS, dated [DATE REDACTED] was marked for hospice. No further MDS assessments were completed until 07/12/2024.

A review of provider notes dated 10/29/2024, 12/03/2024, 12/25/2024, all showed Resident 32 had a right hand contracture. The Quarterly MDS, dated [DATE REDACTED], functional limitation in range of motion section, was marked no impairment for upper extremities (shoulder, elbow, wrist, hand).

On 01/28/2025 at 2:48 PM, Staff G, LPN/MDS Director, said they triggered the Significant Change MDS to ensure staff would have reviewed and updated the care plan due to hospice being discontinued. Staff G said

it had not been completed correctly and the care plan had not been updated accordingly. When asked if the right hand contracture should have been marked on the MDS to ensure the impairment and interventions were on the care plan, she said, yes.

9) Resident 57 was admitted to the facility on [DATE REDACTED] with a diagnosis of end stage renal disease which required hemodialysis (treatment that removes waste products and excess fluids from the blood). The Admission MDS, dated [DATE REDACTED], showed Resident 57 was cognitively intact and needed substantial assistance with most ADLs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0641 Review of an order on the Medication Adminstration Record, dated 12/12/2024, showed nursing staff were to monitor a dialysis catheter to the left chest. Review of disharge hospital notes, dated 12/12/2024, showed Level of Harm - Minimal harm or Resident 57 had a left tunneled hemodyalisis catheter (a central venous access device specifically designed potential for actual harm for kidney replacement therapy).

Residents Affected - Some Review of the Admission MDS, dated [DATE REDACTED], showed the section for Special Treatments, Procedures, and Programs was marked no for intravenous access and was not marked for a central line.

On 01/28/2025 at 10:29 AM, Staff G, MDS Director, said they missed marking the MDS for the intravenous access and central line. When asked if those omissions would have affected the accuracy of the care plan,

she said it would have as the MDS drives the care plan.

Reference WAC 388-97-1000 (1)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945 potential for actual harm Based on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Residents Affected - Few Resident Reviews (PASRR) were complete and accurate for 2 of 7 sampled residents (Residents 11 & 12) reviewed for PASRR. This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life.

Findings included .

1) Resident 11 was admitted to the facility on [DATE REDACTED] with diagnoses of post-traumatic stress disorder (PTSD, a mental health condition triggered by an extremely stressful or terrifying event), depression, and anxiety.

Review of the Electronic Health Record (EHR) showed Resident 11 had a Level II PASRR uploaded in their record, dated 03/03/2023, and a Level I PASRR, dated 05/02/2024. Resident 11's Level II PASRR was completed in 2023 and only addressed their diagnosis of PTSD.

Resident 11's Level I PASRR, completed 05/02/2024 prior to their admission, only had PTSD selected. Resident 11's diagnosis list was updated on admission, 05/02/2024, with the addition of depression and anxiety. The EHR showed no additional Level I PASRRs were completed to account for the new diagnoses

in Resident 11's chart.

During an interview on 02/05/2025 at 1:51 PM, Staff DD, Social Services Director (SSD), said Resident 11's current Level II PASRR was uploaded on 02/24/2023. When asked if the referral needed to be redone due to Resident 11's mood management medications that were added since the Level II PASRR was completed, Staff DD said they had only been advised to redo a PASRR if diagnosis change, not medications.

During an interview on 02/05/2025 at 2:08 PM, Staff B, Director of Nursing Services (DNS), when asked about Resident 11 only having a diagnosis of PTSD with the 2023 Level II PASRR, and with the most recent admission on 05/02/2024 now having additional diagnoses of anxiety and depression, if the Level I PASRR completed on 05/02/2024 was accurate, said they would look into this.

During a follow up in interview on 02/06/2025 at 10:50 AM, Staff B, DNS, said they had looked into Resident 11's PASRRs and the Level II PASRR should have been redone.

37044

2) Resident 12 admitted to the facility on [DATE REDACTED] with orders for: venlafaxine (an antidepressant) for depression, mirtazapine (an antidepressant) for depression with decreased appetite and buspirone (antianxiety medication) for anxiety.

A Level I PASSR, dated 12/31/2024, showed the resident had a diagnosis of depressive disorder, but did not have a diagnosis of anxiety disorder. The assessment determined a Level II evaluation was required for indicators of serious mental illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0645 Review of the 12/30/2024 Psychotropic Medication Therapy consent form for the use of buspirone showed

the reason for use was anxiety. The expected benefits were documented as Decrease Anxiety Symptoms. Level of Harm - Minimal harm or potential for actual harm On 01/28/2025 at 3:09 PM, Staff DD, SSD, said the Level I PASRR was inaccurate and needed to be updated to reflect Resident 12's anxiety disorder. Residents Affected - Few Reference WAC 388-97-1915 (1)(2)(a-c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42960

Residents Affected - Some Based on observation, interview and record review, the facility failed to review and revise a comprehensive plan of care to include resident specific interventions for 7 of 23 sampled residents (Residents 65, 4, 6, 11, 27, 12 and 61) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.

Findings included .

1) Resident 65 was admitted to the facility on [DATE REDACTED] with a diagnosis of cerebral infarction (stroke) affecting left non-dominant side. The quarterly Minimum Data Set (MDS/an assessment tool), dated 12/30/2024, documented the resident was moderately cognitively impaired.

On 01/27/2025 at 7:34 AM, Resident 65 was in bed and appeared asleep. The bed was observed against the wall and window.

On 02/03/2025 at 2:23 PM, Resident 65 was sitting up in bed watching TV. Their bed was observed against

the wall.

A Review of Resident 65's care plan did not show a focus or intervention listed about their bed being against

the wall.

2) Resident 4 was admitted to the facility on [DATE REDACTED]. The quarterly MDS, dated [DATE REDACTED], documented the resident was cognitively intact.

On 01/27/2025 at 7:29 AM, Resident 4 was sitting up in bed watching TV and their bed was observed against the wall.

On 02/03/2025 at 2:21 PM, Resident 4's bed was observed against the wall and they were sitting next to their bed in their wheelchair watching television.

A review of Resident 4's care plan did not show a focus or intervention listed about their bed being against

the wall.

On 01/29/2025 at 12:16 PM, Staff D said Resident 4 and Resident 65 did not have care plan, evaluation, consent or an order for their bed being against the wall.

On 01/29/2025 at 1:57 PM Staff B, Director of Nursing (DNS) said she could not find a care plan, evaluation, consent or order for Resident 4 or Resident 65's bed being against the wall in their charts and it was her expectation that these things were in the chart.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0656 3) Resident 6 was admitted to the facility on [DATE REDACTED] and had a diagnosis that included kidney disease that required dialysis (treatment to filter blood and remove excess fluid and waste buildup). The Quarterly MDS, Level of Harm - Minimal harm or dated [DATE REDACTED], showed Resident 6 was cognitively intact and was dependent on staff regarding their lower potential for actual harm body.

Residents Affected - Some Review of Resident 6's care plans showed their care plan was missing information regarding details of dialysis, such as Resident 6's nephrologist information and their goal dialysis weight. Further review showed Resident 6's care plans showed they were missing information on mobility bars (bars on bed to help resident reposition themselves) being used.

During an interview on 02/03/2025 at 11:51 AM, when asked who Resident 6's nephrologist was, Staff C, RCM said they did not know their specific name and that Resident 6 went to [NAME] for those services. When asked what Resident 6's goal weight was supposed to be, Staff C said it typically was put in the care plan, that it was not in Resident 6's care plans, and it should have been.

During an interview on 02/04/2025 at 11:18 AM, Staff B, DNS, said a care plan should be in each resident's Electronic Health Record (EHR) for the use of side rails/mobility bars, and confirmed the mobility bars were not in Resident 6's care plans. When asked if Resident 6 should have had the name of their nephrologist or their dialysis goal weight, Staff B said yes, they should be in the care plan.

4) Resident 11 was admitted to the facility on [DATE REDACTED] and had diagnoses of post-traumatic stress disorder (PTSD, a mental health condition triggered by an extremely stressful or terrifying event), depression, and anxiety.

Review of the EHR showed Resident 11 had a Level II Preadmission Screening and Resident Review (PASRR) uploaded in their record, dated 03/03/2023.

During an interview on 02/05/2025 at 1:51 PM, when asked if the Level II PASRR recommendations were on

the care plan, Staff DD, Social Services Director said for the 05/02/2024 admission, it was not there and they did not know the reasoning it was not there, and that it should have been.

5) Resident 27 was admitted to the facility on [DATE REDACTED] and had diagnoses of dementia and anxiety. Review of

the Quarterly MDS, dated [DATE REDACTED], showed Resident 27 had severe cognitive impairment, was taking an opioid (strong pain reliever) and psychotropic medications (affect behavior, mood, thoughts or perceptions), and was receiving hospice services (end of life care).

Review of Resident 27's care plans showed they did not have resident specific information in their care plan for their diagnosis of dementia, and did not have non-pharmacological (non-medication) interventions for staff on how to interact with Resident 27 to decrease anxiety or to handle behaviors.

During an interview on 01/31/2025 at 10:53 AM, when asked if the care plan should include what Resident 27's anxiety or behaviors present like, Staff C said that the RCM or nurse would have to know about the behaviors and document them to care plan them. When asked if Resident 27's care plans included anything about opioid usage, Staff C said they did not see anything and that there should be.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0656 During an interview on 02/04/2025 at 11:26 AM, when asked what they expected in the care plan for Resident 27 regarding their diagnosis of dementia, Staff B, DNS, said all care needs, that there was a Level of Harm - Minimal harm or diagnosis of dementia, and interventions on how to care for Resident 27. When asked about Resident 27 potential for actual harm being offered a standard alternative of yogurt and declining, after not eating any of their lunch, Staff B said that staff should have contacted family for information on what Resident 27 liked to eat and this should have Residents Affected - Some been included on the care plan. Staff B said they would expect non-pharmacological interventions, specific to

the resident, for dementia care or psychotropic medication usage to be in the care plans. After reviewing Resident 27's care plan, Staff B said they did not see in the care plan of what worked for Resident 27 related to non-pharmacological interventions.

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6) Resident 12 admitted to the facility on [DATE REDACTED]. Review of the Admission MDS, dated [DATE REDACTED], showed the resident was cognitively intact, had a diagnosis of depression and required use of antianxiety and antidepressant medication during the assessment period

Review of the Psychotropic Drug Use care area assessment (CAA), dated 01/06/2025, showed Resident 12 received psychotropic medications for anxiety and depression. It was documented in the CAA that the psychotropic drug use would be addressed in the care plan.

An antidepressant medication for depression care plan, initiated 01/07/2025, directed staff to administer medications as ordered and to monitor for adverse side effects associated with antidepressant medication use. The care plan did not identify what antidepressant medications the resident received, identify the resident specific Target Behaviors (TB)s each medication was intended to treat or direct staff to monitor for and document when the behaviors were exhibited

On 01/28/2025 at 3:09 PM, Staff DD, Social Services Director, said Resident 12's antianxiety and antidepressant care plans should have identified what medications the resident received, the specific TBs each medication was intended to treat and directed staff to monitor an document when the behaviors were exhibited.

7) Resident 61 admitted to the facility on [DATE REDACTED]. Review of the 11/24/2024 Quarterly MDS showed the resident was cognitively intact, and identified being around animals such as pets, keeping up on the news, and getting fresh air when the weather was nice were somewhat important to them, while listening to music

they liked was, very important.

Review of Resident 61's activity care plan, with a target date of 05/15/2025, identified the resident liked to watch television, listen to music: would have opportunities to watch TV or listen to music and visit with family.

The resident's other activity interests were identified on the 11/24/2024 MDS including being around animals/pets and going outside for fresh air when the weather was nice were not incorporated into their activity plan of care.

On 02/05/2025 at 12:19 PM, Staff C said Residents 61's interest in being around pets/animals and going outside for fresh air when the weather was nice should have been included on their activity care plan.

Reference

F-F656

Reference WAC 388-97-1060 (2)(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46793 potential for actual harm Based on observation, interview and record review, the facility failed to implement individualized activities for Residents Affected - Few 3 of 3 sampled resident (Residents 69, 61 & 27) reviewed for activities. The failure to implement an activity plan of care that incorporated resident's stated interests, hobbies and preferences, placed the residents at risk for boredom, isolation, and a diminished quality of life.

Findings included .

1) Resident 69 was admitted to the facility on [DATE REDACTED]. The Admission Minimum Data Set (MDS, an assessment tool), dated 11/26/2024, documented Resident 69 had a Brief Mental Interview score of 00. Resident 69 does not speak English but was able to understand some English.

Resident 69's communication and activities care plan documented Resident does not use call light, ask for assistant, but is able to make hand gestures and point to items to communicate. Resident 69 will need to be assisted to and from activities. Resident 69 enjoys music, watching TV, one on one visits from staff and being outdoors.

An order, dated 01/14/2025, documented, Daily Skilled note required. Please enter detailed chart note on services provided i.e. PT [physical therapy]/OT [occupational therapy] participation, ADLs [activities of daily living], transfer status, new orders, and any concerns. everyday shift. No documentation found in electronic health record (EHR) related to the listed tasks above.

An activities assessment, dated 11/30/2024, documented Resident 69 likes watching tv, scrolling online, listening to Christian & Marshallese music. Resident 69 also likes Bingo and Painting. The question Activities should be modified to address communication deficit? was marked yes. The question Does resident like independent activities (i.e. reading, puzzles etc.)? was marked yes.

The EHR marked no documentation of activities provided to Resident 69. The Activities task documented Resident 69:

Listened to music on 12/31/2024 and 01/20/2025.

Watched TV on 12/31/2024, 01/01/2025, 01/04/2025, 01/06/2025, 01/11/2025, 01/20/2025 & 01/21/2025.

Did I socialize during the 1:1 visit? On 12/31/2024, 01/01/2025 & 01/20/2025.

Observations on 01/27/2025 at 8:39 AM until 10:54 AM, showed Resident 69 laid in bed in the dark, with no music, no TV, no games or individual activities. During this time, fifteen staff members entered the room and no one offered any activities to Resident 69.

At 10:54 AM Staff CC, Certified Nursing Assistant (CNA) and Staff Y, CNA, entered the room and closed the door behind them.

At 11: 02 AM Staff Y, CNA, brought in the hoyer (mechanical lift) and told Resident 69, they were getting her up for lunch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0679 Observations on 01/28/2025 at 9:01 AM until 11:22 AM, showed resident 69 sat in their wheelchair in the dark, with no music, no TV, no games or individual activities. During this time, twenty staff members entered Level of Harm - Minimal harm or the room and no one offered activities to Resident 69. potential for actual harm At 12:48 PM, Resident 69 was brought their lunch meal tray. Residents Affected - Few

On 01/29/2025 at 10:12 AM, Staff DD, Social Services Director, said the activities assistant quit two weeks prior and the Activities Director was currently out sick. Staff AA said they had not had activities for the past week.

On 01/30/2025 at 12:55 PM, Staff VV, Activities Director, said for dependent residents, activities included bringing the activities to them, things like, playdough (good for sensory), music, talking about family, conversations and busy book (open interactive book). Staff VV said the facility has two stuffed animal cats with brushes, playing with baby dolls and painting their fingernails. Staff VV said some residents don't care for some activities, but she makes a point to just sit with them. Staff VV said she will do spiritual readings/versus. Staff VV said there was also the independent cart; things like movies and popcorn, beading, coloring pages and coloring supplies, box puzzles and magnetic eraser writing tablets. When observations explained of Resident 69 sitting in the dark with no social interactions or activities offered, Staff VV said that was not accepted and staff should have offered/provided Resident 69 with individual activities.

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2) Resident 61 admitted to the facility on [DATE REDACTED]. Review of the 11/24/2024 Quarterly MDS showed the resident was cognitively intact, and identified that being around animals such as pets, keeping up on the news, and getting fresh air when the weather was nice were somewhat important to them, while listening to music they liked was Very important.

On 01/22/2025 at 9:40 AM, 01/23/2025 at 10:19 AM, 01/27/2025 at 02/03/2025 at 9:57 AM and 10:26 AM, and 02/05/2025 at 10:57 AM, Resident 61 was observed lying in bed without their television on or music playing.

An activity care plan, revised 11/12/2024, documented the following goals: will have opportunities to watch TV or listen to music and will socialize in a one-to-one setting with a volunteer/visitor/activity staff two to three times a week. The care plan did not address getting fresh air or being around animals.

Review of the Kardex showed under Activities it was documented one to one visits with family, one to one visits with staff and watching television.

Review of the activities documentation for January 2025 showed on 01/01/2025 the resident passively participated in an activity one to one visit. There was no further documentation that activity staff offered or provided any further one to one visits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0679 On 02/02/2025 at 4:17 PM, when asked why activity staff had not been providing one to one activity visits two to three times a week as care planned Staff VV, Activities Director, said the resident preferred to direct Level of Harm - Minimal harm or her own activities but acknowledged staff should have attempted one to one interaction two to three times a potential for actual harm week in accordance with the plan of care. When asked why Resident 61 did not have music playing or their television on Staff VV indicated they had been out sick and explained that someone should have assisted the Residents Affected - Few resident with their TV or to put music on.

50945

3) Resident 27 was admitted to the facility on [DATE REDACTED] and had diagnoses of dementia and anxiety. Review of

the Quarterly MDS, dated [DATE REDACTED], showed Resident 27 had severe cognitive impairment and was receiving hospice services (end of life care).

The MDS showed Resident 27 found it very important that they had books, newspapers, and magazines to read, and that they had music to listen to. They found it somewhat important to do things with groups of people, to do favorite activities, to go outside to get fresh air when the weather was good, and to participate

in religious services.

Review of Resident 27's activities focus care plan, listed:

-1:1 visits

-Exercise

-Family visits

-Food activity

-Grooming

-Radio/television (TV)

-Reading activities

-Sensory Stim(ulation)

-Staff will encourage Resident 27 to attend group activity, be provided with reading material, to receive two 1:1 visits a week to make sure she's happy with her routine

-Sunshine therapy

-Walking group

Review of the care plan intervention of radio/TV showed it was initiated on 04/14/2021.

During an observation on 01/27/2025 at 9:07 AM, Resident 27 was in bed, eyes closed. Resident 27 opened their eyes, answered a question, then closed them again. No activities were seen in their room, and no TV was on their side of the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0679 At 2:22 PM, Resident 27 was in bed, supine, eyes closed. No activities seen in room.

Level of Harm - Minimal harm or During an observation on 01/29/2025 at 3:16 PM, Resident 27 was in bed, supine, eyes closed, and mouth potential for actual harm opened.

Residents Affected - Few During an observation on 01/30/2025 at 9:40 AM, Resident 27 was in bed, head of bed elevated, bedside table in front of them, eyes closed, mouth opened. No stimulation observed in the room. Blinds were shut.

02/03/25 01:34 PM Resident 27 was seen staring at roommate's TV. Resident 27's roommate had their sound off, as they were on the phone.

At 1:44 PM, Resident 27 was seen staring in direction of roommate's TV.

At 2:00 PM, Resident 27 continued to stare at roommates TV without sound.

During an interview on 01/30/2025 12:10 PM, Staff KK, CNA, when asked what activities Resident 27 liked, said they liked watching TV, resident activities, and showering.

During an interview on 01/30/2025 at 9:53 AM, Staff EE, Licensed Practical Nurse, when asked what activities Resident 27 liked, said they were unsure, then said bingo.

During an interview on 01/31/2025 at 9:58 AM, Staff VV, Activities Director, said Resident 27 liked TV. When asked why they did not have their own TV, Staff VV said Resident 27 liked to watch their roommates. When asked if the curtain is pulled, if Resident 27 could still watch TV, Staff VV said, I see the issue.

During an interview on 02/04/2025 at 11:26 AM, Staff B, DNS, when told about Resident 27 not having a TV, said yes, Resident 27 definitely should have their own entertainment.

Reference WAC 388-97-0940 (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 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** 50488 potential for actual harm Based on interview and record review, the facility failed to ensure bowel management interventions were Residents Affected - Some implemented for 3 of 8 residents (Residents 32, 65 & 3) reviewed for quality of care. This failure placed residents at risk for discomfort, further complications, and a diminished quality of life.

Findings included .

The facilities bowel protocol policy, undated, had the following instructions: FOR PATIENTS WITH CONSTIPATION;

1. lf no bowel movement (BM) within 72hrs, may give MOM (Mild of Magnesia, a laxative) 30cc (cubic centimeter) po (by mouth).

2. lf no results after MOM 30cc, may give Miralax (a laxative) 17gm (grams) po qd (daily) prn (as needed) or .

3. May add Bisacodyl (a laxative) 5mg (milligrams) i to ii (1 to 2) tablets po qd or suppository, NTE (not to exceed) 30mg in a 24hr period

4. May add Fleets (bowel stimulant) enema prn if constipation persists.

1) Resident 32 was admitted to the facility on [DATE REDACTED]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 1/8/2025, showed Resident 32 was moderately cognitively impaired and needed substantial to maximal assistance with Activities of Daily Living (ADLs).

On 1/23/2025 at 11:35 AM, Resident 32 was asked if they had regular BMs. Resident 32 said sometimes it was very hard to go and that there had been times when they weren't able to have a BM for several days.

Review of the care plan revised on 5/1/2024 showed Resident 32 had a history of constipation related to decreased mobility. The goal for Resident 32 was that there would be a normal BM at least every three days.

The staff were to follow facility bowel protocol.

Review of the Medication Administration Record (MAR) for January 2025 showed Resident 32 received both scheduled and PRN opioids (medications used to treat pain with a side effect of constipation). Scheduled senna (bowel stimulant) was given twice a day. Available PRN bowel medications were as follows:

Miralax 17 gm - as needed daily per hospice. Resident 32 was not receiving hospice services in January 2025.

Bisacodyl 5mg - give 10mg by mouth as needed for five days without BM.

Fleet oil enema - one application as needed. If no result, call physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 the aides documentation for January 2025, showed Resident 32 did not have a BM from 1/08/2025 to 1/14/2025, 6 days. No PRN medications were given. There was no documentation the physican Level of Harm - Minimal harm or had been notified. potential for actual harm

On 1/29/2025 at 3:07 PM, Staff B, Director of Nursing Servics, said there should have been pharmacological Residents Affected - Some and non-pharmacological interventions implemented by day three of no BM. Staff B said the policy needed to be reviewed and revised.

42960

2) Resident 65 was admitted to the facility on [DATE REDACTED]. The Quarterly MDS, dated [DATE REDACTED], documented the resident was moderately cognitively impaired.

Review of Resident 65's orders showed four medications for bowel management:

1). STEP 1: If no bowel movement in 72hrs may give 17g Miralax. If no results, go to step 2 of bowel protocol.

2). STEP 2: May give Senna 17.2gm by mouth once a day as needed, for day 4 without BM. If no results from step two, go to step three of bowel protocol.

3). STEP 3: Give Bisacodyl 10mg by mouth one time daily as needed for day 5 without BM. If no results from step three, go to step four.

4). STEP 4: Fleet Oil Enema Insert one application rectally and if not result from step four, call physician.

Review of Resident 65's bowel record, showed they did not have a bowel movement on the following dates:

01/04/2025, 01/05/2025, 01/06/2025, 01/07/2025 (4 days)

01/19/2025, 01/20/2025, 01/21/2025, 01/22/2025 (4 days)

Review of Resident 65's medication administration record (MAR) showed no bowel management medications were given on the dates listed above.

On 01/30/2025 at 10:31 AM, Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) said Resident 65 did not receive a bowel medication and the bowel protocol should have been started.

At 12:42 PM, Staff B, DNS said the expectation would be to start the bowel protocol on the third day.

46793

3) Resident 3 was admitted to the facility on [DATE REDACTED]. The Quarterly MDS, dated [DATE REDACTED], documented Resident 3 was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 An order on 10/08/2024 documented Miralax to be given as needed after three days with no BM. If no BM

after 24 hours go to step two. An order documented step two, may give Senna 17.2gm by mouth as needed. Level of Harm - Minimal harm or If no BM, go to step three. An order documented step three, give Bisacodyl 10 mg by mouth after five days potential for actual harm with no BM. If no results, go to step four. An order documented Step four, Fleet enema, if no results from step four, call physician. Residents Affected - Some Resident 3's Bowel Movement record documented Resident 3 had no BM from 01/16/2025 through 01/21/2025 (6 days). The electronic health record (EHR) documented the Bowel Protocol was never initiated for Resident 3.

On 01/29/2025 at 11:09 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, Staff B explained the facility's bowel protocol and when it should be initiated. When provided the dates of no BM's for Resident 3, Staff B said the bowel protocol should have been initiated for Resident 3.

Reference WAC 388-97-1060 (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0687 Provide appropriate foot care.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37044 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure Podiatry (the treatment of Residents Affected - Few feet and their ailments) care and services were provided for 1 of 1 resident (Resident 27) reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life.

Findings included .

Resident 61 admitted to the facility on [DATE REDACTED]. Review of the 11/24/2024 Quarterly Minimum Data Set (MDS,

an assessment tool), showed the resident was cognitively intact, and required substantial to maximal assistance with hygiene and lower body care.

On 01/23/2025 at 9:40 AM, Resident 61's toenails were observed to long, yellow, thick and untrimmed. The second through fourth digits on the right foot and first, third and fifth digits on the left foot were starting to curve around the end of the resident's toes.

At 10:35 AM, Resident 61 said that staff had not offered or provided toenail care since admission. The resident indicated they went to a podiatrist prior to hospitalization and placement at the facility.

Review of the December 2024 and January 2025 Treatment Administration Records (TAR) showed nurses were directed to provide nail care weekly on Resident 61'a shower day. Review of the documentation showed the following:

12/04/2024 - Not provided 01/01/2025 - Not provided.

12/11/2024 - Blank 01/08/2025 - Not provided.

12/18/2024 - Blank 01/15/2025 - Not provided.

12/26/2024 - Not provided 01/22/2025 - Not provided.

01/29/2025 - Not provided.

On 02/05/2025 at 10:57 AM, Staff C, Resident Care Manager (RCM), Resident 61's toenails were long, thick, yellow and untrimmed, with several on each foot beginning to curve around the end of the resident's toes. Staff C said they wouldn't feel comfortable trimming the resident's toenails and indicated the resident required a podiatry referral.

Review of the facility's podiatry visits showed the podiatrist had been in the facility twice since the resident admitted . The podiatrist came on 11/12/2024 and 01/07/2025. Review of the podiatry referral list showed Resident 61 had not been referred or seen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0687 On 02/05/2025 at 2:14 PM, Staff C, RCM, confirmed Resident 61 was not referred or seen by the podiatry on 11/12/2024 or 01/07/2025. Staff C said Resident 61 should have already been referred/seen by the Level of Harm - Minimal harm or podiatrist. potential for actual harm Reference WAC 388-97-1060 (3)(j)(viii) Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42960

Residents Affected - Some Based on interview and record review, the facility failed to provide restorative services at the frequency residents were assessed to require for 5 of 6 sample residents (1, 42, 61, 69, and 32) reviewed with restorative nursing programs (RNPs). These failures placed residents at risk for decrease in Range of Motion (ROM/movement of a joint through the range of motion with no effort from the patient), increased dependance on staff for care needs and a diminished quality of life.

Findings included .

<Facility Policy>

Review of the facilty's undated Restorative Nursing Documentation policy, showed the need for restorative nursing services would be documented in the medical record, and indicated on the resident's plan of care. Documentation would include: The problem, need, or strength that was being addressed. A measurable goal with target date. The specific interventions/treatments to be provided. The frequency and duration of interventions/treatments. Restorative aide documentation would include the treatment provided, specific distance or repetitions perfomed, use of assistive devices, endurance and tolerance level, and the amount of assistance provided and why.

1) Resident 1 was admitted to the facility on [DATE REDACTED] with a cerebral infarction (stroke) affecting their right dominant side (a condition where blood flow to the brain is interrupted, causing brain tissue to die). The quarterly Minimum Data Set (MDS/an assessment tool), dated 01/02/2025, documented the resident was cognitively intact and on the RNP and receiving passive range of motion and dressing and/or grooming five days in the previous seven calendar days for at least 15 minutes.

Resident 1's restorative nursing care plan, initiated 02/14/2024, showed they would receive restorative services five to seven days per week and record the number of minutes of services received.

A review of restorative frequency for January 2025 for Resident 1 from 01/01/2025 - 01/14/2025 showed passive range of motion was documented as completed four times, refused one time, and two times was documented with an x.

On 02/05/2025 at 12:05 PM, Staff C Licensed Practical Nurse(LPN), Resident Care Manager (RCM) said the x meant the resident was not seen by restorative that day.

On 02/06/2025 at 8:27 AM, Staff B, Director of Nursing said Resident 1's frequency of restorative therapy was five to seven times per week and while looking at the restorative documentation said the resident did not receive therapy at that frequency. Staff B said if they had two restorative aids, they could get that accomplished.

On 02/06/2025 at 8:27 AM, Staff A, Administrator said she was currently trying to hire a restorative aid.

37044

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0688 2) Resident 42 admitted to the facility on [DATE REDACTED]. Review of the Quarterly MDS, dated [DATE REDACTED], showed the resident was cognitively intact, had impaired functional range of motion to both lower extremities, and Level of Harm - Minimal harm or received passive ROM and bed mobility RNPs on two of seven days during the assessment period. potential for actual harm

A restorative nursing care plan, initiated 12/01/2024, showed the resident was to participate in a passive Residents Affected - Some ROM - RNP five to seven days a week to maintain upper extremity (UEs) strength. No explanation was provided related to how a passive ROM program would maintain the resident's UE strength, nor was there documentation that indicated what the resident's current upper extremity strength was. Resident 42 was also to participate in an active ROM program five to seven days a week to maintain lower extremity (LEs) strength. The care plan did not identify measurable goals; why the RNPs were necessary for this resident (resident specific risk factors); personalized interventions; which UE and LE joints would be ranged, through what planes of motion (e.g. flexion, extension, abduction, adduction, internal/external rotation); or how many sets/repetitions would be performed.

Review of the January 2025 RNP flowsheets showed Resident 42's UE passive ROM program and LE active ROM programs were offered/provided twelve times during the month.

3) Resident 69 admitted to the facility on [DATE REDACTED]. Review of the Admission MDS, dated [DATE REDACTED], showed the resident had severe cognitive impairment, impaired functional range of motion to both UEs and one LE and received skilled therapy services.

A RNP care plan, initiated 01/22/2025, identified goals of maintaining ROM to both upper and lower extremities. The care plan did not identify whether Resident 69's ROM to both UE and LEs was currently limited or intact. The care plan did identify the resident was to participate in active and passive ROM programs to upper and lower extremities five to seven days per week. The care plan failed to identify which extremities (upper or lower) required passive ROM or why (e.g. right UE is flaccid secondary to stroke etc.), or which extremities the resident could perform active ROM with. The care plan failed to: identify measurable goals; why the RNPs were necessary for this resident; develop resident specicif interventions; and to identify UE and LE joints would be ranged, to what planes of motion; and identify the the number of repetitions and sets that were to be performed.

Review of the January 2025 RNP flowsheets showed Resident 69's RNPs were offered/provided two times from 01/22/2025 (date initiated) - 01/31/2025 (9 days.)

4) Resident 61 admitted to the facility on [DATE REDACTED]. Review of the Quarterly MDS, dated [DATE REDACTED], showed the resident was cognitively intact, had no functional limitations to range of motion, and received passive and active ROM RNPs on four of seven days during the assessment period.

A RNP care plan, revised 11/19/2024, documented the resident would participate in an active ROM program to both UEs, five to seven days a week to maintain ROM to UE joints and a passive ROM program to both LEs five to seven times a week with a goal of maintaining ROM to the residents lower extremity joints.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0688 The care plan did not indicate if the resident currently had functional limitations to their ROM, and if so what joints/extremities were affected. The care plan failed to identify: a measurable goal; why the RNPs were Level of Harm - Minimal harm or necessary for this resident; personalized interventions; which UE and LE joints would be ranged, through potential for actual harm what planes of motion; or how many sets/repetitions would be performed. Additionally, there was no documentation indicating why the resident required passive ROM to both lower extremities; or how many Residents Affected - Some ROM repetitions and sets would be performed.

On 02/05/2025 at 10:31 AM, when asked who the Restorative Nurse was, Staff C, Resident Care Manager, said the facility's Restorative Nurse recently left and said Staff B, Director of Nursing Services (DNS) was currently performing the Restorative Nurse duties.

On 02/05/2025 at 10:50 AM, Staff B, DNS, said they were not aware they had assumed the Restorative Nurse duties and were not familiar with the requirements for RNPs.

On 02/05/2025 at 10:50 AM, when asked if there was anything prevented them from providing residents their RNPs at the frequency they had been assessed to require Staff M, Restorative Nursing Assistant (RNA), explained the facility usually had to two RNAs, but one had recently left and was not replaced yet. They also reported there were 35 residents currently on restorative services with two RNPs each (approximately16 hours of restorative programs per day). Staff M's schedule was Monday - Friday from 7:00 AM - 3:00 PM with

a half an hour lunch. This provided Staff M with 7.5 hours to complete approximately 16 hours RNPs per day, which they acknowledged was not possible. Additionally, Staff M was pulled from restorative to provide direct resident care when the facility was short staffed.

Reference WAC 388-97-1060 (3)(d), (j)(ix)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945

Residents Affected - Few Based on observation, interview, and record review the facility failed to consistently implement fall prevention interventions for 1 of 3 residents (Resident 27) reviewed for falls. This failure placed residents at risk of falling, injury, and a diminished quality of life.

Findings included .

Resident 27 was admitted to the facility on [DATE REDACTED] with diagnoses of dementia and anxiety. Review of the Quarterly Minimum Data Set Assessment, dated 01/11/2025, showed Resident 27 had severe cognitive impairment, was receiving psychotropic medication (used for treating mental health conditions, can increase risk of falls), required staff assistance for using the restroom, and had a history of falls.

Review of the Electronic Health Record showed that Resident 27's most recent fall was on 10/11/2024, which resulted in a broken nose.

Review of Resident 27's fall and nutrition care plans, listed interventions that included:

-Fall mat to the right side of bed to prevent injury

-Keep call-light and things of interest within reach

-Set-up assistance with all meals

During an observation on 01/24/2025 at 2:10 PM, Resident 27's call light was draped over the head of the bed, outside of the resident's reach. It went above the pillow and went down over the headboard, and was touching the floor behind the bed.

At 2:13 PM, Staff NN, Certified Nursing Assistant (CNA), was seen assisting Resident 27.

At 2:15 PM, Staff NN left room. Resident 27, when asked if they were able to reach their call light, said I don't know. The call light was not adjusted since the 2:10 PM observation.

During an observation on 01/27/2025 at 9:07 AM, Resident 27's call light was behind their mattress, went under their bed, and was observed on floor.

During an observation on 01/30/2025 at 9:40 AM, Resident 27's call light went around the mattress, looped over the right upper mattress, and looped under the head of the bed, went under the bed on the left side, and was dangling just above the ground. The fall mat was seen on the ground, not lined up next to Resident 27. Resident 27 was sitting in bed with the head of the bed elevated, with a bedside table in front of them. The fall matt did not line up with the bed until the resident's shins and was angled to the wall (not in line with the resident). Resident 27 had their eyes closed, their mouth open, and there was no stimulation in room and the blinds were shut.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 During an interview and observation on 01/30/2025 at 12:23 PM, Staff KK, Certified Nursing Assistnt (CNA), when asked where Resident 27's call light was, went into the room and confirmed the call light was behind Level of Harm - Minimal harm or Resident 27 and said they had forgotten to put it back on Resident 27 after cares. potential for actual harm

During an interview on 01/31/2025 at 10:53 AM, Staff C, Resident Care Manager, said it did not meet Residents Affected - Few expectations a CNA had forgotten to put the call light back within reach for Resident 27, or that there were multiple observations of the call light being out of reach.

During an observation on 02/03/2025 at 1:27 PM, Resident 27's fall mat was folded up, against a cabinet, not

on the ground next to the right side of Resident 27's bed. Their call light was draped over their bed, dangling. Resident 27 had a food container at bedside, unopened. The door was slightly cracked, with no visibility to

the resident. When asked if they knew where their call light was, Resident 27 replied no.

During an observation at 2:06 PM, Staff KK, CNA, entered Resident 27's room, and removed the unopened meal. Staff KK left the room without adjusting the fall mat or call light.

During an observation at 2:16 PM, Staff TT, CNA, said the call light was not in an obvious spot for Resident 27 and their matt was not put back down. Staff TT was observed to put the fall matt back down on the right side of Resident 27's bed.

During an interview on 02/04/2025 at 11:26 AM, Staff B, Director of Nursing Services, when asked about Resident 27 having a history of falls and having interventions listed on the care plan, said it did not meet expectations that Resident 27 did not have their fall mat next to them on two observations or that their call light was not within reach. Staff B said when staff brought the meal in for Resident 27, they should have lifted

the container lid since they required set up assistance with food.

Reference

F-F677-ADL Care Provided for Dependent Residents

Refer to

F-F684 Quality of Care (H).

Refer to

F-F687 Foot Care

The governing body failed to ensure systems were in place and staffing was adequate to provide residents with ADLs such as oral care, shaving, assistance with meals, grooming and nail care.

Previously cited 02/2019, 08/2021, 05/2023, 03/2024 & 02/2025.

Refer to

F-F688 Increase/prevent Decrease In ROM (range of motion)/mobility

The governing body failed to ensure staffing levels were appropriate to be able to provide restorative nursing and to ensure the program had sufficient oversight. Documentation provided showed Restorative Nursing Assistants (RNA) were pulled to provide resident care on the floor on 12/03/2024, 12/26/2024, 12/17/2024, 12/18/2024, 12/23/2024, 01/02/2025, 01/03/2025, 01/04/2025, 01/09/2025, 01/10/2025, 01/12/2025, 01/14/2025, 01/19/2025, 01/26/2025, 01/29/2025, 01/30/2025, 01/31/2025, & 02/04/2025.

Refer to

F-F692 Nutrition/hydration status maintenance

The governing body failed to ensure systems were in place to monitor residents for weight loss and obtain and implement timely interventions that resulted in harm to two residents (Resident 71 and Resident 65). The governing body also failed to ensure systems were in place for monitoring and implementing fluid restrictions.

Refer to

F-F725 Sufficient Nursing Staff

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page109of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0837 The governing body failed to ensure the facility had sufficient staff to ensure residents received assistance with activities of daily living, restorative services and staff documentation. Additionally, the aides from the Level of Harm - Minimal harm or Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct potential for actual harm care staff absences resulting in the RNPs not being done.

Residents Affected - Many On 02/04/2025 at 1:48 PM, Staff B, DNS, said they did not know how staffing levels were determined, that was the responsibility of the Staffing Coordinator. When asked about hiring and retention interventions, Staff B said for hiring they were listing open positions on Indeed and did not know of any retention interventions being used. When shown the review of the Staffing Pattern, the facility was missing Registered Nurse (RN) coverage on the following dates: 12/25/2024, 12/26/2024, 12/28/2024, 01/01/2025, 01/02/2025, 01/08/2025, 01/09/2025, 01/11/2025, 01/15/2025 & 01/16/2025, Staff B said they had not reviewed the staffing pattern. When asked how RN coverage affected resident care, Staff B said it could potentially cause a delay in resident care needs being met. When asked how pulling the RNA affected resident care, Staff B said residents in RNA program did not get their Restorative Nursing Program (RNP) that day. Review of facility records showed the Infection Preventionist (IP) and Resident Care Managers (RCM)'s were pulled from job duties to provide resident care on 01/03/2025, 01/08/2025, 01/13/2025, 01/17/2025, 01/27/2025 & 02/04/2025. Staff B acknowledged the dates. Staff B said it made it challenging to get their job done because of oversight to the floor. When asked how this would affect resident care, Staff B said it could potentially cause delays in care, untimely assessments/evaluation, it could have a [NAME] effect on resident care. Staff B acknowledged staffing has been a concern.

Refer to

F-F726 Competent Nursing Staff

The governing body failed to ensure the licensed nurses and nursing aides had the appropriate competencies/skill sets to provide nursing services that included appropriate infection control procedures.

The facility also failed to implement policies for orientation of agency/contracted staff, provide updated trainings to ensure licensed staff were trained and competent in the management and monitoring of central venous catheters (centrally inserted access to veins), and to provide oversight of the Restorative Nursing Program (RNP).

Refer to

F-F757

No Associated WAC

.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page130of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 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 50392

Residents Affected - Few Based on interview and record review, the facility failed to maintain documentation of staff COVID 19 (an infectious respiratory disease caused by a virus) vaccination status. This failure placed residents at risk of contracting COVID 19, medical complications and a decreased quality of life.

Findings included .

On 01/28/2025 at 9:16 AM, when asked if there was documentation of staffs COVID-19 vaccination status, Staff L, Infection Preventionist (IP) and Registered Nurse said it's was not a requirement, it was not part their hiring process and it was not being done.

On 01/29/2025 at 2:07 PM, when clarifying that keeping documentation of staff COVID-19 vaccination was a requirement Staff L, IP, said, I was told that it was not a requirement, that it is not mandated. I was keeping a

record when it was a mandated requirement. Staff L said, I don't yet have a staff list of vaccination status.

No associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page131of131 505254

F-F758-Free from Unnecessary Psychotropic Meds/PRN Use

Refer to

F-F804-Nutritive Value/Appear, Palatable/Prefer Temp. Previous survey deficiency dated 02/2019 (D), 08/2021 (E), 05/2023 (E) & 03/2024 (E).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page115of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0865 Refer to

F-F812 Food procurement, store, prepare, serve (E). potential for actual harm Refer to

F-F865.

Reference WAC 388-97-1760 (1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page117of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 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** 50392 potential for actual harm Based on observation, interview and record review, the facility failed to operationalize an effective Infection Residents Affected - Many Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when the facility failed to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions (used when someone has confirmed or suspected infections) related to lack of prompt isolation and use of precautions when several residents and staff had vomiting and diarrhea and a suspected gastrointestinal outbreak. The facility also failed to ensure the consitent hand hygiene, personal protective equipment (PPE) use and or cross contamination (the unintentional transfer of harmful bacteria, viruses, or allergens from one surface, person, or food to another) for 4 of 4 Halls (Hall A, Hall B, Hall C, & Hall D) reviewed for infection control practices. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications and a decreased quality of life.

Findings included .

Review of the facility policy titled, Standard Precautions Infection Control, undated, described standard precautions as practices applied to all residents, to prevent the spread of infection to residents, staff, and visitors. These precautions included hand hygiene, selection and use of personal protective equipment (PPE) as was appropriate, safe injection practices with the proper disposal of injection equipment in the sharp's container, environmental cleaning and disinfection, and the reprocessing of reusable resident medical equipment.

Review of the Centers for Disease Control and Prevention (CDC) document titled, Clinical Safety: Hand Hygiene for Healthcare Workers, recommends hand hygiene be performed before touching a patient, before moving from a soiled body part to a clean body part on the same resident, after touching a resident or their surroundings, after any contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.

<Standard Precautions>

>Hall A<

Observation of Hall A for the lunch meal on 01/22/2025 showed the following:

At 12:21 PM, Staff PP, Certified Nursing Assistant (CNA), delivered a lunch tray to the resident in room [ROOM NUMBER]/Bed A. Staff PP assisted the resident with positioning and moved the overbed table

before exiting the room without performing hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page118of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 At 12:23 PM, Staff PP retuned to the tray cart, and without performing hand hygiene obtained the tray for the resident in room [ROOM NUMBER]/Bed A and delivered it. Staff PP grabbed the bed control to elevate the Level of Harm - Minimal harm or head of the bed, handled the resident's bedding and then exited the room without performing hand hygiene. potential for actual harm Staff PP proceeded to the beverage cart and poured a cup of milk and coffee and delivered them to room [ROOM NUMBER] and again exited without performing hand hygiene. Residents Affected - Many At 12:25 PM, Staff PP and Staff Y, CNA, entered room [ROOM NUMBER] and approached Resident 69, who was on EBP. Without applying gloves or gowns, Staff PP and Staff Y proceeded to pull back the resident's bedding, grabbed the draw sheet and boosted the resident up in bed. They then used the bed control to elevate the head of the bed, touched the privacy curtains and positioned the overbed table. Once completed, both Staff PP and Y exited the room without performing hand hygiene.

At 12:31 PM, Staff Y entered room [ROOM NUMBER] to pick up a breakfast tray and exited the room and placed the tray on the tray cart. Staff Y, without performing hand hygiene then entered room [ROOM NUMBER].

>Hall B<

During a dining observation of Hall B on 01/22/2025, Staff Z was observed to miss several opportunities for hand hygiene as documented below:

At 12:24 PM, Staff Z passed a lunch tray to the resident in room [ROOM NUMBER]/Bed B, touched the privacy curtain in the room, and did not use hand sanitizer before passing the next tray to bed A.

At 12:27 PM, after Staff Z passed the lunch tray to the resident in room [ROOM NUMBER]/Bed A, staff Z touched their privacy curtain and did not use hand sanitizer when they walked out of the room.

At 12:30 PM, Staff Z delivered a tray to resident in room [ROOM NUMBER]/Bed C, touched the resident's curtain, and did not hand sanitize.

At 12:32 PM, Staff Z delivered a tray to room [ROOM NUMBER], helped set up the resident's tray, did not complete hand hygiene when leaving the room, and then went into room [ROOM NUMBER] to assist a resident.

At 12:39 PM, Staff Z delivered a tray to room [ROOM NUMBER], did not complete hand hygiene afterwards, then went out of the room and got salt and pepper packets, went back into the room, and did not complete hand hygiene.

>Hall C<

During a dining observation of Hall C on 01/22/2025 from 12:33 PM to 12:42 PM, Staff KK, CNA, was observed to miss opportunities for hand hygiene, and did not wear PPE while in a contact precautions room (requiring gown and glove usage upon entry into room) as documented below:

At 12:33 PM, Staff KK assisted room [ROOM NUMBER]/Bed B, (did not complete hand hygiene) then went and helped room [ROOM NUMBER]/Bed A, did not complete hand hygiene and then proceeded to go into

the dining room area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page119of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 At 12:38 PM, Staff KK was observed leaving room [ROOM NUMBER], which had a contact room sign (signage did not indicate which resident it was for), Staff KK did not hand sanitize after opening/closing the Level of Harm - Minimal harm or door, then touched tea container on beverages cart in the hallway. potential for actual harm At 12:39 PM, Staff KK knocked on room [ROOM NUMBER], entered with the tea, did not don (put on) any Residents Affected - Many PPE (gloves, gown, etc.), did not hand sanitize after leaving room and then moved on to the next beverage

on the hall cart.

At 12:41 PM, Staff KK hand sanitized, poured coffee, knocked on room [ROOM NUMBER]s' door, assisted Bed 21A without PPE, and hand sanitized on the way out.

At 12:42 PM, Staff KK knocked on door for room [ROOM NUMBER]/Bed B, did not don PPE, brought in the meal tray and then left the room. Staff KK did not hand sanitize and then touched items on the beverage cart, poured milk into a cup, put lids on cups and brought them into room [ROOM NUMBER] without donning PPE.

>Hall D<

During a dining observation of Hall D on 01/23/2025 at 12:43 PM, Staff AA, CNA, was seen passing food trays to residents on Hall D with the following missed opportunities for hand hygiene:

Staff AA took a tray from the food cart and brought it to room [ROOM NUMBER], put the tray on tray table, moved pillows off of the tray table and dropped a pillow on the floor, picked the pillow off of the floor and put

it on a nearby walker seat, exited the room without performing hand hygiene and went back to the food cart and picked up a tray to take to room [ROOM NUMBER].

Staff AA then went to room [ROOM NUMBER] and put a food tray on the tray table, moved a cup that was already on the table and was half empty with a clear fluid in it and exited the room without performing hand hygiene. Staff AA then went back to the food cart and took a food tray out of the cart and took it to room [ROOM NUMBER] and put the food tray on a side table, moved a bedside table closer to the resident, and opened a drawer on a side table. Staff AA then exited the room without performing hand hygiene and went to hydration station in the hallway where they poured juice into cup and took it back to room [ROOM NUMBER] where Staff AA entered the room without performing hand hygiene and then removed the paper from drinking straw, touched the straw and put in the resident's cup, assisted resident with drinking from straw, touched side table, put a sandwich on the tray, moved a table closer to resident and then exited the room without completing hand hygiene.

Staff AA then went back to food cart and shut the door to the food cart, went back to hydration station, poured juice, and then brought the juice to the food cart and put juice on a food tray. Staff AA then took the tray to room [ROOM NUMBER] and delivered to the bedside table, no hand hygiene noted upon exiting the room and then went back to hydration station to retrieve two milk cartons, went back to room [ROOM NUMBER] to deliver milk, no hand hygiene upon entering or exiting the room, then went back to hydration cart and poured juice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page120of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 At 1:02 PM, Staff AA was observed getting a food tray from the food cart and bringing it to room [ROOM NUMBER], and put the food tray on the tray table, then rubbed a resident's shoulder, and exited the room Level of Harm - Minimal harm or without performing hand hygiene. Staff AA then shut the food cart door and then pulled gloves from a potential for actual harm personal protective equipment cart outside of room [ROOM NUMBER], no hand hygiene was observed

before Staff AA put on one glove, picked up a water bottle from the floor with the ungloved hand, no hand Residents Affected - Many hygiene, and put on second glove and went into room [ROOM NUMBER] again and pushed a resident in a wheelchair into the bathroom.

During an interview on 01/31/2025 at 3:00 PM, when asked about multiple observations of lack of hand hygiene while staff provided care and delivered meal trays, Staff L, Infection Preventionist (IP) said her expectation was for staff to perform hand hygiene during food tray pass and that not doing so did not meet her expectations.

<Enhanced Barrier Precautions>

Review of the facility policy titled, Enhanced Barrier Precautions, undated, described EBP should be implemented for preventing the transmission of multidrug-resistant organisms (MDROs). EBPs were the use of gown and gloves for high-contact resident care activities. Residents with wounds or indwelling (remaining

in the body until removed) medical devices were considered at risk of MDRO acquisition.

This policy stated, Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Examples were provided of wounds that required EBP, including chronic wounds, pressure ulcers, foot ulcers, and unhealed surgical wounds. Examples of indwelling medical devices that required EBP were central lines, hemodialysis catheters, and feeding tubes. High-contact resident care activities included examples of dressing, bathing, transferring, and providing hygiene care.

Review of the CDC document titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, provided guidance for isolation signage, Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure Precautions are followed.

EBP findings included:

A. Lack of consistent understanding by staff of understanding the orange sticker system for indicating EBP. No additional signage for EBP outside of sticker system. The facility did not follow its policy or CDC recommendations for appropriate signage.

B. Residents were missing EBP stickers/signage when they should have been on EBP

C. Lack of gown usage by staff during resident care activities for residents on EBP

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page121of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 On 01/23/2025 at 1:49 PM, when asked how staff knew what the orange stickers (stickers that were on the name plates outside residents' doors) indicated, Staff L said the orange stickers identified residents that Level of Harm - Minimal harm or required EBP. Staff L said the facility had cards with a key that explained the stickers that were on the doors. potential for actual harm Staff L said the stickers were present when she started her position as the Infection Preventionist, and she did not know what they meant at the time, so she developed a card with explanation for agency nurses. Residents Affected - Many At 2:18 PM, Staff AA, CNA, when asked what the orange sticker on a resident' s name plate on the door indicated, Staff AA said, I am not sure. When asked if a resident had a catheter bag what type of precautions would she take when emptying the bag, Staff AA said she would wear gloves, and that was all.

During a phone interview on 01/28/2025 at 9:16 AM, when asked how the facility manages residents who were colonized with MDROs, Staff L, IP said it would be classified under EBP and any indwelling device or wound care required staff to gown and if there were a potential for splashing then staff would be required to wear eyewear. Staff L said a lot of the facility staff did not understand EBP, but nurses and staff were being re-educated on it.

1) Hall A staff were interviewed on residents on EBP.

On 01/22/2025 at 10:58 AM, when asked if any residents were on any type of TBPs, Staff S, Registered Nurse (RN), stated, No. When asked why there were three personal protective equipment (PPE) kits in the hallway but no signage indicating what residents the kits were for, Staff S, RN, explained they were there just

in case someone needed access to PPE and there was no signage because no current residents were on precautions.

At 12:22 PM, a key for the facility's sticker system was requested and provided. Review of the key showed

an orange dot next to a resident's name meant they were on EBP.

On 01/22/2025 at 12:25 PM, observation of the name plates on Hall A showed the following residents had an orange dot sticker next to their name indicating they were on EBP:

-Resident 64

-Resident 61

-Resident 69

-Resident 55

-Resident 42

-Resident 324

-Resident 12

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page122of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 On 01/23/2025 at 12:45 PM, when asked if there were any residents on the hall that were on precautions, Staff QQ, CNA, stated, No, not on this hall. When asked what the orange dot next to Resident 42's name Level of Harm - Minimal harm or (who's room was on Hall A) meant, Staff QQ stated, It means [Resident 42] is on thickened liquids. potential for actual harm 2) Hall C staff were interviewed on residents on EBP. Residents Affected - Many

During an observation 01/23/2025 at 12:22 PM, room [ROOM NUMBER] had three listed residents outside of

the door. Resident 71 was observed to have an orange dot next to their name, no orange dot was observed next to the other resident names (Resident 45 was missing an orange dot).

At 12:38 PM, Staff BB, RN, said this was their first day on the unit. When asked who was on EBP and for what, Staff BB pointed at an orange dot for Resident 71 and said it was for a feeding tube. No other residents

on the hall were identified. When asked when a resident should be placed on EBP, Staff BB said it should be initiated on admission, when the resident has a suprapubic catheter, feeding tube, or any opening/body cavity.

At12:52 PM, Staff HH, CNA, said they were very familiar with Hall C. When asked who was on EBP precautions, Staff HH said Resident 45 possibly was, because of their wound on their back. Staff HH said no one else was on EBP. When asked when EBP should be implemented, Staff HH said for catheters, colostomies, and wounds. Staff HH said you should wear PPE for residents on EBP anytime you provide care to the resident.

3) Resident 45 should have been on EBP for a wound. No signage or sticker for EBP was noted on the door

during an observation on 01/23/2025 at 12:22 PM. Staff HH, CNA, had identified Resident 45, in the above interview, as possibly being on EBP for a wound.

During an observation on 01/23/2025 at 1:09 PM, Staff BB, RN, and Staff HH, CNA, turned Resident 45 to examine their back wound. The dressing that was lifted off was observed to have drainage on the inside of

the dressing, with the site appearing reddened and raw. Neither staff wore gowns for this high contact resident care activity.

During an observation on 01/24/2025 at 1:53 PM, no EBP sticker or signage was seen next to Resident 45's name outside of their door.

During an interview on 01/28/2025 at 12:29 PM, Staff JJ, LPN, said Resident 45 recently had a wound that opened back up, that they should have had the resident on EBP, and they would put Resident 45 on EBP.

4) Resident 324 was observed on 01/27/2025 at 7:47 AM, with an orange sticker (indicating EBP) next to their name outside of their door, with no PPE cart located immediately outside of their door.

At 7:49 AM, Staff II, a contracted phlebotomy technician was observed entering Resident 324's room. Staff II did not wear a gown while caring for Resident 324.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page123of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 At 7:58 AM, Staff II said isolation precautions were not explained to them, and they were not told about the EBP orange dot sticker system. Staff II said that unless they saw a sign on a door, they would not know the Level of Harm - Minimal harm or resident's precautions. Staff II said they used signage to know what PPE to put on, and that they did not see potential for actual harm a PPE cart. Staff II reported they had just drawn blood for Resident 324.

Residents Affected - Many 5) Resident 4 was observed on 01/23/2025 at 9:06 AM, with an orange sticker (indicating EBP) next to their name outside of their room.

During an observation and interview on 01/23/2025 at 9:09 AM, Staff Y, CNA, said she was assisting Staff X, CNA, with resident care for Resident 4. Staff Y, when asked when do you put on PPE when caring for Resident 4, said only when performing catheter care do we use PPE. Staff Y was asked if she was providing resident care and said yes and said she was only wearing gloves.

At 9:12 AM, when asked why Resident 4 had an orange dot by their name outside the room, Staff X, CNA said they only knew cares in pairs, and were not sure why Resident 4 had an orange dot by their name. When asked when do you put on PPE for Resident 4, Staff X said, I think for catheter care. Staff X said she was providing catheter care and that she was only wearing gloves.

On 01/31/2025 at 3:00 PM, Staff L, IP, said when a resident was on EBP she would expect staff to wear a gown and gloves when providing contact care related to the device.

6) Resident 7 admitted to the facility on [DATE REDACTED]. The Quarterly Minimum Data Set, (MDS, an assessment tool), dated 11/05/2024, showed Resident 7 had one Stage 2 pressure ulcer (PU, injury to the skin and underlying tissue resulting from prolonged pressure on the skin), one Stage 4 PU, and had Moisture Associated Skin Damage. Resident 7 was on EBP for wounds, a suprapubic indwelling catheter and had a MDRO.

During an observation of wound care on 01/22/2025 at 2:48 PM Staff BB, RN, was observed providing wound care to Resident 7 without a gown.

At 3:03 PM, when asked how they were aware that a resident was on EBP, Staff BB said if they had an opening in their body like a catheter or something, then they would have an orange dot (sticker). When asked what type of PPE should be worn for someone on EBP, Staff BB said gloves, mask, and gown. When asked why they did not wear those when providing wound care to Resident 7 who was on EBP, Staff BB said, I need a bigger sign, I should have gowned up.

7) Resident 29 admitted to the facility 07/27/2023. The Quarterly MDS, dated [DATE REDACTED], showed Resident 29 had an indwelling urinary catheter (requiring EBP).

During an observation on 01/24/2025 at 1:54 PM, Staff LL, RN, changed a catheter bag for Resident 29 without wearing a gown for the procedure.

During an interview on 01/24/2025 at 1:54 PM, Staff LL, RN, when asked what PPE is used for a resident on EBP, said gloves and gown should be worn. When Staff LL was asked if she should have done this for Resident 29's catheter bag change, she said, yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page124of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 During an interview on 01/31/2025 at 3:00 PM, when asked what her expectations were for when staff should wear PPE Staff L, IP said for any medical indwelling device they should wear gown, gloves, and potentially a Level of Harm - Minimal harm or mask. Staff L said during any close contact related to the care for the reason for which they were on EBP, potential for actual harm staff should both glove and gown. When it was explained to Staff L, that there were multiple observations such as wound care, catheter care and medications being given through a feeding tube without staff wearing Residents Affected - Many gowns for residents on EBP, along with interviews showing that staff and outside contractors did not know what the orange stickers indicated and staff/contractors were observed not following EBP precautions with orange stickers on the door, Staff L said, none of these issues met her expectations. When reviewing the facility EBP policy with Staff L, which documents that signage should be posted outside of the room indicating type of precautions, required PPE, and high-contact resident care activities that require use of gown and gloves, Staff L said, that the orange sticker system currently in use did not meet the facilities policy standards.

During an interview on 02/04/2025 at 11:13 AM, Staff B, DNS, said their expectation was for staff to implement precautions with EBP.

<Outbreak Surveillance/Transmission Based Precautions>

Review of the facility policy titled, Infection Outbreak Response and Investigation, dated 04/27/2023, described Outbreak as the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. The policy further documented, Implementation of infection control measures: a. Symptomatic residents will be considered potentially infected, assessed for immediate needs, and placed on empiric precautions while awaiting physician orders d. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism.

Review of the Case Report Worksheet (a tracking worksheet used for communicable disease tracking) for

the GI outbreak showed staff first had symptoms of vomiting and/or diarrhea on 01/09/2025, and residents became symptomatic with vomiting and/or diarrhea starting on 01/13/2025, the majority of the symptomatic residents were on Hall D.

On 01/23/2025 at 3:06 PM, Staff L, IP said, the outbreak monitoring ends tomorrow, (01/24/2025), that is was officially 4 days as of tomorrow.

Review of a new GI outbreak worksheet, received 02/05/2025, showed symptom onset date was 01/24/2025 through 02/04/2025.

The 3 residents reviewed were all from Hall C.

1) Resident 53 was admitted to the facility on [DATE REDACTED], and was on Hall C.

During an observation on 01/22/2025 at 10:11 AM, Resident 53 said, I have the flu. Resident 53 was observed with their arm draped over their face, and said they were not feeling good and did not want to talk. There was no signage outside of Resident 53's room for any kind of TBP.

During an interview on 01/23/2025 at 10:45 AM, Staff SS, CNA, said Resident 53 had been saying they were sick and did not have an appetite.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page125of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 During an interview on 01/23/2025 at 10:46 AM, Resident 53 said they were feeling a little bit better that day. Resident 53 reported they threw up a little, had zero appetite, were achy, and had horrible headaches. Level of Harm - Minimal harm or Resident 53 said that although they normally got headaches from having high blood pressure, they could tell potential for actual harm the flu [was] triggering it this time.

Residents Affected - Many During an interview on 01/23/2025 at 10:58 AM, Staff SS, CNA, said Resident 53 had reported not feeling well for the last few days, and Resident 53 had reported it to the nurse that they were not feeling good.

During an observation at 01/23/2025 at 11:00 AM, no signage or sticker for precautions were seen outside of Resident 53's door.

During an interview on 01/23/2025 at 11:15 AM, when asked about Resident 53's illness, Staff BB, RN, said that he was not told about any symptoms in report.

At 12:25 PM, Staff BB followed up and reported they had given Resident 53 Tylenol.

Review of the progress note from 01/23/2025 at 11:42 AM, showed Resident 53 reports feeling poorly, states one episode of emesis [vomit] earlier.

Review of the IP note from 01/23/2025 at 2:31 PM, showed Staff L, IP, documented Writer went to assess resident to clarify confusion about resident reporting symptoms. In attempt to assess resident he has already left the facility for the day, at this time it does not appear to be concerns of GI with resident leaving and following the trend with DOH [Department of Health], it reasonable to suspect resident does not meet the criteria at this time.

During an interview on 01/24/2025 at 2:00 PM, Resident 53 said they threw up overnight but had not vomited that day. Resident 53 was observed without a mask in the hallway and then entered their room.

During an interview on 01/27/2025 at 11:45 AM, Resident 53 said they had vomited a couple times over the weekend, but none that day.

On 01/27/2025 at 3:00 PM, Staff L, IP, reported the facility had been out of GI outbreak status since Friday (01/24/2025).

During an observation on 01/27/2025 at 3:19 PM, Resident 53 was observed without a mask on in the dining room with other residents around.

During an interview on 02/03/2025 at 3:19 PM, Staff L, IP, when asked if the nurse documenting Resident 53 was feeling poorly and had vomited, was factored into their decision to leave Resident 53 off the GI symptom list, Staff L said as best as I can, I was on a cart and was unable to check. When I went in, he had already left to go to the store. Staff L also added that Resident 53 was safe with his mask.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page126of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 During an interview on 02/04/2025 at 11:10 AM, when the timeline of symptoms being reported by Resident 53 were reviewed, Staff B, DNS said Resident 53 did have symptoms, whether or not it was related to high Level of Harm - Minimal harm or blood pressure or something else, they would have expected staff to have told the charge nurse, to have potential for actual harm notified the RCMs/IP/DNS, and to have put up precaution signs immediately. Staff B acknowledged the risk Resident 53 had by going out into the community daily. When asked if it met expectations that they were not Residents Affected - Many assessed in person for the IP progress note, Staff B said this did not meet expectations, that they would expect and interview and/or observation of the resident. Staff B said that Resident 53 was alert and oriented and could answer when symptoms occurred.

2) Resident 23 was admitted to the facility on [DATE REDACTED] and was on Hall C.

During an observation and interview on 01/27/2025 at 2:21 PM, Resident 23 was seen with a container on their belly. Resident 23 said it was for vomiting, that they threw up two times that day and four times the previous day. Resident 23 reported they also had a headache, stomachache, and could not eat much. Resident 23 said, I assumed it was a flu because I was told it was going around. When asked if they were also having diarrhea, Resident 23 said yes and added they had had diarrhea for three days. There was no signage for precautions outside of Resident 23's room.

During an interview on 01/27/2025 at 2:27 PM, Staff RR, CNA, said Resident 23 had been vomiting, which started the previous day. Staff RR said Resident 23 was vomiting continuously until they left their shift. When asked if Resident 23 was having diarrhea, Staff RR said yes and that they had helped Resident 23 with a shower the previous day and she had more diarrhea then. Staff RR said, we had a flu outbreak a little while ago, not sure if it is connected. When asked about PPE usage for any of those symptoms, with there being no signage on the door being mentioned, Staff RR said Resident 23 did not have a fever so they would not be wearing a gown. When asked if the resident receiving Tylenol could mask a fever, Staff RR said possibly, but they were unaware of what medications Resident 23 was on.

During an interview on 01/27/2025 at 2:43 PM, Staff JJ, LPN, said Resident 23 was having nausea, vomiting, and loose stools. Staff JJ said they had received in report that it happened through the night. Staff JJ said Resident 23 vomited after lunch and had receiving Tylenol that morning for report of a headache. When asked if Resident 23 required additional PPE be worn, Staff JJ said they had notified the Staff L, IP, twice that day, once when they got on their shift and once after the vomiting after lunch.

During an observation on 01/27/2025 at 3:22 PM, there was still no signage for PPE outside of Resident 23's room. Staff RR was seen going into room without PPE on.

During an interview on 02/04/2025 at 11:13 AM, Staff B, DNS, when asked if it met expectations that Resident 23 had gastrointestinal symptoms and staff did not implement any precautions initially/at the start of symptoms, said no that did not meet expectations, and that precautions should have been taken at the beginning of symptoms.

3) Resident 455 was on Hall C.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page127of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 On 02/03/2025 at 2:20 PM, Staff MM, Housekeeping was observed coming to the threshold of Resident 455's door and announced to Staff NN, CNA, that Resident 455 was throwing up again. Observation of the Level of Harm - Minimal harm or door showed there was no signage to indicate Transmission Based Precautions (TBP) were in place. Staff potential for actual harm NN then entered the room with mask and gloves, but no gown or face shield.

Residents Affected - Many At 2:30 PM, Staff EE, LPN, said Resident 455 had started vomiting that day, after lunch time. Staff EE said

she was told by a CNA that the resident was throwing up, and that Staff EE had given the resident a medication for dizziness at that time. Staff EE said she would check the resident's vital signs again because there was an infection going around Hall C and she would put the resident on TBP. Staff EE said she would check with the Infection Preventionist about implementing TBP for Resident 455.

At 3:49 PM, Staff NN, CNA said when a resident was vomiting, she would use gown, gloves and mask. When asked why she didn't wear a gown when going into the room where Resident 455 was vomiting, she said she didn't wear a gown because the room wasn't on special precautions (TBP), and she didn't see a sign, so she didn't put a gown on.

At 3:54 PM, when asked why Resident 455 did not have a TBP sign up, Staff EE, LPN said the RCM said to not put Resident 455 on precautions (TBP) until the roommate started having symptoms, then to put up the precautions sign, because Resident 455 had a history of nausea and vomiting.

On 02/05/2025 at 2:09 PM, Staff L, IP said in regards to Resident 455 vomiting and her room being on Hall C, where many residents were experiencing gastrointestinal (GI) outbreak symptoms (vomiting and/or diarrhea), yet Resident 455 was not put on TBP said, the RCM had assessed Resident 455 and since Resident 455 had admitted with the same symptoms, it was ruled out to not be part of the GI outbreak symptoms, and Resident 455's roommate had not exhibited any symptoms to indicate otherwise.

At 2:40 PM, Staff B, DNS, said for a resident who was vomiting, that anyone entering the room should have gown and gloves, and since it was coming out of the mouth, a face shield as well. Staff B said if a resident was vomiting, TBP should be put in place. When asked about Hall C having a GI outbreak, and Resident 455 experiencing a vomiting episode but not being placed on TBP due to a history of vomiting, Staff B said she would still expect resident 455 to have been placed on TBP.

<Cross Contamination>

>Wound Care<

Resident 7 admitted to the facility on [DATE REDACTED]. The Quarterly MDS, dated [DATE REDACTED], showed Resident 7 was cognitively intact, and had one Stage 2 pressure ulcer (PU, injury to the skin and underlying tissue resulting from prolonged pressure on the skin), one Stage 4 PU, and had Moisture Associated Skin Damage. Resident 7 was on EBP for wounds, a suprapubic indwelling catheter, and for a MDRO.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page128of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0880 During an observation of wound care on 01/22/2025 at 2:48 PM, Staff BB, RN, was observed providing wound care to Resident 7 without a gown. Staff BB cleansed a wound perimeter with gauze, adjusted Level of Harm - Minimal harm or Resident 7's body with the same gloves on, pulled out a pad that was under Resident 7's body, then rolled potential for actual harm the pad up and tucked it under the resident. Staff BB then adjusted Resident 7 in bed, removed their gloves without performing hand hygiene, and put on new gloves. Staff BB then grabbed gauze and a bottle of Residents Affected - Many wound cleanser, sprayed the gauze with wound cleanser, and put the gauze and wound cleanser on bedside table. Staff BB then remov

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page129of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 50392 potential for actual harm Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Residents Affected - Few Program (ASP) for three of three months (October 2024, November 2024 and December 2023) reviewed.

This failure placed residents at risk for adverse outcomes associated with inappropriate and/or unnecessary use of antibiotics, including for Multi Drug Resistant Organisms (MDRO: germs that are resistant to many antibiotics), and a diminished quality of life.

Findings included .

On 02/05/2025 at 2:09 PM, when asked which residents should be included in the Antibiotic Line Listing (a list that tracks antibiotic use, patterns, or infection cases to track trends and identify inappropriate use of antibiotics) Staff L, Infection Preventionist, said any resident who was on antibiotics should be on the Antibiotic Line Listing. When Staff L was made aware that Resident 32, who had been taking antibiotics since 10/2023 but was not found on the 10/2024, 11/2024, or 12/2024 Antibiotic Line Listing, Staff L said she did not track indefinite antibiotics (antibiotics that are prescribed for long term use, without an estimated end date) on the Antibiotic Line Listing.

At 2:40 PM, Staff B, Director of Nursing Services, said for antibiotic stewardship her expectation was that someone who was taking antibiotics indefinitely, would be reviewed by the provider on a regular basis to make sure the antibiotics were used appropriately. Staff B said the whole case should be reviewed to rule out anything that would indicate need for discontinuation of the antibiotics or need for changes. When asked if residents that were taking antibiotics indefinitely should still be placed on the Antibiotic Line Listing, Staff B said to continue to monitor them, they should be included on the Antibiotic Line Listing.

Reference

F-F868 QAA Committee

The governing body failed to maintain a Quality Assessment and Assurance (QAA) committee that included

the Infection Preventionist (IP) and the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities.

On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, Staff A reviewed the QAPI/QAA required attendees for the past year of QAPI/QAA meetings. Staff

A said she had not yet attended a QPAI meeting, only due to time frame. Staff A acknowledged the missing required QAPI/QAA committee members.

QAPI meeting attendance sheet documented:

May 24th, 2024: No IP in attendance.

August 29th, 2024: No IP or Medical Director in attendance.

September 11th, 2024: No IP or Medical Director in attendance.

December 20th, 2024: No IP in attendance

Refer to

F-F880-Infection Prevention & Control

Reference WAC 388-97-1760(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page116of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 46793 potential for actual harm Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Residents Affected - Some (QAA) committee that included the Infection Preventionist (IP) and the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities. This failure detracted from the effectiveness of the QAA committee and placed residents at risk for quality deficiencies, adverse events, and diminished quality of life.

Findings included .

On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, Staff A reviewed the QAPI/QAA required attendees for the past year of QAPI/QAA meetings. QAPI meeting attendance sheet documented:

May 24th, 2024: No IP in attendance.

August 29th, 2024: No IP or Medical Director in attendance.

September 11th, 2024: No IP or Medical Director in attendance.

December 20th, 2024: No IP in attendance.

Staff A, Administrator, said they had only been in the facility since January 13th, 2025, so was unable to speak to last year's QAPI/QAA attendees. Staff A said she had not yet attended a QPAI meeting, only due to time frame. Staff A acknowledged the missing required QAPI/QAA committee members.

Reference

F-F881 Antibiotic Stewardship Program

The governing body failed to ensure systems and staff were in place to implement an effective Antibiotic Stewardship Program (ASP) for three of three months (October 2024, November 2024 and December 2023) reviewed.

Refer to

F-F887 Covid-19 Immunization

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page111of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0837 The governing body failed to ensure a system was in place for tracking and documenting staff COVID-19 vaccination status. Level of Harm - Minimal harm or potential for actual harm Reference WAC 388-97-1620 (2)(c)

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page112of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945 potential for actual harm Based on interview and record review, the facility failed to ensure the facility's binding arbitration agreements Residents Affected - Some (legal document that required the use of a third party to resolve disputes) included necessary wording of resident rights, and failed to explain to residents what a binding arbitration agreement was in a manner to allow them to understand, for 2 of 3 sampled residents (Residents 53 and 18) reviewed for binding arbitration agreements. This failure placed residents at risk for legal complications and a diminished quality of life.

Findings included .

The facility's blank Arbitration Agreement was reviewed on 01/27/2025 and found to be missing wording that:

1. The resident or their representative had the right to communicate with federal, state, or local officials such as federal or state surveyors, other federal or state health department employees and representative of the State Long Term Care Ombudsman

2. That a neutral arbitrator would be agreed upon by both parties

3. That the selection of a venue would be convenient to both parties

During an interview on 01/27/2025 at 1:08 PM, Staff U, Human Resources/Payroll, was asked questions about the binding arbitration agreement and Staff A, Administrator, was present. When asked where in the agreement that it said the resident/representative could communicate with federal, state, or local officials such as federal surveyors, other federal or state health department employees or the office of the state long term care ombudsman, Staff U said they had looked at the form and it did not show any contact numbers. When asked how the resident would know their right on making a mutual neutral arbitrator, Staff U said they did not see in the document where it would say on how to select one. When asked if there was any wording for the selection of venue that was convenient to both parties, Staff U said they did not see any wording.

At 01/27/2025 at 1:17 PM, Staff A, Administrator, when asked if the binding arbitration agreements were missing the wording just mentioned in the three above questions, said yes they should be listed.

1) Resident 53 was admitted to the facility on [DATE REDACTED]. The Admission Minimum Data Set Assessment (MDS), dated [DATE REDACTED], showed Resident 53 was cognitively intact, was able to make themself understood and was able to understand others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page113of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0847 During an interview on 01/27/2025 at 11:38 AM, Resident 53 said they were not sure they knew what a binding arbitration agreement was, they did not remember signing paperwork for this, and did not understand Level of Harm - Minimal harm or the arbitration process when disputes were to arise. When explained the arbitration process and asked if potential for actual harm they had understood that they were giving up the right to litigation in a court proceeding, Resident 53 said

they did not recall signing the agreement, that if they were aware or had read the fine print, that they would Residents Affected - Some never have signed the agreement. Resident 53 went on to say as an American, they never would have willingly signed away their rights.

2) Resident 18 was admitted to the facility on [DATE REDACTED]. The Quarterly MDS, dated [DATE REDACTED], showed Resident 18 was cognitively intact, was able to make themself understood and was able to understand others.

During an interview on 01/31/2025 at 2:06 PM, Resident 18 knew they had signed a binding arbitration agreement, but when asked about their understanding of what the process was when disputes were to arise, said they did not understand, the facility did not explain this, and they had signed the contract in good faith. Resident 18 said it was not explained to them that they could not sue the facility, that it was not explained that it was optional to sign the agreement (not as a condition of admission/remaining in facility), and did not know they could have terminated or withdrawn the agreement 30 days after signing.

During an interview on 01/31/2025 at 2:26 PM, Staff A, Administrator, when asked if it met expectations that two residents reported they did not know they were signing away their right to be able to sue the facility, said no it did not meet expectations, and their expectation was for residents to be aware of their rights.

No associated WAC

.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page114of131 505254 Department of Health & Human Services Printed: 09/09/2025 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 02/06/2025

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 46793 potential for actual harm Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Residents Affected - Many Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Findings included .

On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, when asked if they had reviewed the [NAME] report (a report with previously cited deficiencies) to identify any repeat deficiencies that needed to be addressed, Staff A, Administrator, said no, they had only been in the facility since January 13th 2025, so was unable to speak to last year's survey. Staff A said she had not yet attended a QAPI meeting, only due to being recently hired.

Refer to the following citations identified during past 4 surveys which were identified and not addressed or had ineffective plans of correction to sustain correction by the QAPI program which led to repeated deficiencies, pattern or widespread of deficiencies, and a pattern of harm (D = Isolated, E = Pattern, F = Widespread, and H = Pattern of harm). Staff A reviewed the [NAME] report and acknowledged the following repeat deficiencies:

Refer to