Avalon Health & Rehabilitation Center - Pasco

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

agency-contracted nurse, employed by the facility. Their first day providing unsupervised care and services to residents was 11/02/2025. Record review of the November 2025 and December 2025 staffing schedule showed Staff G worked six shifts in November and three shifts in December, unsupervised and without a valid BGC. During a concurrent observation and interview on 12/23/2025 at 11:52 PM, Staff B, Scheduling Coordinator, presented a BGC authorization form that was completed by Staff C and dated 07/08/2024.

Staff B stated they thought that was the actual BGC. After reviewing the form, Staff B stated that was not

the completed BGC. They stated they were aware that all staff were required to have an approved BGC prior to working unsupervised with residents, including agency-contracted staff. They stated, I missed this and I own it (the failure to complete the BGC). During a concurrent follow-up observation and interview on 12/23/2025 at 12:14 PM, Staff B stated there were an additional five agency licensed nurses working at the facility. Staff B presented an additional four BGC authorization forms for Staff D, dated 09/15/2025, Staff E, dated 12/09/2025, Staff F, dated 08/21/2025, and Staff G, dated 10/03/1982 (Staff A, Administrator clarified

the date to be 10/03/2025 on 12/23/2025 at 12:44 PM). Staff B stated the BGC authorization forms were

the same as the other (Staff C's) and all staff needed to have the required BGC prior to working. During an

interview on 12/23/2025 at 3:03 PM, Staff A stated the process for screening potential staff included completing a BGC with clearance, prior to the new hire working unsupervised with residents. They stated if

a secondary review was indicated, it also needed to be completed prior to their start date. Staff B stated the process was not followed for BGCs. Reference: WAC 388-97-0640(2)(a)(b)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Health & Rehabilitation Center - Pasco

2004 N 22nd Avenue Pasco, WA 99301

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Milk of Magnesia.There was no documentation that showed the clear indication as to when to initiate the Milk of Magnesia order or in which order the medications would be administered. Record review of Resident 2's December 2025 MAR, showed there was no documentation that a bowel medication had been administered between 12/15/2025 and 12/20/2025, despite the resident's bowel record showing a lack of bowel movement for five days. During an interview on 12/23/2025 at 10:03 AM, Staff H, Nursing Assistant, stated they charted (documented) when a resident had a bowel movement in the medical record. Staff H stated they did not tell the nurses when residents did not have bowel movements, they only charted in the record. During an interview on 12/23/2025 at 10:07 AM, Staff B, Registered Nurse (RN), stated they checked the bowel movement list at the start of their shift. They stated they received an alert on their computer when a resident had gone for three days without a bowel movement. Staff B stated once a resident had gone three days without a bowel movement, they would start the bowel protocol. Staff B stated

the orders showed which medication to administer first and then they followed the protocol for additional medications. Staff B stated the bowel protocol was located at the nurse's station in the standing orders book. They stated if there was a concern that a resident was not having bowel movements, they would complete an assessment and document that. During an interview on 12/23/2025 at 10:37 AM, Staff I, RN, stated the process for monitoring bowel movements included reviewing the clinical dashboard (bowel movement list) at the start of their shift. They stated the system would alert staff after a resident had three days without a bowel movement. Staff I stated they would administer Milk of Magnesia (a medication used to relieve constipation), then the evening shift would follow the protocol. Staff I stated they used their own protocol/paper tracking system for bowel movements. They stated they also asked the alert/orientated residents about their bowel movements, and if a resident was not able to respond, they would do a bowel assessment and ask the NA's if the resident had a bowel movement. Staff I stated standing orders for the bowel protocol were entered into the system upon admission to the facility. Staff I stated there should be standing orders and/or a protocol in the standing orders notebook. An observation on 12/23/2025 at 10:29 AM, showed two notebooks at the nurse's station labeled Standing Orders. Review of the contents of the notebooks showed there were no standing orders or bowel protocol indicating which medications to use or when to initiate the medications. During an interview on 12/23/2025 at 3:03 PM, Staff A, Administrator, stated the facility should have a protocol that was clearly defined for bowel management that was signed by

the provider. Staff A agreed there was not a defined process/protocol for bowel management. Reference: WAC 388-97-1060(1)

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