Snohomish Of Cascadia, Llc

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to thoroughly investigate incidents for one of one resident (Resident 1) reviewed for medication errors. This failure prevented the facility from identifying the potential causes of the occurrence, placed residents at risk for repeated errors, substantial injury, left unanswered questions whether the incident was potentially related to neglect, and unmet care needs. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. <RESIDENT 1>Resident 1 admitted to the facility on [DATE REDACTED] with diagnoses to include fistula (an abnormal tube-like passage that connects two parts of the body that are not normally connected) of the vagina to small intestine, and ileostomy (an opening on your abdomen that diverts stool to from the small intestine directly to the outside of the body). Review of the facilities State Incident Reporting log, dated August 2025 did not show a medication error for Resident 1.

Review of the facilities Med Error Reporting Log Form did not show a medication error for Resident 1.

Review of a physician progress note dated 08/21/2025 showed Resident 1 was having diarrhea and creatinine (shows kidney function) was elevated. Assessment/Plan: Will give 1 liter (L) normal saline (NS).

Review of Resident 1's physician orders showed a prescriber entered order dated 08/21/2025 for Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 1 liter intravenously one time only for diarrhea for 3 days give 1L NS. Review of Resident 1's Medication Administration Record (MAR) dated August 2025 showed an entry dated 08/21/2025 at 8:15 PM PENDING CONFIRMATION Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 1 liter intravenously one time only for diarrhea for 3 days give 1L NS. There was no documentation on the MAR that IV NS was administered. In

an interview on 09/15/2025 at 11:00 AM, Staff D, Licensed Practical Nurse (LPN) stated if a medication error was identified an incident report would be initiated.In an interview on 09/15/2025 at 1PM, Staff E, LPN, Nurse Manager, stated if a medication error was identified, an investigation would be completed by

the Director of Nursing (DNS) or Assistant Director of Nursing. In an interview on 09/15/2025 at 1:26 PM, Staff B, DNS stated if a medication error was identified the medication error would be investigated to determine if it is a true medication error and then guidelines would be followed. Staff B acknowledged that a medication error investigation was not completed for Resident 1. Reference WAC 388-97-0640 (6)(a)

Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Snohomish of Cascadia, LLC

800 10th Street Snohomish, WA 98290

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

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

been confirmed. Staff B stated the expectation was for the nurse to notify the provider and document if they were unable to start an IV and if unable to place an IV after 24 hours, they should notify the provider. Staff B stated unconfirmed orders will stay in the computer as pending until discontinued or confirmed. Staff B stated they would attempt to find documentation that the provider was notified of attempts to place an IV for Resident 1 and provide if found. In an interview on 09/15/2025 at 2:43 PM, Staff B stated they were unable to find documentation of provider notification. No further information was provided. Refer to WAC 388-97-1060 (3)(k)(iii)

Event ID:

Facility ID:

If continuation sheet