Shelton Health & Rehab Center

F-F678 CPR, the IJ was determined to have begun on [DATE REDACTED] when the facility failed to perform complete CPR with respirations. The facility's failure placed residents at risk for serious injury, harm, impairment or death. The facility removed the immediacy on [DATE REDACTED] with an onsite verification by the investigator by review of staff education, verification staff obtained active CPR certifications, observation of facility emergency equipment, conducting staff interviews related to staff re-education regarding CPR policies and procedures which ensured an effective system was in place to safeguard, protect and prevent residents who require CPR.

Findings included .

Review of Lippincott Manual of Nursing Practice, Eleventh Edition, dated 2019, showed the following steps for performing CPR included .3. Deliver 30 compressions at a rate of at least 100 compressions a minute. Always allow for complete chest recoil after each compression without taking your hands off of the chest between compressions. 4. Taking no more than 10 seconds, open the airway and deliver 2 breaths. 5. Continue resuscitation at a rate of 30:2 with one or two rescuers .

Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised ,d+[DATE REDACTED], showed 1 . Licensed nurses (LN) employed by the Center are required to have current CPR certification .7 .CPR is initiated for those residents who .a. Have requested, through advanced directive or POLST/POST (Physicians Order for Life Sustaining Treatment), to have CPR initiated when cardiac or respiratory arrest occurs .b. Have not formulated an advanced directive nor have a POLST in their medical record .c. Do not have a valid DNR (Do Not Resuscitate/a medical order that instructs healthcare providers not to perform CPR if a patient's heart stops beating or breathing stops) .

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 4 505507 Department of Health & Human Services Printed: 09/07/2025 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 505507 B. Wing 03/06/2025

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

Shelton Health & Rehab Center 153 Johns Court Shelton, WA 98584

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 0678 Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses including fracture of the left femur (thigh bone), Chronic Obstructive Pulmonary Disease (restricted airway) and Hypertension (high blood pressure). Level of Harm - Immediate The admission Minimum Data Set (MDS), an assessment tool, dated [DATE REDACTED], showed Resident 2 was alert jeopardy to resident health or and oriented and required staff assistance for activities of daily living. safety Resident 2's POLST form, dated [DATE REDACTED], showed to attempt resuscitation/CPR, full treatment, use Residents Affected - Few intubation, advanced airway interventions, mechanical ventilation, cardioversion (medical procedure used to restore a normal heart rhythm by delivering electrical shock) as indicated, transfer to hospital if indicated, including intensive care treatment.

Resident 2's nurse's note, dated [DATE REDACTED] at 8:03 AM, showed while serving Resident 2 breakfast staff reported the resident was not breathing. The nurse's note showed Staff D, Licensed Practical Nurse (LPN), assessed Resident 2 and found no respiratory rate or heart rate, initiated CPR and called 911.

Resident 2's nurse's note, dated [DATE REDACTED] at 8:12 AM, showed .911 arriving in facility, taking over CPR on resident .

Resident 2's nurse's note, dated [DATE REDACTED] at 8:36 AM, showed paramedics pronouncing Resident 2's death at 8:26 AM.

Review of the facility's investigation, dated [DATE REDACTED], showed a statement by Staff D .this nurse was called to

the residents room by the CNA [Staff C, certified nursing assistant] stating that the resident was not breathing at 0745. Resident was observed lying on her back sideways in the bed .resident was not breathing and did not have a pulse. Resident was Cyanotic (bluish or gray color of skin) but warm to touch. This nurse and RN [Staff E, Registered Nurse] started CPR, CNA [Staff C] brought the crash cart and helped with CPR . 911 was called and CPR continued by this nurse, [Staff E] and [Staff C] until paramedics arrived .

Review of staff CPR certification showed the following:

Staff C CPR certification expired [DATE REDACTED].

Staff D CPR certification expired [DATE REDACTED].

Staff E CPR certification expired [DATE REDACTED].

In an interview on [DATE REDACTED] at 10:11 AM, Staff C, Certified Nursing Assistant (CNA), said she delivered the breakfast tray to Resident 2 on [DATE REDACTED] and found the resident to be lying in bed unresponsive. Staff C said

she went to the hallway and yelled for help. Staff C said nurses responded and Staff C went to the nurse's station to find the Resident 2's code status, retrieved the emergency cart and returned to Resident 2's room. Staff C said Staff E called 911 and Staff D and Staff C did chest compressions. Staff C acknowledged staff did not administer respirations (breaths) during CPR. Staff C said the cart was missing stuff .like the breathing tube .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 505507 Department of Health & Human Services Printed: 09/07/2025 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 505507 B. Wing 03/06/2025

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

Shelton Health & Rehab Center 153 Johns Court Shelton, WA 98584

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 0678 In an interview on [DATE REDACTED] at 10:19 AM, Staff D said she was passing medications on [DATE REDACTED] and a CNA reported Resident 2 was not breathing. Staff D said she went to Resident 2's room and found Resident 2 Level of Harm - Immediate unresponsive. Staff D acknowledged they initiated chest compressions but did not administer respirations jeopardy to resident health or because the ambu bag [bag valve mask/handheld device used to deliver ventilation to patients who are safety breathing inadequately or not at all] was not on the cart. Staff D acknowledged the paramedics arrived on scene and took over CPR. Staff D acknowledged the resident expired at the facility. Residents Affected - Few

In an interview on [DATE REDACTED] at 3:50 PM, Staff A, Administrator, and Staff B, Director of Nursing, acknowledged

the facility had several staff changes and they became aware numerous staff had expired CPR certification. Staff B acknowledged Staff C, Staff D and Staff E had expired CPR certification. Staff A and B acknowledged CPR consists of rescue breathing and chest compressions and is provided to all residents' dependent on their POLST form and advanced directives. Staff B acknowledged staff are expected to provide respirations if resident is not breathing using an Ambu (bag/valve mask), barrier mouthpiece or mouth to mouth if no other equipment is available. Staff A and Staff B acknowledged Resident 2 expired at the facility.

Reference WAC [DATE REDACTED] (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 505507 Department of Health & Human Services Printed: 09/07/2025 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 505507 B. Wing 03/06/2025

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

Shelton Health & Rehab Center 153 Johns Court Shelton, WA 98584

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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49451 potential for actual harm Based on interview and record review the facility failed to ensure timely physician visits were within the first Residents Affected - Few 30 days after admission for 2 residents of 5 sample residents (Resident 11 and 14) reviewed for physician visits. This failure placed residents at risk of being denied face to face contact with a physician, during comprehensive review and for assessment of their health and well-being.

The findings included .

Review of the facility's policy, titled Physician Visits updated 2/2008 showed Residents were to be seen by a physician at least every 30 days for the first 90 days after admission.

<Resident 11>

Resident 11 was admitted to the facility on [DATE REDACTED] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease (Stage 4) and Acquired Absence of the left lower leg. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/20/2024 showed the resident was alert and oriented and able to make needs known.

Resident 11's medical record showed the resident was discharged from the facility on 11/11/2024 and returned to the facility on [DATE REDACTED].

Resident 11's medical record showed no physician's visit was completed after readmission from the hospital 11/14/2024-03/06/2025 (112 days).

<Resident 14>

Resident 14 was admitted to the facility on [DATE REDACTED] with diagnoses including Chronic Systolic Heart Failure.

The quarterly MDS, dated [DATE REDACTED], showed the resident was cognitively intact and could make their needs known.

Resident 14's medical record showed the resident was discharged from the facility to the hospital on 01/09/2025 and returned to the facility on [DATE REDACTED].

Resident 14's medical record showed no physician's visit was completed after readmission from the hospital from 01/15/2025-03/06/2025 (50 days).

On 03/06/2025 at 4:10 PM, Staff A, Administrator and Staff B, Director of Nursing, acknowledged the facility physician had been on leave and were not able to get physician coverage during that time. They said residents were seen by the Nurse Practitioners or Physician's Assistants. Staff A and B acknowledged physician's visits were not completed within 30 days after admission or readmission to the facility for Residents 11 and 14.

Reference WAC 388-97-1260 (4)(c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 505507