Complaint Investigation

Avalon Care Center At Northpointe

Inspection Date: February 7, 2025

Total Violations 2

Facility ID 505496

Location SPOKANE, WA

Inspection Findings

F-Tag F640

Harm Level: Minimal harm or

Residents Affected: Some

F-F640 for additional information.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 37544 potential for actual harm Based on interview and record review, the facility failed to ensure a staff member was available to provide Residents Affected - Few assistance to a resident while they were at an appointment with a provider outside the facility and failed to provide bathing as care planned for 2 of 4 sampled residents (Resident 109 and 54) reviewed for activities of daily living.

Findings included .

The 12/26/2024 admission assessment documented Resident 109 was severely cognitively impaired, was dependent on nursing staff for activities of daily living (ADLS) such as toileting and had diagnoses which included medically complex conditions.

Review of the State Agency's reporting database showed a concern had been reported which documented Resident 109 was wheelchair bound and had conditions that required a caregiver to be with them while attending appointments with providers outside the facility. The report further documented on 01/06/2025, Resident 109 had been dropped off at an appointment without a caregiver and while at the appointment, the resident needed assistance to the bathroom.

Review of the ADL care plan documented Resident 109 required two nursing staff to assist with using the bathroom, and the resident required the use of a mechanical lift for transferring (such as from the wheelchair to the toilet).

A progress note on 01/06/2025 at 4:37 PM documented the facility's transportation driver had been sent to pick up Resident 109 from the appointment with the outside provider due to the resident exhibiting behaviors and screaming.

In an interview on 02/03/2025 at 12:15 PM, Staff O, Nursing Assistant, stated the facility sometimes scheduled a nursing assistant to go to appointments with a resident and reached out to family also to see if

they could attend with the resident.

In an interview on 02/05/2025 at 1:37 PM, Staff B, Director of Nursing, confirmed Resident 109 should have had a staff member and/or family member with them at the appointment due to needing assistance for ADLS.

In an interview on 01/28/2025 at 10:53 AM, Resident 54's representative stated the resident was not getting bathed as care planned and was told they had no one to bathe them or the facility had not hired anyone to do bathing.

According to the 10/22/2024 quarterly assessment, Resident 54 was cognitively intact and needed assistance from staff for activities of daily living, such as bathing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0677 Per the 03/23/2022 care plan, Resident 54 was to be showered/bathed one to two times per week. The resident was to be offered a bed bath if they refused to be showered. Level of Harm - Minimal harm or potential for actual harm Review of the task report bathing documentation from 09/2024 to 01/29/2025 showed the following:

Residents Affected - Few September 2024: September 25th was marked non applicable; no other bathing was documented.

October 2024: October 8th and 18th documented activity did not occur, October 10th and 23rd documented resident refused, and October 30th was marked non applicable.

November 2024: November 7th resident received a bed bath, November 14th and 19th documented resident refused, no other bathing was documented.

December 2024: December 11th resident received a bed bath, November 18th documented resident refused, no other bathing was documented.

January 2025: January 22nd and 29th resident received a bed bath, January 8th documented resident refused, no other bathing was documented.

In an interview on 02/06/2025 at 1:49 PM, Staff N, Registered Nurse, stated showers were given twice weekly unless the resident had another preference. Staff N stated if residents continued to refuse their showers management would be notified to see what interventions could be implemented for the resident to receive bathing.

During an interview on 02/06/2025 at 2:57 PM, Staff B, Director of Nursing, stated bathing was provided one to two times per week per the resident's preference. Staff B stated they were aware that Resident 54 had refused bathing and stated they preferred bed baths in the evening. Review of the care plan showed no preference for Resident 54's desire to have been given bed baths in the evening.

Reference: WAC 388-97-1060 (2)(c)

46115

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 46115 potential for actual harm Based on observation, interview, and record review, the facility failed to identify a pressure ulcer and Residents Affected - Few implement treatement timely for the development of a wound for 1 of 2 sampled residents (Resident 54), reviewed for pressure ulcers. This placed the resident at risk for unidentified wounds, worsening pressure ulcers and delayed wound healing.

Findings included .

Review of the facility policy titled, Quality of Care Skin Integrity dated 08/2018, showed the facility staff would monitor residents skin conditions and be alert to potential changes in the residents' skin condition and identified changes would be reported.

The website nih.gov - in which nih refers to national institute of health- with regard to the revised National Pressure Ulcer Advisory Panel pressure injury staging system showed a pressure injury is localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion [flow of fluid or blood to cells and tissues], comorbid condition [medical conditions that coexist and affect health and treatment], and condition of the soft tissue Stage 1 pressure injury: intact skin with a localized area of non-blanching erythema [redness that does not disappear when pressure is applied to the area] . Stage 2 pressure injury: partial thickness [involving epidermis and/or dermis] loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister Stage 3 pressure injury: full thickness [wound that extends below the epidermis and dermis into the subcutaneous tissue or deeper] skin loss, in which adipose (fat) or granulation [new connective tissue] tissue is visible in the ulcer Stage 4 pressure injury: full thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue], muscle, tendon [strong cords of tissue that connect muscle to bones], ligament [bands that connect bones and joints], cartilage [tough, flexible connective tissue that protects bones and joints, and provides structure to the nose and ears], or bone in the ulcer . unstageable pressure injury: full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead skin or tissue that can appear in a wound] or eschar [dead tissue that forms over healthy skin and eventually falls off] . Deep Tissue Pressure Injury [DTPI]: intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood filled blister It is essential that the intended staging or classification system be used for each type of injury to ensure appropriate treatment.

In an interview on 01/28/2025 at 10:53 AM, Resident 54 stated they had a sore on their left heel and had acquired it at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 During an interview on 01/28/2025 at 11:42 AM, Resident 54's representative stated the resident had a huge, rotting sore on their heel that appeared two weeks ago. The representative stated the resident had been Level of Harm - Minimal harm or dealing with the wound off and on for a year. The representative stated the area on the heel was black and potential for actual harm the staff had been circling the area with a marker. The representative stated a wound consultation was requested and nobody followed up on it. Residents Affected - Few Per the 10/22/2024 quarterly assessment, Resident 54 was admitted with diagnoses which included diabetes, Multiple Sclerosis (a disease in which the immune system breaks down the protective covering of

the nerves, the resulting nerve damage disrupts communication between the brain and body) and depression. The resident was cognitively intact, able to make their needs known and was dependent for bed mobility. The assessment showed the resident was at risk for pressure ulcers and did not currently have a pressure ulcer.

Review of the 03/23/2022 care plan showed Resident 54 had potential for skin impairment related to immobility. On 04/01/2022 the care plan was revised and showed Resident 54 had a pressure ulcer to their left heel related to immobility. The care plan was revised on 09/22/2023 to state the resident had a potential for pressure ulcer development/pressure ulcer to left heel related to immobility. The care plan was again revised on 01/28/2025 to state the resident had a pressure ulcer to their left heel related to immobility. The facility placed interventions which included:

03/23/2022 encourage good nutrition and hydration to promote healthier skin and keep skin clean and dry

02/06/2023 air mattress

04/01/2022 administer medications and treatments as ordered

09/22/2023 keep heels floated while in bed and staff to encourage resident to comply with repositioning

09/29/2023 left foot boot to keep the heel offloading

01/28/2025 betadine to left heel twice daily, United Wound Healing referral

02/03/2025 avoid exposure to temperature extremes: heating pads, hot water bottles, heat lamps, hot/cold solutions and soaks, sunburn, ice packs, avoid mechanical trauma, carefully dry between toes but do not apply lotion between toes, determine and treat cause: poor fitting shoes, poor blood sugar control, pressure area, infection, ensure appropriate protective devices are applied to affected areas, monitor blood sugar levels, monitor pressure areas for color, sensation, temperature, monitor/document wound size, document progress in wound healing on an ongoing basis, notify MD as indicated, monitor and report signs of infection, position resident off the affected area, change position every two hours and as needed, refer to foot care nurse/podiatrist, weekly treatment documentation to include measurements.

A 07/19/2024 Skin and Nutrition Review documented the left heel wound was healed. A 10/09/2024 Skin and Nutrition Review stated to discontinue the nutritional drink as the heel wound was resolved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 A 01/21/2025 Weekly Skin check documented there were no skin concerns. A 01/27/2025 Weekly Skin check documented Resident 54 had an unstageable pressure ulcer that measured five centimeters by three Level of Harm - Minimal harm or centimeters (cm) to their left heel. potential for actual harm

A 01/30/2025 Skin and Wound evaluation documented Resident 54 had a stage four pressure ulcer to their Residents Affected - Few left heel that had been present for one to three months and was facility acquired. The wound measured 7.9 cm by 5 cm and had a depth of 2.1 cm.

A 02/04/2025 progress note by United Wound Healing, stated the wound was a stage four pressure ulcer.

In an interview on 02/06/2025 at 1:43 PM, Staff GG, Nursing Assistant, stated new skin issues were reported to the nurse. When asked if the resident had any wounds, Staff GG stated they had not been at the facility for two days but when last there the resident did not have any wounds.

During an interview on 02/06/2025 at 1:49 PM, Staff N, Registered Nurse, stated skin checks were completed weekly by the nurse. Staff N stated when a wound was identified, the provider and resident representative were notified, a treatment order was obtained, alert charting, and measurements of the wound were taken. Staff N stated Resident 54 had a wound on their heel, and was unsure when it developed, they added they started working at the facility in September and thought it was acting up again but would have to check.

In an interview on 02/06/2025 at 2:05 PM, Staff C, Resident Care Manager, stated Resident 54's representative brought the pressure ulcer to their attention on 01/27/2025 and they placed a referral that day to United Wound Healing. Staff C stated a treatment for the pressure ulcer was implemented on 01/28/2024.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115

Residents Affected - Some Based on interview and record review the facility failed to ensure falls were investigated, safety interventions implemented, and residents monitored after falls were sustained for 4 of 6 sampled residents (Residents 4, 14, 30,and 90), reviewed for falls. In addition, the facility failed to assess residents for risks associated with a substance use disorder (SUD) and their ability to safely smoke for 2 of 3 sampled resident (Resident 46 and 110), reviewed. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life.

Findings included .

Review of the facility policy titled, Fall Prevention Program dated February 2020, showed residents would be evaluated for fall risk upon admission, quarterly, and as needed. The policy showed all residents would be considered at risk for falls upon admission and general precautions implemented. A fall risk decision tree would be utilized to identify potential interventions specific for each resident with identified interventions implemented and added to the resident's person-centered care plan. The policy further showed each fall would be thoroughly investigated and implementation of interventions monitored by nursing staff on a routine basis.

Review of the facility policy titled, Behavioral Health Services revised September 2018, showed the facility provided necessary behavioral health care and services to attain or maintain a resident's highest practicable physical, mental, and psychosocial well-being. The facility utilized assessment, care planning, implementation and plan revision to meet the individual resident's behavioral health needs. The policy further showed non-pharmacological interventions were to be used as clinically indicated and if a resident required more intensive behavioral health services, the facility would document reasonable attempts to provide for and/or arrange for such services.

Review of the facility policy titled, Physical Environment Smoke Free Facility revised March 2019, showed

the facility was designated smoke free within the building with the smoke-free area extending outward from

the building the distance designated by State and local laws. The policy included the utilization of electronic cigarettes, pipes, cigars, tobacco products and/or vaping equipment as smoking materials. Residents, visitors, contractors, and staff were not permitted to smoke on the property at any time.

According to the 01/26/2025 discharge assessment, Resident 110 admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED] with diagnoses including psychoactive (drug or substance that affected how the brain worked and caused changes in mood, awareness, thoughts, feelings, and behaviors) substance abuse, anxiety, and schizophrenia (mental illness that affects a person's thoughts, feelings, and actions). The assessment further showed Resident 110 was independent with making decisions regarding daily life, had fluctuating inattention and disorganized thinking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 Review of the 01/20/2025 hospital social worker mental health assessment showed Resident 110 previously eloped from the hospital and returned with progression of their bone infection. Resident 110 reported Level of Harm - Minimal harm or methamphetamine (meth/amphetamine, powerful addictive central nervous system stimulant) and alcohol potential for actual harm usage, for over [AGE] years. Resident 110 disclosed their substances of choice were meth and beer, consuming 1 ball and two cans of beer per day. Resident 110 explained they used drugs and/or alcohol to Residents Affected - Some calm down when they were mad or angry.

Review of the 01/24/2025 hospital transition of care orders showed Resident 110 used amphetamines and discontinuation of use was recommended. Hospital progress notes were included that showed Resident 110 was recently hospitalized with osteomyelitis (bone infection) in both feet but left the hospital AGAINST MEDICAL ADVICE. The notes further showed concerns of underlying psychotic illness contributed to Resident 110's recent AGAINST MEDICAL ADVICE discharge and possibly interfering with their medical decision-making capacity.

Review of the 01/25/2025 nursing admission assessment showed Resident 110 drank one beer per day and smoked meth, 1 ball per day sometimes.

Review of the 01/25/2025 wander risk assessment showed Resident 110 could move without assistance, did not have a history of wandering, had no diagnoses of cognitive impairment, and had no reported episodes of wandering in the past six months. The assessment identified Resident 110 as low risk for wandering or elopement, contrary to the hospital information.

Review of the 01/26/2025 care plan showed Resident 110 required partial assistance to complete most of their activities of daily living and used a wheelchair for mobility. The care plan showed no documentation Resident 110 had a substance use disorder, no interventions were found to address potential risks associated with a SUD.

Review of January 2025 nursing progress notes showed Resident 110 admitted to the facility on [DATE REDACTED] at approximately 3:30 PM. On 01/26/2025 at 8:00 PM, staff were unable to locate Resident 110 to administer their bedtime medication. At 8:15 PM, an elopement was called. At 8:20 PM, the building was searched inside and out, staff were unable to locate Resident 110. At 8:30 PM, law enforcement was notified of the missing resident. On 01/27/2025 at 7:11 AM, Resident 110 was located at a local hospital, the resident left

the facility and was drinking alcohol and did not know how to get back to the facility. No documentation was found to show what occurred with Resident 110 after the facility located them at the local hospital.

In an interview on 02/05/2025 at 3:30 PM, Staff P, Nursing Assistant, was unsure what staff were trained to recognize signs and/or symptoms of substance use, how the facility dealt with potential emergencies related to substance use or how the facility assessed for potential risks associated with substance use such as a resident leaving the facility without staff knowledge. Staff P further stated the facility cared for residents with SUDs but had not seen it care planned.

In an interview on 02/05/2025 at 3:44 PM, Staff Q, Licensed Practical Nurse (LPN), stated the facility used a wander risk assessment to assess for elopement risk. Staff Q further stated the facility monitored resident behaviors for potential signs and/or symptoms of substance use. Staff Q reviewed Resident 110's medical record. Staff Q acknowledged Resident 110 had a SUD with a history of smoking a ball of meth a day but no care plan was implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 In an interview on 02/05/2025 at 4:08 PM, Staff C, Resident Care Manager (RCM), stated the facility determined if a resident had a SUD history by reviewing the medical records. Staff C was unsure how Level of Harm - Minimal harm or residents with SUD were assessed for potential risks associated with substance use. Staff C acknowledged potential for actual harm the facility cared for residents with history of SUDs. Staff C reviewed Resident 110's medical record. Staff C acknowledged Resident 110 had psychoactive substance abuse listed as a diagnoses but did not have a Residents Affected - Some care plan or interventions implemented. Staff C further stated Resident 110 eloped from the facility, drank alcohol, was unable to get back to the facility, and ended up in the hospital.

In an interview on 02/06/2025 at 11:29 AM, Staff L, Social Service Director (SSD), explained a SUD disorder could be use of alcohol, marijuana, or an illicit substance that alters a person's life. Staff L explained resident records were reviewed to attempt to determine if a resident had a history of SUD and a social service psychosocial evaluation with questions on SUD was to be completed. Staff L reviewed Resident 110's medical record. Staff L acknowledged Resident 110 had a SUD diagnoses but a social service psychosocial evaluation with questions on SUD was not completed and Resident 110 did not have a SUD care plan with interventions implemented.

In an interview on 02/26/2025 at 1:17 PM, Staff B, Director of Nursing, was unsure if the facility had an assessment to assess for risks associated with SUD. Staff B further stated the facility maintained resident safety by monitoring resident behaviors and implementing care plan interventions. Staff B reviewed Resident 110's medical record. Staff B stated Resident 110 admitted on the weekend and social services did not have time to complete their assessment because Resident 110 eloped prior.

In an interview on 02/06/2025 at 1:31 PM, Staff A, Administrator, stated a SUD would fall under the facility's behavioral health program policy, the facility did not have a policy specifically for dealing or managing SUDs.

The 12/04/2024 quarterly assessment showed Resident 46 had diagnoses including anxiety and depression, was cognitively intact and able to make their needs known.

Review of the 08/20/2024 hospital history and physical showed the resident had an alcohol level of less than ten and a urine toxicology which was positive for cannabinoids. The intake stated the resident used marijuana seven days per week.

Review of the 08/25/2024 nursing admission assessment showed Resident 46 used marijuana.

Review of the 08/28/2024 care plan showed showed no documentation Resident 46 had a SUD, no interventions were found to address potential risks associated with a SUD.

In an interview on 02/05/2025 at 3:44 PM, Staff Q reviewed Resident 46's medical record. Staff Q acknowledged Resident 46 had a history of SUD, but no care plan was implemented.

In an interview on 02/05/2025 at 4:08 PM, Staff C reviewed Resident 46's medical record. Staff C stated Resident 46 did not have a SUD listed as a diagnosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 In an interview on 02/06/2025 at 10:32 AM, Staff C stated Resident 46 was asked on 01/18/2025 if they had smoked marijuana and they stated yes. Staff C stated when asked on 01/19/2025 if they had smoked Level of Harm - Minimal harm or marijuana because they had glossed eyes and slurred speech, the resident stated they were not going to potential for actual harm smoke it earlier but was shaking their head yes and that they would hide it outside. Staff C stated there was no assessment to assess for marijuana use, the nurses used their clinical judgment, notified providers and Residents Affected - Some placed the resident on alert charting for continued monitoring. When asked if counseling was offered for drug use, Staff C stated they were unsure, but they had meetings for those dealing with alcohol abuse.

In an interview on 02/06/2025 at 11:29 AM, Staff L acknowledged Resident 46 voiced marijuana use but when asked Resident 46 would deny a SUD. Staff L reviewed Resident 46's medical record. Staff L acknowledged Resident 46 did not have a SUD care plan or interventions implemented.

During the entrance conference meeting on 01/28/2025 at 8:42 AM, with Staff A, when asked if the facility had residents who smoked, Staff A stated the facility was a non-smoking facility but they had smokers and residents who smoked and they had to be 25 feet away from the building and there were no designated smoking times, since residents had to be independent to smoke.

The 12/04/2024 quarterly assessment showed Resident 46 had diagnoses including stroke, respiratory failure and high blood pressure, was cognitively intact and able to make their needs known. They required assistance for transfers and wheelchair mobility.

An 08/28/2024 care plan documented Resident 46 was a smoker or used an electronic cigarette/vape device and would not smoke without supervision.

An 08/28/2024 smoking screen documented the resident smoked one to two times per day, had visual deficits, was unable to demonstrate a safe technique for extinguishing matches/lighter and dispose of ashes safely, unable to retrieve a cigarette if it were dropped, unable to use a fire extinguisher to extinguish a fire as a result of smoking and used medications that could cause drowsiness. The resident stated they stopped smoking one month prior.

A 11/23/2024 hospital note documented the resident had reported smoking cigarettes and that they had never used smokeless tobacco.

A 01/22/2025 provider note documented the resident was seen related to their falls and their smoking regimen was discussed as they were going outside to smoke. The resident informed the provider they had vaped. The provider advised cessation; however, the resident was not going to quit smoking.

Resident 46 was not observed smoking during the survey.

In an interview on 02/06/2025 at 10:16 AM, Staff N, Registered Nurse, stated smoking supplies were kept in

the nurse's carts and they thought smoking assessments were completed quarterly and with a significant change in condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 During an interview on 02/06/2025 at 10:32 AM, Staff C when asked who smoked on the unit, stated Resident 46 did, but had not seen them go outside to smoke since they had moved to the unit. Staff C stated Level of Harm - Minimal harm or the resident smoked on 01/28/2025 when they were on the east side of the facility. Staff C stated the potential for actual harm resident should have had another smoking assessment when they found out they were smoking again. Staff C stated it was brought up in a progress note on 01/18/2025 that the resident had smoked. Staff C added the Residents Affected - Some smoking assessment was important to ensure the resident was capable of smoking without injuring themselves, capable of disposing the cigarette in a safe area and that they could hold the cigarette safely. Staff C stated the facility was non-smoking, but the residents had a right to smoke. Staff C stated the smoking area was on the facility grounds, in the corner to the right of the parking lot when you exited the front door. Staff C stated they should have a fire blanket and there were fire extinguishers on all hallways. Staff C stated they have not provided supervision for any of the smokers because they have never had anyone that needed it. When Staff C was asked to look at Resident 46's smoking assessment from 08/28/2024, they stated the resident needed supervision and was unsafe to smoke independently.

In an interview on 02/06/2025 at 11:09 AM, Staff A stated the facility did not have a fire blanket because they were a non-smoking facility and to get a blanket would say they were a smoking facility. Staff A stated they did not have a designated smoking area, and the residents went 25 feet away from the front entrance of the building. Staff A stated when Resident 46 arrived at the facility they smoked cigarettes, and they educated them on doing so. Staff A stated the resident was unsafe to smoke independently. Staff A stated the facility did not provide supervision for smokers and they could not stop them from going outside to smoke. Staff A stated they offered cessation and needed to make sure the residents were safe. Staff A stated if the resident could not get themselves outside to smoke, they were not allowed to smoke. Staff A stated Resident 46 should have had a new smoking assessment after they returned from the hospital in November.

During an interview on 02/06/2025 at 12:36 AM, the Fire Marshall stated the facility needed to define their policy that they were a non-smoking facility and that smoking was not allowed on the property or if they allowed smoking on the property the area that the residents were allowed to smoke had to be defined and must be 25 feet away from entrances, exits, windows, and ventilation intakes. The facility also needed to have things ready such as a fire blanket, fire extinguisher and a place to dispose of cigarettes.

<FALLS>

According to the 12/05/2024 quarterly assessment, Resident 4 had diagnoses including a right hip fracture, dementia and high blood pressure. The assessment further showed Resident 4 had not sustained a fall since

the most recent admission but had undergone a surgery to repair the fracture. Resident 4 was cognitively intact and able to make their needs known.

The 11/23/2024 discharge assessment showed Resident 4 had two or more non injury falls, two or more falls with minor injury and one fall with major injury.

Review of the 12/02/2024 fall risk evaluation showed Resident 4 had a history of falls and was at risk for additional falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 Review of the 12/02/2024 risk for falls care plan showed Resident 4 slid from their wheelchair on 05/07/2024, slid in the bathroom on 05/28/2024, rolled out of bed on 06/28/2024, slid from edge of bed onto floor on Level of Harm - Minimal harm or 09/09/2024, found on floor on 10/23/2024, had an unwitnessed fall on 11/07/2024, res found on floor on potential for actual harm 11/08/2024 and had three unwitnessed falls on 11/23/2024. The care plan had multiple fall interventions in place to include placing a fall mat on the floor which was initiated on 10/10/2022. Residents Affected - Some Per the 10/23/2024 incident investigation, Resident 4 had a fall when they had attempted to transfer from their bed to their wheelchair without assistance. The intervention was to place an impact mat at bedside to reduce injury with falls. Resident 4 hit their head and received a hematoma (a localized collection of blood that pools in an area). The resident was supposed to have a fall mat in place as care planned on 10/10/2022, but that had not occurred.

In an interview on 02/07/2025 at 9:36 AM, Staff B stated the impact mat was probably the same as the floor mat, same concept. Staff B stated Resident 4 should have had a fall mat in place prior to the fall on 10/23/2024 to help prevent injury.

According to the 12/03/2024 admission assessment, Resident 14 had diagnoses including atrial fibrillation (irregular heartbeat), dementia and repeated falls. The assessment further showed Resident 46 had a fall prior to admission. Resident 14 was cognitively impaired and was able to make their needs known.

Review of the 11/27/2024 fall risk evaluation showed Resident 14 had a history of falls and was at risk for additional falls.

Review of the 11/27/2024 risk for falls care plan, last updated 01/30/2025, showed Resident 14 had unwitnessed falls on 12/08/2024, 12/09/2024, 12/10/2024, 01/04/2025 and 01/07/2025. The care plan had multiple fall interventions in place which included the bed against the wall, a floor mat in front of the bed, and for the resident not to be left alone in their room in their wheelchair.

In an observation on 01/30/2025 at 1:53 PM, Resident 14 was lying in bed asleep. There was a fall mat on

the resident's right side of the bed. The bed was not up against the wall and there was no fall mat on the left side of the bed.

During an observation on 02/03/2025 at 09:43 AM, Resident 14 was sitting in their wheelchair in their room alone.

In an observation at 11:29 AM, that same day, the resident was brought to their room by a nursing assistant and was alone in their wheelchair in their room. At 11:49 AM, the resident was lying in bed with a fall mat on their right side, the bed was not up against the wall and there was no fall mat on the left side of the bed.

In an observation on 02/03/2025 at 2:05 PM, the resident was lying in bed and there was no fall mat on the floor. At 2:11 PM, Resident 14 was sitting on the side of the bed yelling they needed to go to the bathroom. At 2:14 PM, the resident attempted to stand and sat back down on the bed. At 2:17 PM, the resident sat up and then laid back down.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 During an observation on 02/04/2025 at 8:57 AM, Resident 14 was lying in bed and had no fall mat on the floor. At 1:26 PM, the resident was sitting in their wheelchair in their room alone. Level of Harm - Minimal harm or potential for actual harm In an observation on 02/07/2025 at 8:08 AM, the resident was sitting in their wheelchair in their room alone.

Residents Affected - Some During an interview on 02/07/2025 at 12:09 PM, Staff GG, Nursing Assistant, stated fall risk interventions were found on the care plan. Staff GG stated Resident 14 was a fall risk and had fall mats and interventions needed to be implemented to minimize the risk of injury.

In an interview on 02/07/2025 at 12:12 PM, Staff B stated the expectation was for nursing staff to follow the care planned interventions and it was important to prevent future falls and to keep the resident safe.

47328

According to the 01/14/2025 quarterly assessment, Resident 90 had severe cognitive impairment and sustained two or more falls while in the facility. The assessment further showed Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation.

Review of 11/15/2024 hospital notes showed Resident 90 had progressive dementia with frequent falls including a recent ground level fall that resulted in a neck fracture.

Review of the 11/20/2024 fall risk evaluation showed Resident 90 had a history of multiple falls in the past 3 months.

Review of the 11/20/2024 care plan showed Resident 90 was at risk for falls and instructed staff to anticipate resident needs, ensure the call light was within reach, maintain a safe environment, ensure proper footwear was worn, and keep commonly used items within reach. The care plan further showed Resident 90 sustained 9 falls, two falls on 11/22/2024, and additional falls on 11/23/2024, 11/25/2024, 12/26/2024, 01/07/2025, 01/11/2025, 01/15/2025, and on 01/22/2025.

Review of November 2024 nursing progress notes showed on 11/18/2024 the facility transported Resident 90 from the hospital to the facility for admission. During transport Resident 90 repeatedly attempted to get out of their wheelchair (WC) while the vehicle was in motion requiring the driver to pull over three times. Once at the facility, staff attempted to admit Resident 90, but the resident was too impulsive to participate in

the admission process with several attempts to self-transfer out of the WC, bed, and off the toilet with redirection only successful for a short time. Resident 90 was unaware of their safety needs and required constant supervision as they would transfer in less than a minute and seemingly required one on one supervision as Resident 90's safety would be compromised if left alone at any time. Resident 90 was transported back to the hospital for more adequate and safer placement at a later time. Resident 90 returned to the facility for admission on 11/20/2024. The notes further showed Resident 90 sustained three falls prior to having one-on-one supervision initiated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 Review of the Resident 90's fall incident reports showed the following:

Level of Harm - Minimal harm or -11/22/2025 unwitnessed fall near the nurses' station. A 12/15/2024 summary showed a new intervention to potential for actual harm provide activities that promote exercise and strength building when possible. Review of the care plan showed

this intervention was initiated on 11/20/2024, four days prior to the fall. Residents Affected - Some -11/23/2024 unwitnessed fall self-transferring out of bed. A 12/15/2025 summary showed a new intervention of physical therapy consult for strengthening was added. Review of provider orders showed physical therapy was ordered on 11/20/2024, three days prior to the fall.

-11/23/2024 (second fall that day) staff overheard resident having an unwitnessed fall. A 12/15/2024 summary showed a new intervention of 1:1 care.

-11/24/2024 fall during staff assist. A 12/15/2024 summary showed a new intervention of safety reminders to resident. Review of the care plan showed this intervention was initated 01/31/2025, seven days after Resident 90 discharged the facility.

-11/25/2025 fall while working with therapy. A 12/15/2024 summary showed a new intervention of medication review. Review of the record showed no documentation Resident 90's record was reviewed for high-risk medications.

-12/07/2024 no incident report provided. Nursing progress notes showed Resident 90 had a near miss fall in

the bathroom.

-12/26/2024 fall during staff assisted toileting. A 01/26/2025 summary showed a new intervention of using a mechanical lift for transfers as needed was initiated.

-01/07/2025 witnessed fall near bed. A 01/30/2025 summary showed a new intervention of activities that minimize falls while providing diversion and distraction was implemented.

-01/11/2025 fall during staff assist. A 01/31/2025 summary showed an intervention of reviewing past falls to determine root cause and removing potential fall causes was implemented. No specific intervention was identified.

-01/15/2025 fall during staff assist. A 01/31/2025 summary showed a new intervention of right side of bed placed against the wall with fall mat on floor in front of bed.

-01/22/2025 witnessed fall during resident transport to the bathroom. A 01/31/2025 summary showed an intervention of reminding resident to lock wheelchair brakes was implemented.

In an interview on 02/05/2025 at 2:28 PM, Resident 90's power of attorney (POA, person who can make healthcare decisions) stated Resident 90 had numerous falls at home, including a fall that resulted in a neck fracture prior to facility placement. The POA further stated Resident 90 sustained a few falls prior to the facility implementing 1:1 monitoring. The POA was concerned Resident 90 continued to fall even after 1:1 monitoring was implemented and wondered how that was possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 According to the 01/21/2025 admission assessment, Resident 30 admitted to the facility on [DATE REDACTED] with diagnoses including stroke with weakness and/or paralysis affecting one side of the body. The assessment Level of Harm - Minimal harm or further showed Resident 30 sustained a fall in the month prior to admission and a fracture related to a fall in potential for actual harm the past six months. Resident 30 was cognitively intact and able to clearly verbalize their needs.

Residents Affected - Some Review of the 01/06/2025 history and physical showed Resident 30 had an unwitnessed fall on 12/22/2024 with head injury and loss of consciousness. On 12/23/2024 Resident 30 had a craniotomy (surgical procedure where part of the skull was removed to access the brain) performed to remove a hematoma (collection of blood that pools outside of a blood vessel).

Review of the 01/15/2025 fall risk evaluation showed Resident 30 had a history of falls and was at risk for additional falls.

Review of the 01/15/2024 risk for falls care plan showed Resident 30 had an unwitnessed fall on 01/18/2025 and instructed staff to anticipate resident needs, clip the call light to the bed within reach, ensure commonly used items were within reach and resident wore appropriate footwear.

Review of the 01/18/2025 facility fall incident report showed Resident 30 had an unwitnessed fall reaching for their call light at 1:15 AM. Upon assessment a bump was noted to the back of Resident 30's head and neurological (neuro, series of simple tests done to assess how the brain and nervous system was functioning) assessment was initiated. Review of the attached neurological flow sheet instructed staff to obtain vital signs and complete neuro checks every 15 minutes x one hour, then every 30 minutes x one hour, then every hour x four hours, then every four hours x 24 hours. The form documented vital signs, and neuro checks every 15 min x the first hour through 2:15 AM, then starting again at 6:00 AM, nearly four hours later, not as instructed on the form.

Review of the January 2025 nursing progress notes showed Resident 30 had an unwitnessed fall on 01/18/2025 at 1:15 AM. No documentation of vital signs or neuro assessment was found between 2:15 AM and 6:00 AM. At 7:04 AM, Resident 30 was medicated for a headache. At 1:44 PM, Resident 30's family member visited and was unhappy with cares. The provider was notified of Resident 30's fall that morning, the provider assessed Resident 30, and Resident 30 was transported to the hospital for further evaluation related to hitting their head after having a recent craniotomy.

Review of 01/18/2025 provider progress note showed Resident 30 sustained a fall around 1:00 AM with redness and swelling noted to the right side of the head. Resident 30 reported 5 out of 10 pain (on a scale of 0-10, 0 being no pain and 10 being worst pain experienced). Resident 30 explained they hit the same location on their head as the previous fall that occurred on 12/23/2024 (prior to admission) that resulted in a craniotomy. Resident 30 was transferred to the hospital for additional testing.

In an interview on 01/31/2025 at 4:06 PM, Resident 30's family member explained Resident 30 had a recent fall out of bed and hit their head. Resident 30 was on blood thinners and experienced a brain bleed before. Resident 30's family member had to insist Resident 30 be sent to the hospital for further evaluation because

the facility was not monitoring them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0689 In an interview on 02/06/2025 at 3:54 AM, Staff N, Registered Nurse, explained residents were assessed for fall risk upon admission, quarterly, and when a fall occurred. Staff N further stated when a fall was Level of Harm - Minimal harm or unwitnessed neuro checks were to be performed, a fall incident report was to be completed, and care plan potential for actual harm updated with a new intervention. Staff N acknowledged if a new fall intervention was not implemented timely

it could lead to further falls. Residents Affected - Some

In an interview on 02/07/2025 at 8:58 AM, Staff C, Resident Care Manager, explained neuro checks were performed for unwitnessed falls, if the resident was a poor historian and when a resident hit their head during

a fall. Staff C further stated a resident was to be placed on alert charting to monitor for latent injuries and care plan updated with a new fall intervention to prevent reoccurrence. Staff C stated they expected staff to monitor residents and implement interventions when falls occurred.

In an interview on 02/07/2025 at 9:18 AM, Staff B, Director of Nursing, defined a fall as any unplanned change in plane and explained a new intervention should be implemented each time a fall occurred to prevent further falls. Staff B stated staff were expected to complete fall incident reports, implement new interventions, and follow the facility fall policies when falls occurred.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 505496

F-Tag F758

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115

Residents Affected: Few allegations of abuse for 2 of 3 sampled residents (Residents 30 and 83), reviewed for abuse. The facility

F-F758 for additional information.

47328

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115 potential for actual harm Based on observations, interview and record review, the facility failed to thoroughly investigate potential Residents Affected - Few allegations of abuse for 2 of 3 sampled residents (Residents 30 and 83), reviewed for abuse. The facility further failed to investigate falls for 2 of 6 sampled residents (Residents 4 and 14) reviewed for falls. Specifically, Resident 30 had a fall in which they alleged the call light had been removed by staff and the call light concern was not investigated and Resident 83 had a scabbed area on their arm allegedly caused by staff and the cause of the scab was not investigated to rule out abuse. This failure placed residents at risk of further potential abuse and diminished quality of life.

Findings included .

Review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation revised November 2017, showed staff would conduct a thorough investigation of allegations.

In an interview and observation on 01/28/2025 at 2:49 PM, Resident 83 stated a week or two ago a nursing assistant was rough when they repositioned them and bumped their arm on the tray table. The resident stated they did not think staff liked them because they had to call for things because they could not get out of

the bed. The resident was lying in bed and had a scab similar in size to a sunflower seed on their right forearm.

Per the 09/26/2024 quarterly assessment, Resident 83 had diagnoses of stroke with hemiplegia (paralysis that affected one side of the body) and anxiety. Resident 83 had severe cognitive impairments and was not able to make their needs known.

The 06/20/2024 care plan stated the resident had an activity of daily living performance deficit and required substantial to maximal assistance with repositioning in bed.

Review of the 01/28/2025 facility investigation showed Resident 83 had an older scab, a light purple/pink discoloration and a dark blue bruise to their right forearm. According to the investigation, Resident 83 was cognitively intact, and never stated someone was rough with them. The resident used their forearms to scoot and adjust themselves which would explain the bruising and scabbed areas. There were no staff interviews included in the investigation. It was determined that no abuse or neglect occurred.

During an interview on 02/06/2025 at 1:01 PM, Staff L, Social Service Director, stated they asked Resident 83 how they got the scab, and the resident stated they got it from a girl. Staff L stated the resident was more cognizant since medications changes had been made.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0610 In an interview on 02/06/2025 at 3:46 PM, Staff B, Director of Nursing, was notified of the statement made by Resident 83 regarding the scab during the conversation with Staff L and was asked how they were able to Level of Harm - Minimal harm or rule out abuse. Staff B stated they were unaware of the comment about the scab. Staff B read the progress potential for actual harm note that staff L had made regarding the allegation of abuse, and it did not include the part about the scab or

the girl. Residents Affected - Few

During an interview on 02/06/2025 at 3:59 PM, Staff B was present, Resident 83 stated they were flipped in bed, and did not think it was an accident. Resident 83 stated the person had been rough in flipping them from left to right. Resident 83 gave Staff B a description of what the person looked like.

In an interview on 02/06/2025 at 4:11 PM, Staff B stated the investigation needed to be continued and they were going to look at staffing to see if a staff member fit the description, they were given by Resident 83.

During an interview on 02/07/2025 at 11:33 AM, Staff B stated it was important to do a thorough investigation to keep the resident safe and the expectation was for staff that did interviews related to the investigation needed to present complete information.

According to the 01/21/2025 admission assessment, Resident 30 had diagnoses including stroke with weakness and/or paralysis affecting one side of the body. Resident 30 was cognitively intact and able to clearly verbalize their needs.

A 01/20/2025 nursing progress note documented Resident 30 was told they activated their call light too often and the call light was removed from their reach. Resident 30 stated they were looking for their call light and fell out of bed.

The 01/20/2025 facility incident report documented Resident 30's family member reported Resident 30's call light was moved out of their reach and they fell on [DATE REDACTED]. The investigation contained three resident and three staff interviews that asked three simple questions 1) who were falls reported to, 2) should residents always have access to a call light, and 3) were staff allowed to take away a resident's call light. The incident report did not include staff or witness statements about the specific nature of Resident 30's allegation that their call light had been taken away due to excessive use. A 01/24/2025 investigation conclusion showed abuse and/or neglect was ruled out through interviews and determined Resident 30's call light was placed in

a way that it had most likely fallen off the bed and was not taken away from the resident.

In an interview on 01/31/2025 at 4:06 PM, Resident 30 stated the nurse told them they pushed their call light too much and took the call light away. Resident 30 explained they fell out of bed recently because they were trying to reach their call light.

In an interview on 02/07/2025 at 9:28 AM, Staff C, Resident Care Manager, stated when an allegation of abuse was received, resident safety was the first priority, then they would notify Staff A, Administrator, because they were the abuse coordinator. Staff C was unsure how an allegation of abuse was investigated. Staff C acknowledged reports of rough care and staff taking resident call lights away were potential allegations of abuse that needed to be investigated as such.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0610 In an interview on 02/07/2025 at 11:19 AM, Staff B stated when allegations of abuse were received, they were reported to the State Survey Agency and investigated. Staff B explained abuse and/or neglect was Level of Harm - Minimal harm or ruled out by conducting resident and staff interviews. Staff B acknowledged reports of rough care and staff potential for actual harm taking resident call lights away were potential allegations of abuse that needed to be investigated as such.

Residents Affected - Few In an interview on 02/07/2025 at 12:03 PM, Staff A, Administrator, stated they expected staff to complete thorough investigations for allegations of abuse and/or neglect.

the most recent admission but had undergone a surgery to repair the fracture. Resident 4 was cognitively intact and able to make their needs known.

Review of the 12/02/2024 fall risk evaluation showed Resident 4 had a history of falls and was at risk for additional falls.

Review of the 12/02/2024 risk for falls care plan showed Resident 4 was at risk for falls related to confusion, balance problems, and history of falls.

An 11/10/2024 progress note documented the resident was found lying on their floor mat in their room. The resident was sent to the hospital for behaviors.

On 02/05/2025 the investigation for the fall on 11/10/2024 was requested and Staff A sent an email stating there was no investigation as the resident was sent to the hospital.

In an interview on 02/07/2025 at 9:36 AM, Staff B stated the fall on 11/10/2024 should have been logged on

the required incident log and investigated.

According to the 12/03/2024 admission assessment, Resident 14 had diagnoses including atrial fibrillation (irregular heartbeat), dementia and repeated falls. The assessment further showed Resident 14 had a fall prior to admission. Resident 14 was cognitively impaired and was able to make their needs known.

Review of the 11/27/2024 fall risk evaluation showed Resident 14 had a history of falls and was at risk for additional falls.

Review of the 11/27/2024 risk for falls care plan, last updated 01/30/2025, showed Resident 14 was at risk for falls related to deconditioning, balance problems, incontinence, vision and hearing problems and medication use.

A 01/16/2025 progress note documented Resident 14 was found in their room on the floor mat next to the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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 0610 On 02/03/2025 at 12:30 PM the investigation for the fall on 01/16/2025 was requested and Staff A stated there was no investigation as they were not notified of the fall. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/07/2025 at 9:34 AM, Staff B stated the fall on 01/16/2025 should have been logged on

the incident log and investigated and it was important to put interventions in place to help prevent falls and Residents Affected - Few monitor the effectiveness of the interventions.

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

47328

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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

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

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47328 potential for actual harm Based on interview and record review the facility failed to routinely timely and accurately complete Minimum Residents Affected - Some Data Sets (MDS - an assessment tool) for 9 of 11 sampled residents (Residents 3, 12, 14, 39, 82, 83, 90, 109, and 510), reviewed for timely MDS assessment completion. This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life.

Findings included .

Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11 revised October 2024, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. The MDS contained data elements that reflect the acuity level of

the resident, including diagnoses, treatments, and an evaluation of the resident's functional status. A RAI (MDS, CAA process, and utilization guidelines) assessment must be completed initially and periodically for any resident residing in the facility. The assessment reference date (ARD) was the end of the resident

observation period and served as the reference point for determining the care and services captured on the MDS assessment.

According to the 09/28/2024 quarterly assessment, Resident 3 required supervision up to partial assistance to complete most activities of daily living (ADL).

Review of Resident 3's 12/29/2024 quarterly assessment showed the assessment observation end date was 12/29/2024. The assessment further showed it was not signed as completed as of 02/05/2025.

According to the 12/19/2024 quarterly assessment, Resident 12 was able to perform most ADLs independently. The assessment further showed the observation end date was 12/19/2024 and was signed as completed on 02/04/2025.

Review of the 12/20/2024 discharge assessment showed Resident 12's discharge date was 12/20/2024. The assessment further showed it was signed as completed on 02/04/2025.

According to the 10/13/2024 quarterly assessment, Resident 39 required substantial up to dependent staff assistance to perform most ADLs. The assessment further showed the observation end date was 10/13/2024 and was signed as completed on 10/25/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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

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

F 0641 Review of Resident 39's 01/01/2025 annual assessment showed the observation end date was 01/01/2025 and the assessment was not signed as completed as of 02/06/2025. Level of Harm - Minimal harm or potential for actual harm <Resident 82>

Residents Affected - Some According to the 09/26/2024 quarterly assessment, Resident 82 required supervision up to partial assistance to complete most ADLs. The assessment further showed the observation end date was 09/26/2024 and was signed as completed on 10/14/2024.

Review of Resident 82's 12/27/2024 quarterly assessment showed the observation end date was 12/27/2024 and the assessment was signed as completed on 02/05/2025.

Review of Resident 82's discharge assessment showed Resident 82 discharged from the facility on 01/24/2025 with a return not anticipated. The assessment further showed it was signed as completed on 02/05/2025.

According to the 09/26/2024 quarterly assessment, Resident 83 was dependent on staff assistance to perform most ADLs. The assessment further showed the observation end date was 09/26/2024 and was signed as completed on 10/14/2024.

Review of Resident 83's 12/27/2024 quarterly assessment showed the observation end date was 12/27/2024 and was signed as completed on 02/05/2025.

According to the 01/09/2025 admission assessment, Resident 510 admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED] with a return not anticipated. The assessment further showed it was not signed as completed as of 02/06/2025.

Review of an against medical advice (AMA) release form showed Resident 510 discharged from the facility AMA on 01/09/2025.

During an interview and record review on 02/05/2025 at 12:09 PM, Staff E, MDS Director, explained the process for completing MDS assessments included reviewing data in resident records to complete the MDS by the ARD. Staff E acknowledged the facility was behind on completing MDS assessments, as required. Staff E provided a list of MDS assessments that were currently late. Review of the MDS in progress list from 11/01/2024 through 02/04/2025 showed 76 MDS's were still in progress beyond the ARD.

37544

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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

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

F 0641 According to the 12/03/2024 admission MDS assessment, section B showed Resident 14 was able to make themselves understood and understood others, however this conflicted with the information under section C Level of Harm - Minimal harm or which documented Resident 14 was not interviewed due to being severely cognitively impaired and rarely or potential for actual harm never understood. The assessment further documented Resident 14 had diagnoses which included non-Alzheimer's dementia. Residents Affected - Some

Review of the nursing progress notes from 11/27/2024 through 02/04/2025 showed Resident 14 was cognitively impaired, had dementia, was alert to self only, but able to make needs known at times.

According to the 12/26/2024 admission MDS assessment, section B showed Resident 109 was sometimes able to make themselves understood and usually understood others, however this conflicted with the information under section C which documented Resident 109 was not interviewed due to being severely cognitively impaired and rarely or never understood.

According to the 11/26/2024 admission assessment, Resident 90 had diagnoses including dementia. Section B of the assessment documented Resident 90 was able to make themselves understood and understood others, however this conflicted with the information under section C which documented Resident 90 was not interviewed due to being severely cognitively impaired and rarely or never understood. The assessment further showed the observation end date was 11/26/2024 and was signed as completed on 12/04/2024.

Review of Resident 90's quarterly assessment showed the observation end date was 01/14/2025 and was signed as completed on 02/01/2025.

Review of Resident 90's 01/24/2025 discharge assessment showed Resident 90 discharged from the facility

on 01/24/2025 with a return not anticipated. The assessment further showed it was not signed as completed as of 02/03/2025.

In an interview on 02/04/2025 at 3:18 PM, Staff B, Director of Nursing, was asked about the conflicting information in sections B and C of Resident 14, 109, and 90's MDS assessments. Staff B stated a resident was marked as being able to make themselves understood and understanding others when they have the ability to make their needs known whether in a verbal or non-verbal manner and staff understood them. Staff B explained to be marked rarely or never understood meant the resident could not respond verbally, in writing or by using any other method. Staff B acknowledged Resident 14, 109 and 90's assessments did not accurately reflect the resident's status as of the ARD and should have.

In a follow-up interview on 02/05/2025 at 12:29 PM, Staff B acknowledged the facility was behind on completing MDS assessments, as required.

In an interview on 02/05/2025 at 12:37 PM, Staff A, Administrator, acknowledged the facility was behind on completing MDS assessments, as required. Staff A stated they expected staff to complete MDS assessments per the required time frames.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 505496 Department of Health & Human Services Printed: 09/09/2025 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 505496 B. Wing 02/07/2025

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

Avalon Care Center at Northpointe 9827 North Nevada Spokane, WA 99218

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

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

F 0641 Refer to

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Avalon Care Center At Northpointe

Inspection Findings

F-Tag F640

F-Tag F758

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