Three Creeks Post Acute

F 0584 Level of Harm - Potential for minimal harm

12/18/2025 at 11:45 AM, Staff A, Administrator In Training, stated that the building was purchased by the current corporation in June of 2025 and that since then a new generator had been on the facility wish list.

During the interview, Staff A provided a receipt for two 3000W output/6000W battery generators, with a delivery date of December 24, 2025. Staff A stated that the two generators would cover all the requirements for the building, including heat, if another power outage occurred. Reference: WAC 388-97-0880 (3)

Residents Affected - Many

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

Event ID:

Facility ID:

If continuation sheet

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Creeks Post Acute

Northwest 1310 Deane Pullman, WA 99163

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

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

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR, a two-part screening assessment; Level I was determined by the presence of a Severe Mental Illness [SMI] or Developmental Disability. If present, a Level II evaluation by a specialized evaluator would then occur where it would be determined if nursing home placement was the appropriate level of care, and if behavioral health or other community services were recommended for the given resident. A Level I, and if indicated, a Level II PASRR was required to be completed prior to nursing home admission) were completed correctly and PASSR Level II were referred for evaluation prior to admission as required for 1of 6 sample residents (Resident 1). This failure placed residents at risk of behavioral health needs not being met and diminished quality of life.Findings included . A record review showed Resident 1 was admitted to the facility on [DATE REDACTED] and had diagnoses that included major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, changes in sleep/appetite, fatigue and difficulty concentrating, significantly impacting daily life) and vascular dementia (a decline in memory thinking and judgement due to reduced blood flow to the brain). Further record review for Resident 1 found A PASRR Level I, dated 06/12/2025, that documented Resident 1 had a mental health diagnosis, did not have a diagnosis of dementia, and indicated the resident needed a Level II evaluation referral required for SMI. A PASRR Level II Initial Psychiatric Evaluation Summary, the detailed findings of

the Level II evaluation, was not included in Resident 1's record. Further record review found a SLUMS examination (St. Louis University Mental Status - A set of questions used to assess adults for orientation, memory, attention and executive function), completed after Resident 1 admitted to the facility on [DATE REDACTED], indicating the resident had severely impaired cognition. No behavioral health provider notes were found in Resident 1's record. During an interview on 12/16/2025 at 12:45 PM, Resident 1 was in their room finishing their lunch. They stated that they believed the year was 1974 and they had just been discharged from the military to the current facility. They further stated that they did take medication for depression daily. During

an interview on 12/22/2025 at 1:20 PM, Staff J, Admissions Director, stated that Resident 1 had not been admitted to the facility through the standard process. They stated that the resident had transferred from a sister facility after the directors of the current facility and the former facility had discussed the transfer. They further stated that prior to a resident being admitted they, or social services, would review the resident

record to see if a PASRR Level I had been completed and if a Level II was needed. They stated that if a Level II was needed it should occur prior to the resident having admitted to the facility. Staff J further stated that they did not review this resident's records prior to admission and were not aware that the resident had

a need for a Level II to be completed, nor that the Level I was filled out incorrectly. During an interview on 12/22/2025 at 2:05 PM, Staff A, Administrator In Training, stated that they had accepted the transfer of Resident 1 from their sister facility. They further stated that they were not aware that prior to their admission to the facility, Resident 1 had a Level I PASRR which indicated they needed a PASRR Level II completed, and they had not reviewed the resident's PASRR prior to admission. Reference: WAC 388-97-1915(4)

Event ID:

Facility ID:

If continuation sheet

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Creeks Post Acute

Northwest 1310 Deane Pullman, WA 99163

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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many

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

resident's and was still in the refrigerator during the interview. During an interview with Staff F, Dietary Aide,

on 12/18/2025 at 11:35 AM, they stated that they and Staff D worked together on the day shift on 12/17/2025, starting at 5:00 AM. They stated that shortly after they started work there was a power outage.

They stated that during the power outage they were told to keep the kitchen appliance doors closed as the backup generator did not power the refrigerators or freezer. They stated that they did not take any temperatures of foods inside the refrigerators or freezer during the power outage and was not sure if temperatures in the refrigerator and freezer stayed within acceptable limits. In an observation of the refrigerator identified by Staff D as being above acceptable temperature limits for PHFs, on 12/18/2025 at 11:22 AM, there was milk present with dates written on the containers showing prior to 12/16/2025. Record

Review of the Refrigerator/Freezer Temperature logs for December 2025 showed the refrigerator temperature for the identified refrigerator as 40 degrees F on the morning (identified as Temp AM freezer/fridge). The line for recording temperatures for 12/17/2025 was lined out with red marker and a comment was written, OO service, under the section titled If temperature is outside of specification, what was done about it? For the second refrigerator a line was drawn through 12/17/2025 and a comment was written in, OO service. The freezer temperature log for 12/17/2025 for AM was recorded as -10. The line for recording temperatures for 12/17/2025 was lined out with red marker and a comment was written, OO service. In an interview with Staff C, Dietary Manager, on 12/18/2025 at 11:40 AM, they stated that they were aware of the power outage on 12/17/2025 that started at 5:10 AM and ended at 3:30 PM. They further stated that they came to work that day at 2:00 PM and they did not check the temperatures in the refrigerators or freezer during their shift or when the power came back on. They stated that Staff D had texted them that the temperature in the one refrigerator was 50 degrees F and there was milk in that refrigerator. They stated that they served the milk for dinner that night and for breakfast on 12/18/2025.

They stated that they knew what items were in the refrigerators because they dated them when they came into the building. They further stated that no food was thrown away after the power outage, that they did notice that the freezer items were frozen solid after the power outage, and they thought the other refrigerator was in the safe zone because the door was not opened. In an interview with Staff A, Administrator In Training, on 12/18/2025 at 10:45 AM, they stated that the generator in the building was old and did not provide power for the kitchen or heat during the power outage on 12/17/2025. They stated that

a new generator was on the list of things to purchase after a change in ownership in June of 2025. At 1:00 PM on 12/18/2025, Staff A, stated that they were not aware that temperatures in the one refrigerator were above 45 degrees F on 12/17/2025 and that no food was discarded. In an Interview with Staff B, Director of Nursing, on 12/18/2025 at 2:25PM, they stated that they would monitor residents in the building for signs or symptoms of food borne illness. During an interview on 12/22/2025 at 12:10 PM they stated that all residents in the building on 12/17/2025 were monitored for signs and symptoms of food borne illness and no concerns were identified. Reference: WAC 388-97-1100 (3)

Event ID:

Facility ID:

If continuation sheet