Crestwood Health And Rehabilitation Center

F-F609

Reference WAC 388-97-0640 (6)(a)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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** 46793 potential for actual harm Based on interviews and record review, the facility failed to ensure the Minimum Data Sets (MDS), an Residents Affected - Few assessment tool, accurately reflected residents' health status and/or care needs for 1 of 35 sampled residents (Residents 32) reviewed for MDS accuracy. The failure to accurately assess residents nutritional needs, placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Findings included .

Resident 32 was admitted to the facility on [DATE REDACTED]. The annual Minimal Data Set, (an assessment tool), dated 05/21/2024, documented Resident 32 was cognitively intact. The MDS, selection K, for Resident 32 read, Yes, on a prescribed weight loss regimen.

On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said Resident 32 was not on a prescribed weight-loss regimen. Staff B said she would have to check with the MDS Coordinator to know why Resident 32 was checked as being on a weight-loss regimen.

At 2:26 PM, Staff E, Registered Dietitian, said Resident 32 was not a weight-loss regimen and Resident 32 had no calorie or diet restrictions.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46751

Residents Affected - Some Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident

Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the care plan for 2 of 5 residents (Resident 17 and 18) reviewed for PASRRs. This failure placed residents at risk for not receiving necessary mental health care and services.

Findings included .

<Resident 17>

Resident 17 was admitted to the facility on [DATE REDACTED] with multiple diagnoses. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 05/17/2024, documented the resident was severely cognitively impaired.

According to a Level 1 PASRR, dated 09/20/2023, Resident 17 had a Serious Mental Illness (SMI) of anxiety disorder (mental health condition), dementia (characterized symptoms affecting memory and social abilities) and mood disorders (characterized by persistant depressed mood or loss of interest in activities). Referal for

a Level 2 evaluation was indicated on the Level 1 PASRR.

Per facility documentation, the level 2 PASRR was not completed.

On 07/25/2024 at 9:55 AM, Staff F, Social Service Director (SSD), said he could not find documentation of

an invalidation request sent by fax. Staff F stated, the previous social services missed that. She never contacted them to follow up.

On 7/25/2024 at 2:43 PM, Staff B, Director of Nursing Services said it was her expectation to complete PASRRs in a timely manner. Staff B was unable to provide further documentation that a Level 2 PASRR had been completed.

46793

<Resident 18>

Resident 18 was admitted to the facility on [DATE REDACTED]. The quarterly, MDS, dated [DATE REDACTED], documented Resident 18 was cognitively intact.

Resident 18's admitting PASRR, dated 11/21/2023, documented no serious mental illness indicators. There were no other PASRR's in Resident 18's electronic health record (EHR). Resident 18 was prescribed an antidepressant for depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0644 On 07/25/2024 at 10:19 AM, Staff F, SSD, confirmed Resident 18's PASRR documented no serious mental illness indicators. Staff F said this should have been caught and a new PASRR should have been completed. Level of Harm - Minimal harm or potential for actual harm Reference WAC 388-97- 1915 (1-2)

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46793 potential for actual harm Based on observations, interview, and record review, the facility failed to ensure ongoing communication and Residents Affected - Few collaboration occurred with the dialysis (procedure to clean and filter waste from the blood) center for 1 of 1 sampled resident (Resident 32) reviewed for dialysis. These failures placed residents at risk for unidentified medical complications, adverse health outcomes, and unmet care needs.

Findings included .

The undated Dialysis Management (Hemodialysis) policy including the following directions:

1. Review the Dialysis Center Communication for pertinent information from the Dialysis Clinic and transcribe

the information into section II.B of the Dialysis Center Communication Records UDA (User Defined Assessment) in the EMR (Electronic Medical Record)

2. If original is not returned with resident, contact Dialysis Center

3. Retain the original document in the hard chart behind the assessment tab

4. Check vital signs upon return post-dialysis and per physician's orders

The Service Agreement for Northwest Kidney Centers, dated 02/2019, documented the medical management of facility's resident would be under the direction of the resident's attending physician. The facility would retain primary responsibility for the development and implementation of the resident's plan of care.

Resident 32 was admitted to the facility on [DATE REDACTED]. The Annual Minimal Data Set, (MDS, an assessment tool), date 05/21/2024, documented Resident 32 was cognitively intact. Resident 32 attended dialysis treatment three times a week on the following days: 07/05/2024, 07/08/2024, 07/10/2024, 07/12/2024, 07/15/2024, 07/19/2024, 07/22/2024 & 07/24/2024. Resident 32's EMR documented the last communication between the facility and dialysis center as 07/05/2024.

Resident 32's weights completed by the facility as followed:

07/21/2024 10:25 240.8 Lbs (pounds)

07/18/2024 12:43 264.0 Lbs

07/15/2024 12:35 263.9 Lbs

07/12/2024 08:42 263.9 Lbs

07/09/2024 09:39 262.4 Lbs

06/30/2024 08:18 262.4 Lbs

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0698 06/27/2024 10:42 262.1 Lbs

Level of Harm - Minimal harm or 06/24/2024 15:13 262.3 Lbs potential for actual harm Resident 32's post treatment dialysis records (from the dialysis center) showed Resident 19's weights as Residents Affected - Few followed:

07/05/2024 117.3 Kg (258.60223 lbs)

07/08/2024 117.1 Kg (258.16131 lbs)

07/10/2024 115.1 Kg (254.63391 lbs)

07/12/2024 114.3 Kg (251.98837 lbs)

07/15/2024 113.0 Kg (249.122 lbs)

07/19/2024 110.0 Kg (242.508 lbs)

07/22/2024 111.0 Kg (244.713 lbs)

07/24/2024 110.1 Kg (242.72895 lbs)

The above weights from the dialysis center showed a 7.3% weight loss in the previous 30 days and a 17.1% weight loss in the previous six months.

On 07/25/2024 at 1:28 PM, Staff E, Registered Dietitian, said nursing staff was responsible for obtaining the communication binder for the updated communication sheets regarding communication between the dialysis center and the facility. Staff E said the facility should not have been using the facility weights that were obtained and should have only been using the post-treatment dialysis weights from the dialysis center. Staff E said when weightloss was identified the facility would place the resident on alert to be discussed at the next interdisciplinary team meeting, for plan of care changes and recommendations. Staff E said the registered dietitian should have been doing weekly weight checks and check ins with the resident.

At 1:57 PM, Staff B, Director of Nursing Services, said medical records was responsible for obtaining all documentation for the dialysis center. Staff B said the dialysis facility was sending them once a week but due to a recent change in management they were now only sending them once a month. When asked if the communication binder had been obtained weekly, would the weights have been identified sooner, Staff B, said, yes, we would have had a better understanding of the weight loss.

At 2:05 PM, Staff G, Medical Records, said they were responsible for obtaining all dialysis records. Staff G said there had been no communication with the dialysis since 07/05/2024.

Reference WAC 388-97-1900(1), (6) (a-c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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

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

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50488 Residents Affected - Few Based on observation, interview, and record review, the facility failed to assess and maintain safety of quarter bed rails for 1 of 4 sampled residents (Resident 3) reviewed for accidents. This failure placed the resident at risk of injury and a diminished quality of life.

Findings included .

Resident 3 was admitted to the facility on [DATE REDACTED]. The Annual Minimum Data Set (MDS), an assessment tool, dated 02/10/2024, documented the resident was cognitively intact and required supervision assistance with Activities of Daily Living (ADL's).

On 07/22/2024 at 11:14 AM, Resident 3 had a quarter rail attached to the right side of the bed. The rail was leaning away from the bed, and when tested , moved forwards and backwards and side to side. Resident 3 stated, It's been like that for a long time. I just pulled the commode against it so it doesn't move when I get up.

On 07/23/2024 at 3:12 PM, Staff H, Registered Nurse, said quarter rails should not move once attached so would not present a hazard. Staff H said if they did become loose, the aides would tell her and she would let maintenance know.

On 07/24/2024 at 10:15 AM, Staff I, Certified Nursing Assistant, was asked if she ever tested the bed rails and she said she did and could tighten them if they were loose. She was asked to test Resident 3's rail and stated, This is way too loose, Staff I attempted to tighten the rail but was unable. When asked if a loose rail could cause injury, she stated, yes, absolutely.

At 10:52 AM, Staff B, Director of Nursing, said nursing completed safety enabling assessments every quarter but did not test the devices. She said maintenance completes the testing and audits.

At 3:22 PM, Staff J, Maintenance Director, said they try to complete safety enabling device testing monthly but doesn't always get to them. He said they rely on nursing staff to tell them if a device needs to be adjusted.

Reference WAC 388-97-0230

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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

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

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 37044 Residents Affected - Some Based on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 1 of 1 medication room (East Medication) and 1 of 2 medication carts (East medication carts) observed. These failures placed residents at risk to receive incorrect and/or expired medications.

Findings included .

<East Medication Room>

Observation of the East Medication room on 07/26/2024 at 10:35 AM, with Staff C, Unit Manager (UM), revealed the following expired, opened and undated and/or improperly stored medication:

1) Resident 117 - a Novolin 70/30 insulin pen, was opened and undated. The manufacturer guidelines showed the insulin pen should be discarded 28 days after opening.

On 07/26/2024 at 10:39 AM, Staff C, UM, said because Resident 117's Novolin 70/30 flex pen was opened and undated and it needed to be discarded.

2) A Refrigerator Temperature Log located on the counter next to the medication refrigerator, directed staff to

record the medication refrigerators temperature twice daily to ensure it is maintained between 36 - 46 degrees Fahrenheit (F). If the temperature was not within range, staff were instructed to adjust the temperature and re-check in 30 minutes. If still out of range staff were to move items out of the refrigerator.

Review of the medication refrigerator temperature log for May, June and July 2024 showed:

May 2024: The AM and PM temperatures were recorded for only 1 of 31 days.

June 2024: The AM temperature was recorded for 3 of 30 days, and the PM temperature was recorded for 2 of 30 days.

July 2024: The AM and PM temperatures were recorded only once through 07/26/2024 (26 days).

On 07/26/2024 at 10:47 AM, Staff C, UM, said staff were expected to check and record the temperature of

the medication refrigerator twice a day as directed, but acknowledged they failed to do so.

<East Medication Cart>

Observation of the East medication cart on 07/26/2024 at 10:53 AM, with Staff C, UM, revealed the following expired and/or undated medications:

1) An opened and undated Wixela inhaler, for Resident 51.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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

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

F 0761 2) An opened and undated Wixela inhaler, for Resident 167.

Level of Harm - Minimal harm or 3) Nineteen expired cards of calcium acetate, for Resident 43. The individual cards had various expiration potential for actual harm dates, but all expired prior to 07/26/2024.

Residents Affected - Some Review of the manufacturer's recommendations for Wixela inhalers, showed the inhalers were good for one month after opening.

On 07/26/2024 at 10:56 AM, Staff C, UM, said facility staff should have dated Resident 51's and 167's Wixela inhalers when opened, and discarded Resident 43's nineteen expired cards of calcium acetate, but failed to do so.

Reference WAC 388-97-1300(1)(b)(ii), (c)(ii-v), 1300 (2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50488 potential for actual harm Based on observation, interview, and record review, the facility failed to provide prompt dental services for 1 Residents Affected - Few of 3 sampled residents (Resident 6), reviewed for dental services. This failure placed the resident at risk for unmet dental needs, nutritional compromise, and a diminished quality of life.

Findings included .

Resident 6 was admitted to the facility on [DATE REDACTED]. The Annual Minimum Data Set (MDS), an assessment tool, dated 05/29/2024, documented the resident was cognitively intact and needed extensive assist for Activities of Daily Living (ADL's).

On 07/22/2024 at 11:46 AM, Resident 6 stated, I have been waiting for some bottom dentures. He said his lack of lower dentures affected his ability to eat and to enjoy his food.

The facility Dental Policy, revised 12/30/2022, stated, the social services department will work to assist/and or coordinate services such as routine dental services. The procedure section stated, identify those residents who need routine services that include fitting dentures.

Dental care services documentation showed Resident 6 was visited on 11/22/2023 and on 05/24/2024 for hygiene visits. Recommendations included, wants a future lower partial or full denture when discharged .

A Social Services note, dated 01/19/2024, documented Resident 3 had hoped to return home to live with a brother who would provide care, but the brother was having health issues of his own. The note stated Resident 3, plans to stay with us for now.

On 07/24/2024 at 1:32 PM, Staff G, Medical Records, said she didn't know if any referral had been made for his lower dentures.

Reference WAC 388-97 -1060 (3)(j)(vii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37044 potential for actual harm Based on observation and interview, the facility failed to serve foods that were appetizing, palatable, and Residents Affected - Some served at the proper temperature for 5 of 7 (Residents 23, 18, 39, 116 and 61) sampled residents reviewed for dining. The failure to ensure meals were served at appropriate temperatures, with a good presentation, and that were palatable, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss, and a diminished quality of life.

Findings included .

<Resident Council Meeting>

On 07/25/2024 at 10:30 AM, during a Resident Council Meeting , residents expressed the following food quality concerns:

1) No hot items on the bistro menu

2) Hot food is cold and cold food is melted or warm. Example: ice cream is served melted

3) Failure to follow the menu, menu says one thing and that is not what is delivered on tray

4) Poor presentation - unable to determine what some foods are supposed to be, don't go the extra mile

5) Food is frequently unpalatable, the quiche was horrible last night, and the pizza is frequently rock hard.

6) Concerns about food are not being addressed, suggestions and likes/dislikes are not being followed.

7) Some residents receiving items on their trays that are listed allergies.

<Resident Interviews/Observations>

<Resident 18>

On 07/22/2024 at 2:30 PM, Resident 18 said the food comes out cold, that the scrambled eggs and bacon were cold and the only thing that was good were the salads.

<Resident 39>

On 07/22/2024 at 11:33 AM, Resident 39 said the food was not good, and the staff did not know how to cook. Resident 39 said the pizza was so hard it couldn't be cut with a knife. The resident indicated he loved ice cream, but the ice cream was never served frozen and by the time it was delivered it was soup.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0804 <Resident 116>

Level of Harm - Minimal harm or On 07/23/2024 at 9:16 AM, Resident 116's family member said they had attempted to eat the facility food the potential for actual harm day prior and the food was 'terrible' and the carrots weren't cooked and there had been a pile of noodles that were still hard/uncooked and a blob that they thought might have been spinach. Residents Affected - Some <Resident 61>

On 07/22/2024 at 2:10 PM, Resident 61 said the food was not good, it was served cold, and they only received one butter for four slices of toast.

<Resident 23>

On 07/22/2024 at 12:37 PM, Resident 23 said, most of the food is garbage and that's being polite. Resident 23 said the food was served ice cold. Resident 23 said sometimes the vegetables were al [NAME], but other times they were mush.

At 12:48 PM, Resident 23's lunch meal was delivered with a container of chocolate ice cream. When the container was opened a brown soupy liquid was observed. The ice cream was melted with exception of an approximately 1 x 1 inch small ball of frozen liquid in the middle.

Reference WAC 388-97-1100(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50392

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 (East Nurse, [NAME] Nurse and Prep)refrigerators reviewed for food service. These failures placed residents at risk for food-borne illness and a diminished quality of life.

Finding included .

Review of the April 2024, May 2024, June 2024, and July 2024 temperature logs for the [NAME] Nurse refrigerator, East Nurse refrigerator and Prep refrigerator, showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates:

<West Nurse refrigerator>

April 2024, AM, temperature readings:

1st 43F, 2nd 42F, 3rd 42F, 4th 42F, 6th 42F, 7th 42F, 8th 43F, 9th 42F, 10th 42F, 11th 42F, 13th 42F, 14th 43F, 15th 43F, 16th 42F, 17th 45F, 18th 42F, 19th 42F, 20th 45F, 21st 44F, 22nd 42F, 23rd 46F, 24th 49F, 25th 42F, 26th 43F, 28th 50F.

April 2024, PM, temperature readings:

6th 42F, 7th 42F, 8th 42F, 9th 42F, 15th 42F, 17th 45F, 18th 45F, 19th 46F, 20th 46F, 24th 45F, 25th 45F, 27th 49F.

May 2024, AM, temperature readings:

1st 42F, 2nd 43F, 3rd 42F, 5th 42F, 6th 43F, 7th 48F, 8th 42F, 9th 42F, 10th 42F, 11th 42F, 12th 42F, 13th 42F, 14th 49F, 15th 43F, 16th 43F, 17th 42F, 18th 42F, 19th 42F, 20th 42F, 23rd 43F, 24th 43F, 25th 43F.

May 2024, PM, temperature readings:

1st 59F, 2nd 43F, 3rd 50F, 4th 50F, 5th 40F, 6th 44F, 7th 44F, 8th 45F, 9th 50F, 10th 45F, 11th 45F, 12th 43F, 13th 50F, 14th 47F, 15th 49F, 17th 42F, 18th 48F, 19th 48F, 20th 42F, 21st 42F, 23rd 43F, 27th 42F, 28th 44F.

June 2024, AM, temperature readings:

1st 42F, 3rd 42F, 4th 43F, 6th 42F, 7th 42F, 8th 43F, 9th 42F, 10th 42F, 11th 45F, 12th 42F, 13th 42F, 14th 42F, 16th 43F, 17th 45F, 20th 42F, 21st 42F, 22nd 42F, 23rd 43F.

June 2024, PM, temperature readings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0812 1st 48F, 2nd 46F, 3rd 42F, 4th 42F, 10th 42F, 11th 42F, 12th 42F, 13th 42F, 14th 42F, 15th 42F, 20th 42F.

Level of Harm - Minimal harm or July 2024, AM, temperature readings: potential for actual harm 16th 42F, 17th 50F, 18th 42F, 22nd 42F. Residents Affected - Some July 2024, PM, temperature readings:

8th 43F, 9th 43F, 10th 45F, 16th 44F.

<East Nurse refrigerator>

April 2024, AM, temperature readings:

1st 42F, 5th 42F, 6th 42F, 7th 42F, 16th 42F, 19th 43F, 21st 43F, 26th 43F, 28th 42F.

April 2024, PM, temperature readings:

1st 42F, 14th 58F, 15th 45F, 16th 42F, 17th 42F, 24th 45F, 25th 45F, 27th 45F, 28th 50F.

May 2024, AM, temperature readings:

1st 43F, 2nd 43F, 3rd 43F, 4th 42F, 5th 42F, 6th 50F, 7th 43F, 8th 49F, 9th 43F, 10th 42F, 11th 45F, 12th 45F, 13th 50F, 14th 49F, 18th 42F, 19th 42F, 24th 42F, 27th 48F, 28th 42F, 29th 42F, 30th 42F, 31st 49F.

May 2024, PM, temperature readings:

3rd 48F, 4th 45F, 5th 45F, 6th 47F, 8th 49F, 9th 50F, 10th 45F, 11th 45F, 12th 50F, 13th 51F, 15th 49F, 16th 43F, 18th 45F, 19th 45F, 23rd 42F, 27th 45F.

June 2024, AM, temperature readings:

4th 42F, 5th 42F, 7th 42F, 8th 48F, 9th 42F, 10th 42F, 11th 45F, 12th 48F, 13th 42F, 14th 42F, 15th 48F, 20th 42F, 21st 49F, 24th 42F, 28th 42F, 30th 42F.

June 2024, PM, temperature readings:

1st 45F, 3rd 45F, 4th 45F, 5th 45F, 11th 45F, 12th 48F, 19th 49F, 20th 45F, 21st 45F, 22nd 45F, 23rd 45F.

July 2024, AM, temperature readings:

1st 49F, 2nd 42F, 3rd 42F, 5th 42F, 7th 51F, 8th 48F, 12th 42F, 14th 42F.

July 2024, PM, temperature readings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 0812 1st 42F, 2nd 49F, 6th 52F, 7th 48F, 8th 51F, 9th 51F, 13th 51F, 18th 42F, 19th 58F, 20th 42F.

Level of Harm - Minimal harm or <Prep refrigerator> potential for actual harm July 2024, AM, temperature readings: Residents Affected - Some 3rd 42F, 5th 42F, 6th 45F.

On 07/22/2024 at 10:52 AM, Staff H, Dietary Manager, said when temperatures were out of required ranges

they would recheck the temperature and document on the log if corrections made. When shown temperatures for the Prep refrigerator were over 41 degrees and lacked documentation of what was done about elevated temperatures, Staff H said there should have been documentation of what was done about it.

On 07/24/2024 at 2:31 PM, when asked who was responsible for obtaining temperature logs for the unit refrigerators, Staff H said she was.

Reference WAC 388-97-2980

.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 505185 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505185 B. Wing 07/26/2024

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

Olympic View Care 1116 E Lauridsen Boulevard Port Angeles, WA 98362

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 50392 potential for actual harm Based on observation and interview, the facility failed to provide proper infection prevention techniques for 1 Residents Affected - Few of 3 sampled residents (Resident 35) reviewed for pressure ulcer/injury. This failure put residents at risk for infection and a diminished quality of life.

Findings included .

On 07/23/2024 at 12:39 PM, Staff C, Registered Nurse, Unit Manager, and Staff G, Certified Nursing Assistant, Medical Records, began wound care for Resident 35. Staff C retrieved scissors from her pocket and began to cut Alginate (a wound care product) with the scissors.

At 1:02 PM, Staff C said that when she pulled her scissors out of her pocket, they were considered dirty, and

the scissors should have been cleaned before proceeding to use them during wound care.

On 07/24/2024 at 9:51 AM, Staff B, Director of Nursing Services, said it was not acceptable for equipment from staff pockets to be used for wound care.

Reference WAC 388-97-1320 (2)(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 505185