Crestwood Health And Rehabilitation Center

F-F553

Reference WAC 388-97-1020(1), (2)(a)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

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 services provided met Residents Affected - Few professional standards of practice for 2 of 32 residents (Residents 127 & 20). Facility staff's failure to administer medications in accordance with physician's orders, and to complete assessments and treatments as ordered placed residents at risk for ineffective treatment of disease processes, medication adverse side effects and other potential adverse health outcomes.

Findings included .

1) Resident 127 admitted to the facility on [DATE REDACTED] with orders for intravenous (IV) cefazolin (antibiotic) every eight hours at 8:00 AM, 4:00 PM and midnight. Review of Resident 127's Admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of pneumonia (infection in lungs) and sepsis (infection in blood), and received IV antibiotics via Peripherally Inserted Central Catheter (PICC - long, flexible, thin tube inserted into a vein in your arm, usually the upper arm, and threaded up to a larger vein near your heart).

Review of Resident 127's April and May 2025 Medication Administration Records (MAR) showed Resident 127's midnight dose of IV cefazolin was not consistently administered at the ordered time/intervals:

- On 04/25/2025 the midnight dose was administered at 2:53 AM, 3 hours late.

- On 04/27/2025 the midnight dose was administered at 6:27 AM, 6.5 hours late.

- On 04/28/2025 the midnight dose was administered at 5:31 AM, 5.5 hours late.

- On 04/30/2025 the midnight dose was administered at 5:35 AM, 5.5 hours late.

- On 05/02/2025 the midnight dose was administered at 4:50 AM, 5 hours late.

- On 05/05/2025 the midnight dose was administered at 4:23 AM, 4.5 hours late.

On 05/09/2025 at 11:33 AM, Staff C, Resident Care Manager (RCM), said facility nurses failed to administer Resident 127's IV cefazolin in accordance with the physician's order or professional standards of practice.

Review of the April and May 2025 MAR and TAR showed Resident 127 had an order to change the PICC dressing every 72 hours, with instruction to measure the external length catheter and resident's arm circumference with each dresing change. The MAR/TAR did not provide a place for staff to record the measurements.

Review of the Electronic Health Record (EHR) showed no PICC external catheter length or resident's arm circumference measurements were documented, upon admission or with the 72-hour dressing changes as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0658 The MAR/TAR showed facility nurses signed they measured the arm circumference and PICC external length with PICC dressing changes on 04/26/2025, 04/29/2025, 05/05/2025 and 05/08/2025 as ordered. Level of Harm - Minimal harm or potential for actual harm On 05/09/2025 at 11:25 AM, Staff C, Resident Care Manager, acknowledged there was no documentation to show staff measured Resident 127's arm circumference and PICC line external length upon admission or Residents Affected - Few with the 72 hour PICC dressing changes. When asked if facility nurses erroneously signed for tasks they did not complete Staff C, RCM, said yes.

Resident 127 had an order to monitor IV insertion site for signs and symptoms of infection every shift.

Review of the April and May 2025 Treatment Administration Records (TAR) showed staff failed to sign they completed the task on 04/24/2025 at 6:00 AM; 04/26/2025 at 6:00 PM; 04/28/2025 at 6:00 AM; and 04/29/2025 at 6:00 PM.

Resident 127 had an order for oxygen at two liters per minute continuously via nasal canula to keep oxygen saturation greater than 92%.

Review of the April 2025 TAR showed staff failed to sign they administered the oxygen on 04/26/2025 evening shift; 04/29/2025 day shift; and 04/29/2025 evening shift.

Resident 127 had an order to check oxygen saturation every shift.

Review of the April 2025 TAR showed staff failed to check the resident's oxygen saturation on 04/26/2025 evening shift; 04/28/2025 day shift; and 04/29/2025 evening shift.

Review of Resident 127's May 2025 TAR showed Resident 127 had an order for staff to measure their upper arm circumference and the external length of their PICC upon admission and every 72 hours with the PICC dressing change.

Review of the May 2025 TAR showed staff failed to sign the task off as completed on 05/01/2025 and 05/08/2025. Staff did sign the task was completed on 05/05/2025, but review of the EHR showed no documentation of the resident's arm circumference PICC external length was present.

Resident 127 had an order to change their primary administration set (IV tubing) every 24 hours.

Review of the May 2025 TAR showed staff failed to sign the task off as completed on 05/03/2025, 05/04/2025 and

05/08/2025.

On 05/12/2025 at 3:41 PM, Staff C, RCM, said it was the expectation nurses administer medications and perform treatments as ordered by physician, and to only sign for tasks they completed.

42960

<Blanks on the MAR and TAR>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0658 3) Resident 20 was admitted to the facility on [DATE REDACTED] with multiple diagnosis including depression and atrial fibrillation (a common type of arrhythmia where the heart beats irregularly and often rapidly). The Quarterly Level of Harm - Minimal harm or MDS, dated [DATE REDACTED], documented Resident 20 was cognitively intact. potential for actual harm

A review of Resident 20's MAR and TAR for April 2025 showed the listed orders had blank boxes (no Residents Affected - Few documentation) on the dates and times below:

-High Calorie/High Protein Nectar Thick Liquids three times a day for supplement for healing on 04/13/2025, 04/15/2025, and 04/16/2025 at 2:00 PM.

-Eliquis two times a day on 04/13/2025, 04/15/2025, and 04/16/2025 at 2:00 PM.

-Monitor for Antidepressant Medication side effects every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM.

-Monitor for Antipsychotic Medication side effects every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM.

-Target Behavior: Insomnia document every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM.

- Target Behavior: Major Depressive Disorder document every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM.

On 05/09/2025 at 9:45 AM, Staff C, RCM said the blanks on the MAR/TAR meant it was not given, or it was not done, and it should be given and if not it should be documented why if there was a refusal of another reason.

On 05/12/2025 at 11:30 AM, Staff B, Director of Nursing said the blanks mean they were not documented on

the MAR or TAR, and she said any medication or treatment should be documented on administration.

Refer to

F-F760

Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 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** 50945 potential for actual harm Based on interview and record review, the facility failed to ensure the bowel protocol was implemented, Residents Affected - Few bowel movements were monitored and/or documented on, for 2 of 6 residents (Residents 56 & 48) reviewed for unnecessary medication and constipation. This failure placed residents at risk of bowel obstructions, pain, and a diminished quality of life.

Findings included .

Review of the facility's policy titled, Management of Constipation, revised 11/2023, showed the facility monitored bowel movements through point of care documentation (computer charting system used most frequently by nursing assitants) and clinical alerts. After 64 hours of no/small bowel movement, the nurse would assess and determine if the bowel protocol would be initiated and document findings, and interventions would be documented on the clinical alert. The standard bowel protocol would be as follows:

1. Milk of Magnesia (MOM) after 8 shifts of no bowel movement

2. Bisacodyl suppository if no results from the MOM

3. Fleets Enema if no results from the Bisacodyl suppository

1) Resident 56 was admitted to the facility on [DATE REDACTED]. The Significant Change Minimum Data Set Assessment (MDS), dated [DATE REDACTED], showed Resident 56 was able to be understood and understands.

During an interview on 05/05/2025 at 4:05 PM, Resident 56 reported they had both constipation and diarrhea.

Review of Resident 56's orders showed three bowel stimulation orders:

1. Dulcolax suppository (Bisacodyl), insert 1 suppository rectally every 24 hours as needed for constipation if no results from MOM after 12 hours

2. Senna oral tablet, give 2 tablets by mouth every 6 hours as needed for constipation

3. MiraLax oral packet, give 1 packet by mouth one time a day for constipation hold for loose stool

Review of the previous 30 days of bowel movements, showed Resident 56 had no documented bowel movements from 04/19/2025 to 04/24/2025 (6 days). Review of the electronic health record (EHR) showed no bowel medications were given during those dates.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0684 During an interview on 05/09/2025 at 10:31 AM, Staff C, Resident Care Manager (RCM), said they started

the bowel protocol medications and would progress through the steps until a bowel movement was charted. Level of Harm - Minimal harm or Staff C alert charting should also be started. For Resident 56, Staff C said that based on the charting it potential for actual harm looked like the resident had not had a bowel movement during those days, but the resident had reported they had one verbally. When asked if this was confirmed, due to no staff being identified and the resident being Residents Affected - Few dependent on staff for changing their brief, Staff C said the they thought the conversation had happened the week of April 21st, but siad they did not have documentation of this conversation and there should have been. Staff C reviewed the EHR and confirmed there were not bowel medications given during that time frame, and there was no alert charting.

50392

2) Resident 48 was admitted to the facility on [DATE REDACTED]. The Significant Change MDS, dated [DATE REDACTED], showed Resident 48 was rarely or never understood and sometimes understands, and had constipation during the assessment window.

Review of Resident 48's medications for bowel stimulation showed three medications:

1. MOM, by mouth as needed for constipation, give at bedtime or at resident preferred time if no bowel movement on 3rd day

2. Dulcolax suppository(Bisacodyl), insert 1 suppository rectally every 24 hours as needed for constipation if no results from MOM after 12 hours.

3. Fleet enema, insert 1 application rectally every 24 hours as needed for constipation if no results from Dulcolax in 4-6 hours. If no results from enema, notify provider.

Review of Resident 48's bowel record showed three stretches of no bowel movement from 04/18/2025 to 04/22/2025 (5 days), 04/26/2025 to 04/29/2025 (4 days), and 05/01/2025 to 05/05/2025 (5 days). Review of

the EHR showed no bowel medications were given during those days.

Review of Resident 48's care plan for alteration in bowel elimination showed they had the goal of a normal bowel movement at least every 3rd day, with interventions to follow the facility protocol for bowel management.

On 05/12/2025 at 10:13 AM, Staff C, RCM, after reviewing Resident 48's bowel records and the three stretches without bowel movements, said the bowel medications were either not started or not documented on, and it should have been done.

Reference WAC 388-97-1060 (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50392 potential for actual harm Based on interview and record review the facility failed to consistently provide weekly skin assessments and Residents Affected - Few failed to implement supplements as recommended for wound healing for a pressure ulcer (PU, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. These failures placed residents at risk of developing avoidable pressure ulcers and/or delayed healing of pressure ulcers and a diminished quality of life.

Findings included .

Review of the facility policy, titled Documentation-Skin Conditions revised on 12/2024 documented weekly skin assessments were to be documented weekly using the Total Body Skin Evaluation.

<Failed to do weekly skin assessments>

Resident 24 admitted to the facility 03/06/2020. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 01/23/2025, documented Resident 24 had one Stage 3 (involves damage to the innermost layer of skin tissue, exposing the fatty tissue underneath), PU.

On 05/08/2025 Staff O, Wound Care Nurse Practitioner said Resident 24's Stage 3 PU had been identified

on 06/13/2024.

Record review showed Resident 24 had a Total Body Skin Evaluation (assessment) done on 05/14/2025 (no PU identified on this assessment) and did not have another Total Body Skin assessment until over 4 weeks later, on 06/19/2024 (PU documented).

On 05/12/2025 at 12:41 PM, Staff C, Resident Care Manager, when asked what type of evaluations were completed for skin assessments said, Total Body Evalutions were to be done weekly by floor nurses. When asked if [NAME] Body Evaluations were being done weekly for Resident 24, Staff C looked in the Electronic Health Record (EHR) and said it did not look like they were being completed weekly, and it did not meet her expectations. When asked what the facility was doing to prevent Resident 24 from developing the Stage 3 PU, Staff C said repositioning, peri care, putting barrier cream on, and if staff were completing the Total Body Evaluation's the PU could have been prevented. Staff C said if there was a red mark on the skin, it could have been prevented before the skin opened (PU developed). When asked if the Total Body Evaluations were being completed prior to Resident 24 developing the PU, Staff C said, not as often as they should have been, not weekly. Staff C acknowledged the missing assessments between 05/14/2024 and 06/19/2024 and said staff missing those assessments was not acceptable.

<Failure to provide wound healing supplement>

On 05/08/2025 at 9:31 AM, Staff O, Wound Care Nurse Practitioner, when asked if she had made any nutrition recommendations for wound healing, said she had recommended a supplement, Arginade (Powdered supplement which is added to a liquid that can improve wound healing) to the facilities Registered Dietician, a couple of months previously. Staff O said she made recommendations, and it was up to the facility staff to follow up on them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0686 Review of Resident 24's EHR documented the following Wound Pros Progress Report signed by Staff O:

Level of Harm - Minimal harm or On 11/18/2024 conversation with facility dietician (Staff G's first name indicated here) about significant potential for actual harm wound. She is prescribing nutritional supplements. Recommend Vitamin C and zinc, and Arginaid wound supplement. Residents Affected - Few

Record search of Resident 24's orders showed no order for Arginaid had been implemented.

On 05/08/2025 at 12:38 PM, Staff G, Registered Dietician, when asked what specific supplements the facility used to promote wound healing said, Arginaid, it truly works. When asked what steps the facility was taking to promote wound healing for Resident 24, Staff G said Resident 24 had Arginaid and Zinc in the past. Staff G said Arginaid was started in November of 2024, and Resident 24 had taken it for a whole month. When asked to provide documentation that Resident 24 had received the supplement Arginaid, Staff G looked at Resident 24's orders and Medication Administration record and said, I can't seem to find it. Staff G said that since Resident 24 required honey thick fluids (a thicker consistency of liquids) and that Arginaid is not a honey thick liquid that maybe staff couldn't do it and that was why it wasn't done. When asked if Arginaid could have been made honey thick consistency (with added thickener) for Resident 24, Staff G said it was worth trying.

On 05/08/2025 at 2:03 PM, Staff G said Resident 24 had tried the supplement Arginaid mixed in thickened water, that nursing had said they were ok mixing it for Resident 24 and that Resident 24 was liking it. When asked why this had not been attempted at the time the recommendation was made for Resident 24, Staff G said Arginaid would have had to have been put in a liquid that could be thickened to honey thick consistency, kitchen staff couldn't do it, but nursing could.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

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 intravenous (IV) services Residents Affected - Few were provided in accordance with professional standards of practice for 1 of 1 resident (Resident 127) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC line, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, PICC dressing changes, measuring external length to verify the line had not migrated, and arm circumference to monitor for swelling. deep vein thrombosis. These failures placed residents at risk for loss of vascular access, infection, and other potential negative outcomes.

Findings included .

Resident 127 was admitted to the facility on [DATE REDACTED]. Review of the Admission Minimum Data Set (MDS, an assessment tool), dated 04/29/2025, showed the resident was cognitively impaired, had a diagnosis of pneumonia and received IV antibiotic therapy via PICC during the assessment period.

Review of Resident 127's electronic health record (EHR) showed the following IV therapy orders:

a) Cefazolin IV every 8 hours for six weeks for a diagnosis of bacteremia.

b) Flush unused lumens with 10 milliliters (ml) normal saline and follow with heparin every 8 hours.

c) Monitor IV insertion site for signs and symptoms of infection every shift.

d) Change the PICC dressing every 72 hours. Measure the external catheter length and resident's arm circumference with each dressing change.

The physician orders did not include direction to:

a) Flush the PICC dressing before and after medication administration.

b) To change the needleless injection caps on each lumen with dressing changes, after each blood draw and as needed.

On 05/06/2025 at 11:18 AM, Resident 127 a PICC was observed to the resident's right upper arm. The PICC dressing was clean, dry, and intact, and dated 05/05/2025.

Review of the May 2025 Medication and Treatment Administration Records (MAR/TAR) showed on 05/01/2025 Resident 127's PICC dressing was due to be changed, the external catheter length measured, as well as the resident's arm circumference. Further review showed no place was provided to record the measurements and staff failed to sign that the tasks were completed as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0694 On 05/08/2025, Resident 127's PICC dressing change, and measuring of the external length and the residents arm circumference were again due. The TAR showed that the nurse signed off that the tasks were Level of Harm - Minimal harm or completed. potential for actual harm

On 05/09/2025 at 10:31 AM, Resident 127's PICC dressing was still dated 05/05/2025, This showed the Residents Affected - Few dressing was not changed on 05/08/2025 as ordered and signed for.

Review of the EHR showed no PICC external catheter length or resident arm circumference measurements were documented.

On 05/09/2025 at 11:25 AM, Staff C, Resident Care Manager, acknowledged there was no documentation to show staff measured Resident 127's arm circumference and PICC line external length upon admission and every 72 hours with the PICC dressing changes as ordered. Staff C also confirmed there were no orders in place to change the needleless injection caps, to flush the PICC line before and after medication administration. Staff C confirmed facility nurses had erroneously signed for tasks they did not complete on 04/26/2025, 04/29/2025, 05/05/2025 and 05/08/2025.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 37044

Residents Affected - Few Based on interview and record review, the facility failed to have a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 1 of 1 medication carts (East B cart) reviewed for narcotic records. The failure to consistently reconcile controlled medications at shift change and to co-sign the ledger to show both nurses validated the accuracy of the medication count, placed residents at risk for misappropriation of their medication and detracted from the facility's ability to promptly identify potential diversion.

Findings included .

On 05/09/2025 at 7:52 AM, two controlled medication books/ ledger were observed on the East B medication cart. One ledger contained the count for schedule two medications (drugs that have a high potential for abuse and are regulated under the Controlled Substances Act) and the other for schedule three and four medications (drugs with low to moderate potential for abuse and/or addiction).

On 05/09/2025 at 11:18 AM, Staff C, Resident Care Manager (RCM), said facility nurses were supposed to count all schedule two, three and four medications at shift change (twice a day due to 12-hour shifts). After counting and validating all medications were accounted for, both nurses would co-sign each medication ledger to validate that the counts were correct.

Review of schedule three and four medication ledger showed facility nurses signed the ledger to validate the schedule three and four medications were accounted for as follows:

- In January 2025, nurses signed the schedule three and four medication count was correct for one of 62 shift changes (01/17/2025).

- In February 2025, nurses signed the schedule three and four medication count was correct for 0 of 56 shift changes.

- In March 2025, nurses signed the schedule three and four medication count was correct for one of 62 shift changes (03/20/2025).

During an interview on 05/09/2025 at 7:45 AM, when asked why nurses were not signing that the schedule three and four medications were counted and the count was accurate at shift change, Staff L, Licensed Practical Nurse, stated, Some nurses sign in that book, some don't. I figure we did the count we can just sign once for both books.

On 05/09/2025 at 11:34 AM, Staff C, RCM, said nurses were expected to count controlled medications daily at shift change with both nurses (oncoming and off going) signing each ledger to validate the counts were accurate. When asked if that had occurred for the schedule three and four medications on the East B cart Staff C stated, No.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50945 potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents were free from Residents Affected - Some unnecessary medications by providing and documenting on non-pharmacological interventions (NPI) for pain management, having parameters for medications, and/or using non-opioid medications for 4 of 6 residents (Residents 56, 37, 40 & 48) reviewed for unnecessary medications or pain. This failure placed residents at risk of medication tolerance, increased pain, and a diminished quality of life.

Findings included .

1) Resident 56 was admitted to the facility on [DATE REDACTED] with diagnoses of chronic pain and muscle spasm. The Significant Change Minimum Data Set Assessment (MDS), dated [DATE REDACTED], showed Resident 56 was able to be understood and understands.

Review of Resident 56's pain orders showed they had two as needed medications for pain:

1. Morphine, an opioid (strong pain medication), for every 3 hours as needed for end of life care (not listed for pain, no parameters/pain score listed on when to give).

2. Ibuprofen, a non-opioid, for every 8 hours as needed for headache/pain (no parameters/pain score listed

on when to give).

Review of the Medication Administration Record (MAR) showed the following:

-04/01/2025 to 04/30/2025: morphine was given 14 times, with no ibuprofen given on any of those dates. Ibuprofen was only administered one day (04/01/2025). Morphine was given 3 times for 4/10 pain, and once for 5/10 pain.

-05/01/2025 to 05/06/2025: morphine was given 5 times; no ibuprofen given. Morphine was given once for 5/10 pain, and once for 0/10 pain.

Review of the electronic health record (EHR) showed no order for NPI interventions. Review of Resident 56's care plan showed NPI should be provided for pain management, such as position change, relaxation techniques, massage, smooth linens, mobility or physical activity.

On 05/07/2025 at 12:13 PM, Resident 56 had their call light on due to 4/10 pain.

On 05/07/2025 at 12:32 PM, Staff went into the room and told Resident 56 they would find the nurse to give pain medication.

On 05/07/2025 at 1:02 PM, Resident 56 reported they were told they were outside of the timeframe to receive medication (last given at 10:14 AM that day, next dose could be given at 1:14 PM).

On 05/07/2025 at 1:37 PM, Staff N, Licensed Practical Nurse (LPN), gave Resident 56 morphine and left the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0757 On 05/07/2025 at 1:38 PM, Resident 56 reported no NPI was given, they were not offered ibuprofen, and yes

they would have taken ibuprofen. Level of Harm - Minimal harm or potential for actual harm On 05/07/2025 at 2:25 PM, Staff N, LPN, said Resident 56's pain was an 8/10 when the morphine dose was given. When asked if anything improved Resident 56's pain, said morphine. When asked what NPI works for Residents Affected - Some Resident 56, Staff N said turning or distraction can help. Staff N, when asked about Resident 56 being outside of the window for morphine, acknowledged they had not offered other pain medications (ibuprofen) for this specific occurrence, nor did they offer NPI.

During an interview on 05/09/2025 at 10:10 AM, Staff C, Resident Care Manager (RCM), said NPIs should be offered every shift and when residents were requesting pain medication. When asked how the facility was preventing the use of unnecessary medication if pain medication orders do not have parameters on them for when to administer, Staff C said by using NPI such as going on a walk, going outside, repositioning, and that medication should not be the first step. Staff C said if a resident was not due for a narcotic/opioid pain medication, then they should be offered as needed ibuprofen or acetaminophen/Tylenol. When asked about Resident 56's ibuprofen and morphine orders not having parameters, Staff C said yes they should have parameters. When asked about there being no documented NPI for the pain medications given in March, April, and May 2025, Staff C said this did not meet expectations.

46793

2) Resident 37 was admitted to the facility on [DATE REDACTED]. The Quarterly MDS, dated [DATE REDACTED], documented Resident 37 was cognitively intact.

A physician's order dated 07/25/2022, documented, Assess for pain and provide non pharmalogical interventions to reduce pain and document effectiveness. 1-Repositioning 2-Relaxation 3- Diversional Activities 4-Redirection. Doc number used and effectiveness.

Resident 37's April and May 2025 MAR and Treatment Administration Record (TAR) documented NPIs 1-4 were used daily, even on days when Resident 37 reported no pain. The April and May 2025 MAR & TAR showed no documentation of effectiveness. Progress notes provided no documentation to support what NPIs were being used, only stated pain and did not document effectiveness.

3) Resident 40 was admitted to the facility on [DATE REDACTED]. The Significant Change MDS, dated [DATE REDACTED], documented Resident 40 was severely cognitively impaired.

A physician's order dated 08/23/2023, documented, Assess for pain and provide non pharmalogical interventions to reduce pain and document effectiveness. 1-Repositioning 2-Relaxation 3- Diversional Activities 4-Redirection. Doc number used and effectiveness.

Resident 40's April and May 2025 MAR and TAR documented NPIs 1-4 were used daily, even on days when Resident 40 reported no pain. The April and May 2025 MAR & TAR showed no documentation of effectiveness. Progress notes provided no documentation to support what NPIs were being used, only stated pain and did not document effectiveness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0757 On 05/09/2025 at 8:22 AM, Staff C, RCM, reviewed Resident 37's and Resident 40's MAR and TAR's, and said they say the exact same thing. Staff C said the actual intervention needed to documented, along with Level of Harm - Minimal harm or the effectiveness of the NPIs. potential for actual harm

On 05/09/2025 at 9:20AM, Staff B, Director of Nursing Services (DNS), said the copy and paste item was Residents Affected - Some removed from the system and they believed staff have completed the listed NPIs. When shown the MAR and TAR's for Resident 37 and Resident 40, Staff B confirmed the exact NPIs used and their effectiveness were not documented. When progress notes for both residents were shown, documenting pain only, Staff B confirmed NPIs and the effectiveness should have been documented.

50392

4) Resident 48 was admitted to the facility 02/07/2024. The Significant Change MDS, dated [DATE REDACTED], showed Resident 48 was rarely or never understood, and sometimes understood.

Review of Resident 48's physician pain orders showed they had the following pain medication order in place, dated 04/30/2025: morphine, give by mouth two times a day for pain management AND give by mouth every 2 hours as needed for moderate pain, air hunger, EOL (End of Life) symptoms AND Give by mouth every 2 hours as needed for severe pain, air hunger, EOL symptoms.

Review of the EHR showed there was NPI monitoring for pain and staff were instructed to provide NPI to reduce pain and document effectiveness every shift, these instructions were not linked to the morphine order.

Review of Resident 48's April 2025 MAR showed staff had administered morphine 12 times, it was unclear if

they attempted NPI's prior to administering the pain medication as the NPI's were not linked to the morphine order.

On 05/12/2025 at 10:30 AM, Staff C, RCM, reviewed Resident 48's morphine order, and when asked how

the nurse would know what was moderate pain versus severe pain without the order listing a numerical pain scale to follow (0/10 pain scale, 0 being none, with 10 being the worst), Staff C said the provider inputing the order should have added the pain scale with parameters. Regarding EOL symptoms, Staff C said the order should be more specific. Staff C, when asked if staff were providing and documenting NPIs that were attempted prior to morphine being given, said no, they did not see it in the EHR and they should be. Staff C said there should be a plan and documentation of NPI's for morphine. When asked for documentation that

the facility was monitoring for adverse side effects of the administered morphine (such as slow or stopped breathing, signs of increased effort to breath, mental status changes), Staff C said they were not seeing that

the facility was doing that for morphine, but it should be there for sure.

Reference WAC 388-97-1060 (3)(k)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37044 potential for actual harm Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 127) reviewed for Residents Affected - Few intravenous (IV) therapy, was free of significant medication errors. The failure to administer IV antibiotics at ordered times/intervals, placed residents at risk for ineffective treatment of infection, prolonged antibiotic therapy and associated adverse side effects.

Findings included .

Resident 127 was admitted to the facility on [DATE REDACTED]. Review of the Admission Minimum Data Set (an assessment tool), dated 04/29/2025, showed the resident was cognitively intact, had a diagnosis of bilateral lower lobe pneumonia (infection in both sides of lower lungs), and received IV antibiotics during the assessment period.

Review of the electronic health record (EHR) showed the resident had a 04/23/2025 order for IV Cefazolin (antibiotic) every eight hours at 8:00 AM, 4:00 PM and Midnight, with direction to infuse over one hour via Peripherally Inserted Central Catheter.

Review of the April 2025 Medication Administration Record (MAR) showed Resident 127's IV cefazolin was administered as follows:

- On 04/27/2025 the midnight dose of IV cefazolin was administered on 04/27/2025 at 6:27 AM, six and half hours after the scheduled time and 14 hours after the previous dose (04/26/2025 at 4:00 PM). The nurse then administered the 04/27/2025 8:00 AM dose at 9:29 AM, two hours after the previous dose completed.

-On 04/28/2025 the midnight dose of IV cefazolin was administered on 04/28/2025 at 5:31 AM, five and half hours after the scheduled time and 13 hours after the previous dose. The nurse then administered the 04/28/2025 8:00 AM dose at 8:35 AM, two hours and four minutes after the previous dose completed.

-On 04/30/2025 the midnight dose of IV cefazolin was administered on 04/30/2025 at 5:35 AM, five and half hours after the scheduled time and 14 hours after the previous dose. The nurse then administered the 04/30/2025 8:00 AM dose at 8:47 AM, two hours and 12 minutes after the previous dose completed.

-On 05/02/2025 the midnight dose of IV cefazolin was administered on 05/02/2025 at 4:50 AM, five hours late and 13 hours after the previous dose. The nurse then administered the 05/02/2025 8:00 AM dose at 8:19 AM, two hours and 29 minutes after the previous dose completed.

-On 05/05/2025 the midnight dose of IV cefazolin was administered on 05/05/2025 at 4:23 AM, four and a half hours late and 13 hours after the previous dose. The 05/05/2025 8:00 AM dose was then administered at 8:19 AM, two hours and 56 minutes after the previous dose completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0760 On 05/09/2025 at 11:33 AM, when asked if facility nurses administered Resident 127's IV cefazolin at the prescribed times and intervals, Staff C, Resident Care Manager, stated, No. Staff C confirmed facility nurses' Level of Harm - Minimal harm or pattern of administering the resident's midnight doses four to five hours late and then failed to adjust the potential for actual harm administration time of the next dose. Staff C acknowledged this resulted in 13-14 hours between the 4:00 PM and midnight dose, and 2-3 hours between the midnight and 8:00 AM dose, rather than every eight hours as Residents Affected - Few ordered.

Reference WAC 388-97-1060 (3)(k)(iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 - Few Based on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures, dated when opened when required, and expired medications were discarded in accordance with professional standards of practice for 2 of 2 medication rooms (East and [NAME] Medication rooms) and 1 of 2 medication carts (West A cart) reviewed. This placed residents at risk of taking and/or receiving expired/outdated medications and biologicals.

Findings included .

<East Medication Room>

On 05/13/2025 at 11:40 AM, observation of the medication refrigerator showed it contained 11 bags of intravenous cefazolin (to be stored at 37.5 - 41 degrees Fahrenheit (F)), multiple unopened insulin pens (to be stored at 36 - 46 degrees F), and an opened multi-use vial of Tuberculin purified protein derivative (PPD, to be stored at 35 - 45 degrees F).

Review of the refrigerator temperature log showed staff had not checked the medication refrigerator temperature since October 2024 (greater than six months prior).

On 05/09/2025 at 11:42 AM, Staff C, Resident Care Manager (RCM), said nurses should have been checking and recording the medication refrigerator internal temperature at least once daily, but acknowledged they failed to do so.

<West Medication Room>

On 05/09/2025 at 11:56 AM, a multi-use vial of Tuberculin PPD was stored in the freezer and had an open date of 03/18/2025 (56 days prior).

On 05/09/2025 at 11:58 AM, Staff C, RCM, said the Tuberculin vial should have been stored in the refrigerator between 35 - 45 degrees F and discarded 30 days after the open date, but was not.

<East A Medication Cart>

Review of the East medication cart showed the following:

1) Resident 45 had a medication card of benzonatate 100 mg which expired 06/19/2024.

2) Resident 16 had a medication card of mirtazapine 7.5 mg that expired 05/31/2024.

On 05/13/2025 at 12:24 PM, Staff C, RCM, said the above referenced medications were expired and needed to be discarded.

Reference WAC 388-97-1300 (2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 46793

Residents Affected - Some Based on observation, interview and record review the facility failed to store food for residents in accordance with professional standards for 2 of 2 nursing station refrigerators (East, West) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Findings included .

Review of the following refrigerator temperature logs located at nurses stations included the following out of range temperatures (greater than 40 degrees Fahrenheit (F):

February 2025 [NAME] refrigerator:

5th 43F AM shift/ 5th 43F PM shift

8th 43F AM shift

9th 42F AM shift

10th 43F AM shift

15th 43F AM shift

16th 44F AM shift

there was no documentation of corrective action taken.

February 2025 East refrigerator:

11th 43F AM shift

12th 45F AM shift

19th 43F AM shift

there was no documentation of corrective action taken.

March 2025 [NAME] refrigerator:

4th 45F AM shift

7th 43F AM shift

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 11th 49F AM/42F PM shifts

Level of Harm - Minimal harm or 12th 43F PM shift potential for actual harm 13th 43F AM/47F PM shifts Residents Affected - Some 14th 47F PM shifts

15th 45F AM/46F PM shifts

16th 43F PM shift

17th 47F PM shift

18th 44F PM shift

19th 43F AM/44F PM shifts

20th 44F AM/44F PM shifts

21st 44F PM shift

22nd 44F PM shift

23rd 44F PM shift

25th 45F AM/44F PM shifts

26th 43F AM shift

29th 44F PM shift

a line was drawn through comments section Kept Fridge Shut marked next to line.

April 2025 [NAME] refrigerator:

21st 42F AM shifts

22nd 45F AM shifts

23rd 42F AM shifts

28th 42F PM shifts

there was no documentation of corrective action taken.

April 2025 East refrigerator:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 9th 44 PM

Level of Harm - Minimal harm or 12th 42 PM potential for actual harm 14th 43 PM Residents Affected - Some 15th 45 PM

16th 48 PM

17th 47 PM

18th 47 PM

19th 47 PM

20th 47 PM

21st 47 PM

22nd 47 PM

23rd 47 PM

24th 47 PM

26th 42 PM

there was no documentation of corrective action taken.

On 05/07/2025 at 10:39 AM, Staff I, Dietary Manager, said refrigerator temperatures were supposed to be 40 degrees or below. When asked what the process was for when a refrigerator temperature was out of range, Staff I said staff would make sure the door was closed, wait and hour then come back and recheck the refrigerator temperature. Staff I said if the problem persisted, then they would contact maintenance and the Administrator. When shown multiple dates of out-of-range refrigerator temperatures with no corrective action documented, Staff I said the corrective action should have been documented. Staff I said out of range refrigerator temperatures were not acceptable.

Reference WAC 388-97-1100 (3), 2980.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 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 binding arbitration agreements (legal Residents Affected - Some document that required the use of a third party to resolve disputes) were reviewed in a manner that explicitly informed the resident or their representative of what they were consenting to, or were understood in their entirety, for 3 of 3 residents (Residents 39, 126, & 127) reviewed for binding arbitration. This failure placed residents at risk for legal complications and a diminished quality of life.

Findings included .

1) Resident 39 was admitted to the facility on [DATE REDACTED]. Resident 39 signed their binding arbitration agreement

on 11/25/2024.

Review of the electronic health record showed Resident 39 was admitted after being in the hospital for sepsis (infection of the blood) and was re-hospitalized on [DATE REDACTED] with altered mental status.

During an interview on 05/07/2025 at 10:57 AM, Resident 39 was asked what their understanding of the arbitration process was, and said they did not really know. When asked if they knew they were giving up their right to litigation in a court proceeding,Resident 39 said no. When asked if they were told of their right to terminate or withdraw the agreement within 30 days of signing, Resident 39 said they did not think so. Resident 39 stated, I think maybe we went over it too quickly. I would not have signed it. They did not explain

it in totality. Resident 39 explained that when they were admitted , they were getting over a urinary tract infection, had previously been hallucinating while at the hospital, and was unsure they had the mental acuity to agree to the binding arbitration agreement at that time.

2) Resident 126 was admitted to the facility on [DATE REDACTED]. Resident 126's Power of Attorney (POA) signed the binding arbitration agreement on 05/05/2025.

During an interview on 05/06/2025 at 3:17 PM, Resident 126's POA was asked if they understood they were giving up their right to litigation in a court proceeding and answered no. When asked what their understanding of the arbitration agreement was, Resident 126's POA said they had no idea what it involved. When asked if the arbitration agreement was explained in a way they understood, Resident 126's POA said no and stated, I want nothing to do with the arbitration agreement.

3) Resident 127 was admitted to the facility on [DATE REDACTED]. Resident 127's responsible party signed the binding arbitration agreement on 04/25/2025.

On 05/06/2025 at 3:25 PM, when asked who filled out their admission paperwork, Resident 127 stated, I was out of it.

During an interview on 05/06/2025 at 3:37 PM, Resident 127's responsible party said they did not know what

they signed and stated, I was in a state, my husband was dying for all I knew.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0847 During an interview on 05/06/2025 at 1:16 PM, Staff D, Business Office Manager, said they went over the binding arbitration agreements. When asked how they ensure the resident or representative understood the Level of Harm - Minimal harm or terms of the arbitration agreement, Staff D said they explained that it was mediation, that if they had a potential for actual harm grievance it would go in front of an administrative judge, and if they did not like the result then they could go to court. Staff D said the agreement did not keep the residents from going to court, just added another step. Residents Affected - Some When asked how they ensure the agreement was explained in a form or manner that accommodated the residents or his/her representative's needs, Staff D said they would change the wording, let them know it was voluntary, that it was for mediation for if they had a grievance that they wanted to sue or reach a court level decision, and that by signing the document they were giving both parties an opportunity to go before an administrative judge prior to including the court.

During an interview on 05/09/2025 at 12:06 PM, Staff A, Administrator, said their expectation for staff reviewing the binding arbitration agreements was for them to be explained in a way for them to be understood. When asked what, This agreement waives the right to trial by judge or jury meant, Staff A said

they (the residents/representatives) could not take it to court. When asked if it met expectations that 3 of 3 residents/representatives answered no, to if they understood they were giving up the right to litigation in a court proceeding, Staff A stated, probably not.

No Associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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

Level of Harm - Minimal harm or 42960 potential for actual harm Based on interview and record review, the facility failed to show evidence of an ongoing, effective, Residents Affected - Some comprehensive, data-driven Quality Assurance and Performance Improvement program (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice). The facility failed to provide evidence of documentation that demonstrated the development, implementation, and evaluation of a performance improvement activity for 1 of 1 sampled Process Improvement Projects (PIP) reviewed. The facility failed to provide evidence of the medical director participating in the QAPI program. This failure placed residents at risk for ongoing unmet care needs and a diminished quality of life.

Findings included .

Record review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Process effective July 2015, stated, The center pursues the highest quality of care and services for their customers through a data-driven, proactive approach to improving the quality of life, care, and services. The activities of QAPI involve members at all levels of our organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement corrective plan; and continuously monitor effectiveness of interventions. Each Center leadership team with Client Support Center is accountable for actively participating in the formalized and documented Quality Assurance and Performance Improvement (QAPI) process that includes efficient mechanisms for monitoring, revising, analyzing, documenting and improving process .The committee will be accountable to develop and implement corrective measures or, when necessary, initiate an action plan or assign a Performance Improvement Project(PIP).

On 05/13/2025 at 2:22 PM, Staff A, Administrator, said she did not have sign-in sheets for the QAPI meetings or proof that the medical director attended the QAPI meetings at least quarterly. Staff A said the medical director was not local and does not always come in. Staff A was asked to provide documentation of

a QAPI plan the facility was working on that had been successful for the committee and she said no, I don't have a plan. When Staff A was asked if they were working on anything currently? she said, let me think about it. And when Staff A was asked if they'd worked on anything in the past? she said, let me think about it.

On 05/13/2025 at 3:08 PM, Staff A, Administrator, said she would follow up with the state agency and provide documentation of a Process Improvement Plan (PIP) within 48 hours of exit.

On 05/13/2025 at 3:50 PM, Staff A provided a document titled [facility] QAPI meeting March 25, 2025. The document was sparse and did contain the relevant information.

Staff A did not provide a PIP or sign-in sheets from the facility's QAPI meetings.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50392 potential for actual harm Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program that Residents Affected - Few ensured accurate and complete information (signs/symptoms) was collected monitored and/or documented

on for 2 of 3 monthly infection line listings (a document that tracks resident infections) reviewed (February 2025 & April 2025). The facility also failed to implement a process for documenting on McGeer's Criteria (tool that provided criteria to show if antibiotics were indicated), that included provider notification, intervention implemented (if provider wanted to continue or stop the antibiotic and the reason for it), and an accurate list for tracking residents that did and did not meet criteria, for 1 of 1 residents (Resident 26) reviewed for McGeer's Criteria. These failures placed residents at risk for unnecessary antibiotic use, development of [NAME]-drug-resistant organisms (MDROs), and other negative health outcomes.

Findings included .

Review of the facility's policy titled, Antibiotic Stewardship, revised October 2019, documented the purpose of the antibiotic stewardship program was to monitor the use of antibiotics. The facility policy documented orientation, training and education of staff would emphasize the importance of antibiotic stewardship and would include how inappropriate use of antibiotics affects individual residents and the overall community.

Review of the Nebraska Antimicrobial Stewardship Assessment and Promotion Program's document titled, Revised McGeer Criteria for Infection Surveillance Checklist, dated 11/05/2024, lists criteria for treatment with antibiotics. For cellulitis (a common, potentially serious bacterial skin infection), soft tissue, or wound infection, the resident must meet the following criteria:

1.Must fulfill at least 1 criterion- Pus at wound, skin, or soft tissue site.

Or

2. At least four of the following new or increasing signs or symptoms:

A. Heat (warmth) at affected site

B. Redness (erythema) at affected site

C. Swelling at affected site

D. Tenderness or pain at affected site

E. Serous (clear fluid) drainage at the affected site.

F. At least one of the following: Fever, Leukocytosis (a high level of white blood cells in the blood), Acute change in mental status, Acute functional decline.

<Failure to meet McGeer's Criteria and add to April Line Listing>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0881 Resident 26 admitted to the facility 06/21/2020. Resident 26 had a diagnosis of Bullous Pemphigoid (a rare skin condition causing large, fluid-filled blisters). Level of Harm - Minimal harm or potential for actual harm An order in the electronic health record (EHR) showed Resident 26 was prescribed an antibiotic on 03/04/2025, doxycycline, two times a day for left thigh cellulitis for 10 days. Residents Affected - Few

A physician progress note, dated 03/04/2025, documented Resident 26 had new redness of left thigh lesion and no other new symptoms were listed. The resident was noted to still be taking a topical steroid skin medication for skin lesions, which was instructed to not be applied to the infected lesion.

Another provider progress note, also dated 03/04/2025, documented Resident 26 had new redness surrounding the left thigh lesion, without abscess (collection of pus) or lymphangitis (infection or inflammation of the lymphatic vessels) noted.

Review of the March 2025 Infection Control Line Listing showed Resident 26 had an entry on 03/04/2025 for

a wound infection of the left thigh. The signs and symptoms listed were serosanguinous drainage (common wound drainage that is a combination of clear watery fluid and blood, typically normal and expected during wound healing) and redness. No other symptoms were found.

Review of Resident 26's vital signs showed there were no temperature readings done in 2025, the facility did not rule out if the resident had a fever on 03/04/2025.

Review of McGeer's Criteria and the EHR showed Resident 26 did not meet the criteria for antibiotic treatment.

A second order in the EHR showed Resident 26 was prescribed an antibiotic on 04/28/2025, doxycycline, two times a day for cellulitis of the left hand for 10 days.

A physician documentation progress note, dated 04/25/2025, documented due to increased redness left hand concern? new infection. Started patient on Doxycycline, Probiotic and dose of Oxycodone QHS [every night] for pain relief. Will recheck next week and if infection improved will start short course of oral steroids.

She has an appointment to see dermatologist in May.

Review of McGeer's Criteria and the EHR showed Resident 26 again did not meet criteria for antibiotic treatment.

Review of the April 2025 Infection Control Line Listing, showed it was missing the entry for Resident 26.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0881 On 05/13/2025 at 8:27 AM, Staff A, Administrator/ Infection Preventionist, was interviewed along with Staff B, Director of Nursing. When asked if McGeer's criteria was the infection assessment tool the facility used to Level of Harm - Minimal harm or determine if a resident required antibiotic treatment, Staff B confirmed it was. Staff B confirmed the facility potential for actual harm was using McGeer's Criteria when a provider prescribed an antibiotic. When asked how the facility communicated McGeer's criteria to the provider when residents were not meeting criteria, Staff B said it was Residents Affected - Few communicated, the decision was made by the provider to continue or discontinue the antibiotic, and their expectation was for the provider to have documented this conversation. When asked where the documentation was of McGeer's criteria being reviewed, Staff B said it would help if the provider documented that. Staff B was unable to recall any specifics regarding the two 10-day courses of antibiotics prescribed for Resident 26 or if McGeer's criteria was reviewed by the facility. When asked how the facility was meeting antibiotic stewardship for Resident 26, Staff B said she could not recall a specific conversation before the initiation of antibiotics, that there was usually a discussion had if McGeer's criteria was met or not, and that

the reasoning for antibiotics should have been documented by the provider. Regarding the second course of doxycycline started on 04/28/2025 not being on the April Infection Control Line Listing, Staff B said any antibiotic started should be on the line listing.

On 05/15/2025 at 2:13 PM, Additional documentation was received from Staff A, Administrator, with an Infection Screening Evaluation that can be utilized in the EHR. This screening tool was based on McGeer's or Loeb's (another clinical decision-making tool to determine if an antibiotic should be started for suspected infections) criteria. The last completed Infection Screening Evaluation found in the EHR for Resident 26 was from 2022.

<Incomplete Line Listing Documentation>

Review of the February 2025 line listing showed, under type of symptoms/diagnosis, the following entries lacked documentation of signs/symptoms:

1. Date of onset lists hospitalization -Type of Symptoms/Diagnosis lists Cholecystitis [inflamed gallbladder] (No signs/symptoms documented)

2. Date of onset lists hospitalization -Type of Symptoms/Diagnosis lists UTI [urinary tract infection](No signs/symptoms documented)

3. Date of onset lists 02/06/2025- Type of Symptoms/Diagnosis lists Wound Infection-continued ongoing infection (No signs/symptoms documented)

4. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists Osteomyelitis [bone and muscle infection] (No signs/symptoms documented)

5. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists UTI (No signs/symptoms documented)

6. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists Cellulitis LUE [skin infection left upper extremity] (No signs/symptoms documented)

7. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists Osteomyelitis (No signs/symptoms documented)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 0881 8. Date of onset lists 02/21/2025- Type of Symptoms/Diagnosis lists Foley removal, followed by urology [tube into bladder/urinary tract and bladder specialist] (No signs/symptoms documented) Level of Harm - Minimal harm or potential for actual harm 9. Date of onset lists 02/14/2025- Type of Symptoms/Diagnosis lists Went to ER (emergency room ) for edema, rtn with UTI [returned with urinary tract infection] (No signs/symptoms documented) Residents Affected - Few 10. Date of onset is blank- Type of Symptoms/Diagnosis is also blank, treatment was Cipro (antibiotic) started on 02/25/2025 (No signs/symptoms documented)

11. Date of onset lists 02/03/2025- Type of Symptoms/Diagnosis lists UTI- had a fall, went to hospital (No signs/symptoms documented)

12. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists Cellulitis BLE (Both lower extremities) (No signs/symptoms documented)

13. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists Sepsis [blood infection] (No signs/symptoms documented)

14. Date of onset lists hospitalization - Type of Symptoms/Diagnosis lists Cellulitis (No signs/symptoms documented)

On 05/13/2025 at 8:27 AM, when asked if signs and symptoms should be tracked on the line listing, Staff B said symptoms should be documented and kept together to be tracked.

No Associated WAC

.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 58 505185 Department of Health & Human Services Printed: 08/27/2025 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 05/13/2025

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 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 - Some Based on interview and record review, the facility failed to have a system in place for maintaining documentation of staff screening, education, offering and current COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccination status for 12 of 12 months (May 2024 - May 2025) reviewed.

These failures placed residents and staff at risk of contracting COVID-19, related complications and a diminished quality of life.

Findings included .

On 05/06/2025 at 1:06 PM, when asked to provide documentation of screening, education, offering and current COVID-19 vaccination status for staff, Staff A, Administrator and Infection Preventionist said they did not have any staff that agreed to take the COVID-19 vaccination. Staff A said they would talk about the importance of it, but they all had a choice. Staff A said they had last year's records, but did not have this year's records because all staff had refused the vaccination.

On 05/10/2025 at 11:06 AM, Staff A was emailed a request for documentation of screening, education, offering and current COVID-19 vaccination status for 3 staff members. A subsequent email was received on 5/13/2025 at 11:45 AM, from Staff A, with an attached statement that facility staff were offered the Covid-19 vaccine, and a Vaccine Information Statement (VIS) was also attached but no staff records of screening, education, offering and current COVID-19 vaccination status was provided.

Reference WAC 388-97-1320

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 58 505185