Health Inspection - AVALON CARE CENTER AT NORTHPOINTE

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 20 of 81 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115 potential for actual harm Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Residents Affected - Few Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions], was completed after an exempted hospital stay for 1 of 5 sampled residents (Resident 46), reviewed for PASARR services. This failure placed the resident at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs.

Findings included .

Per the [DATE REDACTED] quarterly assessment, Resident 64 admitted to the facility in [DATE REDACTED] from the hospital and had diagnoses which included depression and anxiety.

Review of Resident 46's record showed a level I PASARR was completed prior to admission on [DATE REDACTED] by

the hospital, which showed a level II PASARR (a more in-depth screening, to identify whether nursing home services were needed, and if specialized mental health services were required), was needed, due to meeting

the guidelines for an exempted hospital stay (meaning the resident was admitted to the facility directly from a hospital after receiving acute inpatient care, and the expected stay at the facility was 30 days or less).

Further record review showed Resident 46 did not discharge from the facility within 30 days or less as expected and was currently still a resident at the facility. A new PASARR was not completed until [DATE REDACTED], 40 days after the exempted 30-day stay had expired.

In an interview on [DATE REDACTED] at 1:11 PM, Staff L, Social Service Director, stated the PASARR should have been completed timely and this was important so recommendations could be implemented to care for the resident's mental health.

Reference: WAC [DATE REDACTED] (1)(2)(a-c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 81 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 22 of 81 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)

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 81 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 37544 potential for actual harm Based on observation, interview and record review, the facility failed to consistently monitor and provide Residents Affected - Some bowel care timely for 7 of 7 sampled residents (Residents 23, 36, 54, 62, 4, 39, and 46) reviewed for constipation. This failure placed the residents at risk for medical complications and unmet care needs.

Findings included .

The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for activities of daily living (ADLS) such as toileting.

On 01/28/2025 at 3:51 PM, Resident 23 was observed lying in bed watching television. During the conversation with the resident, they stated they took pain medications and had trouble with constipation at times.

Review of the Order Summary Report from 11/15/2024 through 02/04/2025 documented on 11/15/2024, the physician had ordered a laxative (Senna tablets) to be given on an as needed basis if the resident had not had a bowel movement (BM) in 48 hours, and if the resident still had not had a BM 24 hours after receiving

the Senna, an additional laxative (Miralax) was to be given.

Review of the bowel records from 01/04/2025 through 02/01/2025 documented Resident 23 had not had a BM on the following dates as follows:

- 01/06/2026 through 01/12/2025, a period of seven days

- 01/16/2025 through 01/20/2025, a period of five days, and

- 01/28/2025 through 01/31/2025, a period of four days.

Review of the January 2025 Medication Administration Record (MAR) showed the Senna and Miralax had not been administered as ordered during the above time frames, and no documentation was found in Resident 23's record that stated the reason for the omissions.

In an interview on 02/03/2025 at 9:33 AM, Staff R, Licensed Practical Nurse, stated bowel medication was usually given if a resident had not had a BM in 72 hours, unless the physician had ordered something different. After discussion and review of Resident 23's record, Staff R confirmed that bowel medication should have been administered on the dates identified, and if the medication had been offered and refused it should have been documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 81 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 0684 The 12/16/2024 quarterly assessment documented Resident 36 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for ADLS such as toileting Level of Harm - Minimal harm or potential for actual harm Review of the Order Summary Report from 01/01/2025 through 02/06/2025 documented on 11/06/2023, the physician had prescribed both Senna tablets and Miralax to be administered on an as needed basis for Residents Affected - Some constipation (no time frame was specified).

Review of the bowel records from 01/05/2025 through 02/03/2025 documented Resident 36 had not had a BM from 01/18/2025 through 01/22/2025, a period of five days.

Review of the January 2025 MAR showed neither the as needed Senna or Miralax had been administered or offered to Resident 36 during the above time frame, and no documentation was found in the resident's

record that stated the reason for the omission.

In an interview on 02/04/2025 at 11:03 AM, Staff N, Registered Nurse, stated the facility process was to give bowel medication after 72 hours unless the physician had ordered something different for the resident.

In an interview on 02/05/2025 at 1:10 PM, Staff B, Director of Nursing (DNS), stated the expectation was residents would be offered bowel care medication after 48 hours of not having a BM unless the resident's provider had ordered differently. After review of Resident 23 and Resident 36's records, Staff B confirmed bowel care medication should have been offered.

The 12/05/2024 quarterly assessment documented Resident 4 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for ADLS such as toileting.

Review of the 10/11/2022 care plan documented the resident was at risk for constipation and had interventions which instructed nursing to monitor BMs and implement interventions as ordered.

Review of the January 2025 MAR documented on 12/02/2024, the physician had ordered laxatives (Miralax and Senna) to be given as needed.

Review of the bowel records from 01/05/2025 through 02/02/2025, documented Resident 4 had not had a BM on the following dates:

- 01/22/2025 through 01/26/2025, except for a small BM on 01/26/2025, a period of five days

- 01/28/2025 through 01/30/2025, a period of three days

Additional review of the MARS for January 2025 and February 2025, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 48's record that stated the reason for the omissions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 81 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 0684 Per the 10/22/2024 quarterly assessment, Resident 54 was cognitively intact, able to make decisions regarding their cares, and needed assistance from staff for ADLS, such as toileting. Level of Harm - Minimal harm or potential for actual harm Review of the 03/23/2022 care plan documented the resident was at risk for constipation secondary to reduced mobility and use of pain medication and had interventions which instructed nursing staff to monitor Residents Affected - Some BMs and implement interventions as ordered.

Review of the January 2025 MAR documented on 11/06/2023 the physician had ordered laxatives Miralax and Senna to be given as needed. On 01/18/2024, the physician had ordered the following laxatives: Lactulose every two hours as needed times three and if no BM give Milk of Magnesia daily as needed and if no BM give a Bisacodyl suppository.

Review of the bowel records from 01/01/2025 through 01/31/2025 documented Resident 54 had not had a BM on the following dates:

-01/01/2025 through 01/08/2025, a period of eight days

-01/20/2025 through 01/24/2025, except a small BM on 01/21/2025

a period of five days

-01/25/2025 through 01/28/2025, except for a small BM on 01/27/2025 and 01/28/2025, a period of four days

Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 54's

record that stated the reason for the omissions.

Per the 10/13/2024 quarterly assessment, Resident 39 was cognitively impaired, unable to make decisions regarding their cares, and needed assistance from staff for ADLS, such as toileting.

Review of the 10/12/2018 care plan documented the resident was at risk for constipation and had interventions which instructed nursing staff to monitor BMs and implement interventions as ordered.

Review of the January 2025 MAR documented on 09/29/2023 the physician had ordered the following laxatives: Lactulose every two hours times three doses and if no BM give Milk of Magnesia as needed and if no BM after six hours, give a Bisacodyl suppository. On 11/06/2023 the physician had ordered Miralax and Senna as needed.

Review of the bowel records from 12/29/2024 through 01/29/2025 documented Resident 39 had not had a BM on the following dates:

-12/31/2024 through 01/05/2025, except for a small BM on 01/01/2025 and 01/03/2025, a period of six days

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 81 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 0684 -01/08/2025 through 01/11/2025, except a small BM on 01/08/2025 and 01/09/2025, a period of three days

Level of Harm - Minimal harm or -01/27/2025 through 01/29/2025, a period of three days potential for actual harm Additional review of the MARS for January 2025 documented the resident had not received the bowel Residents Affected - Some medication as ordered during the above time frames, and no documentation was found in Resident 54's

record that stated the reason for the omissions.

Per the 12/04/2024 quarterly assessment, Resident 46 was cognitively impaired, able to make decisions regarding their cares, and needed assistance from staff for ADLS, such as toileting.

Review of Resident 46's record showed no care plan for constipation.

Review of the January 2025 MAR documented on 11/17/2024 the physician had ordered the following laxatives: Senna as needed for no BM after 48 hours and Miralax for no BM after the Senna was administered.

Review of the bowel records from 01/01/2025 through 01/30/2025 documented Resident 46 had not had a BM on the following dates:

-01/04/2025 through 01/08/2025, a period of five days

-01/11/2025 through 01/13/2025, a period of three days

-01/15/2025 through 01/17/2025, a period of three days

-01/22/2025 through 01/24/2025, a period of three days

Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 54's

record that stated the reason for the omissions.

In an interview on 02/06/2025 at 10:16 AM, Staff N, Registered Nurse, stated the bowel protocol was initiated

on day three of no BM. Staff N stated the bowel protocol should have been initiated for the above time frames. At 1:49 PM that same day, Staff N stated a small bowel movement did not count.

During an interview on 02/07/2025 at 9:36 AM, Staff B, DNS, stated bowel medications should have been administered as ordered and this was important to prevent a bowel obstruction.

Per the 12/15/2024 quarterly assessment, Resident 62 had diagnoses including kidney disease (damage to

the kidneys in which they lose function) and diabetes. The resident was cognitively intact to make decisions regarding their care. The resident was always incontinent of bowels and had an indwelling catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 81 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 0684 Review of the December 2024 MAR documented on 12/09/2024, the physician ordered a laxative, Senna, to be offered as needed for constipation and given for no BM after 48 hours. An additional laxative, Miralax, Level of Harm - Minimal harm or was to be offered as needed for constipation and given for no BM 24 hours after Senna. potential for actual harm

In an observation and interview on 01/28/2025 at 3:18 PM, Resident 62 was laying in bed, eating snacks, Residents Affected - Some and watching television. The resident stated that they have had issues with constipation and the medications were variable in relief.

Review of the bowel records from 01/01/2025 through 01/30/2025, showed Resident 62 had no BM's from 01/01/2025 through 01/05/2025 (5 days), 01/08/2025 through 01/10/2025 (3 days) and 01/26/2025 through 01/28/2025 (3 days).

Additional review of the MARS for January 2025 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 62's

record that stated the reason for the omissions.

In an interview on 02/06/2025 at 3:06 PM, Staff T, Licensed Practical Nurse, confirmed Resident 62 did not have a BM on the above dates and the bowel protocol should have been followed.

Reference (WAC): 388-97-1060(1)

46115

50027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 81 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 29 of 81 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 30 of 81 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 31 of 81 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 0687 Provide appropriate foot care.

Level of Harm - Minimal harm or 46115 potential for actual harm Based on interview and record review, the facility failed to ensure a physician ordered foot care referral for a Residents Affected - Few podiatrist was followed for 1 of 2 sampled residents (Resident 54), reviewed for wound care. This failure placed the resident at risk for skin impairment, discomfort, and a diminished quality of life.

Findings included .

Per the 10/22/2024 quarterly assessment, Resident 54 had diagnoses which included diabetes, Multiple Sclerosis (a disease in which the immune system breaks down the protective covering of the nerves and the resulting nerve damage disrupts communication between the brain and the body), and depression. The resident was cognitively intact and able to make their needs known.

In an interview on 01/28/2025 at 10:53 AM, Resident 54's representative stated the resident's toenails were extremely bad and had curled over their toes. The representative stated they were told the facility could not get a podiatrist to come into the facility. The representative stated the nurse practitioner did the resident's toenails on 01/27/2025.

Review of a 09/30/2024 provider progress note showed Resident 54 had long/thick toenails and needed a podiatry referral to evaluate and treat the resident for hypertrophic toenails (thickened, overgrown toenails that can cause pain, discomfort, and difficulty with footwear).

In an interview on 02/06/2025 at 1:49 PM, Staff N, Registered Nurse, stated nursing staff processed provider orders. Staff N stated if a resident had a podiatry referral, depending on their insurance, the resident would have an appointment arranged with an outside provider.

During an interview on 02/07/2025 at 7:46 AM, Staff C, Resident Care Manager, was asked why the order in September for podiatry was not followed and they stated the facility was trying to get a podiatrist to come into

the facility to see the residents and was unsure if residents could be sent out to see the podiatrist.

In an interview on 02/07/2025 at 7:48 AM, Staff L, Social Service Director, stated the facility was getting a list of residents who needed podiatry because they were trying to get a podiatrist to come into the facility. Staff L stated they could send the residents out to see the podiatrist.

During an interview on 02/07/2025 at 7:53 AM, Resident 54 stated they did not leave the facility for appointments because it was too hard for them to do so.

In an interview on 02/07/2025 at 11:05 AM, Staff B, Director of Nursing, was asked if the resident's nail care could have occurred earlier than January and they stated staff could have asked the provider sooner to assist with nail care and nursing could have attempted nail care as well. Staff B stated nail care was important to prevent infections. At the time of the survey exit Resident 54 had still not been seen by a podiatrist.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 81 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 33 of 81 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 34 of 81 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 35 of 81 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 36 of 81 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 37 of 81 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 38 of 81 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 39 of 81 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 40 of 81 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 41 of 81 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 42 of 81 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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Actual harm 46115

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutrition were maintained for 2 of 2 sampled residents (Residents 4 and 14) reviewed for nutrition. Resident 4 experienced harm when they had a significant weight loss of 7.9% in approximately three months and 14. 29% in six months. Resident 14 experienced harm when they had a significant weight loss of 8.51% in one month and their weight loss was not reported to the dietician. This failure placed the residents at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life.

Findings included .

Review of the facility policy titled, Nutrition and Hydration dated 01/22/2021, showed residents would be provided with the nutrition and hydration needed to attain or maintain a healthy nutritional status, to the extent possible, and to identify residents with special needs or at risk for nutritional deficiencies. Residents whose nutritional screen indicated a risk for nutritional deficiencies, or current nutritional deficiencies, will be further evaluated by the Registered Dietician (RD) to identify nutritional needs and potential interventions. Meal intake will be documented following each meal to assist in early identification of reduced intake. A resident who takes less than 50% of a meal will be offered an alternate meal. A resident with consistently low intake of meals may be referred to the RD for evaluation and recommendation.

A significant weight loss is defined as a 5% loss in one month, a 7.5% loss in three months and a 10% loss

in six months.

Per the 12/05/2024 quarterly assessment, Resident 4 had diagnoses which included malnutrition (reduced availability of nutrients that leads to changes in the body composition and function), depression and dementia. The resident was cognitively intact, did not reject cares, and was able to eat with set up assistance and had no weight loss.

Resident 4's 10/04/2022 comprehensive care plan had the following care areas implemented:

-Activities of daily living (ADL) self-care performance deficit, the resident is independent for eating with set-up assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 81 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 0692 -Risk for alteration in nutritional status related to increased nutritional needs secondary to healing needs as evidenced by bone fracture and surgical incision, altered metabolism (glucose) as evidenced by diabetes, Level of Harm - Actual harm irritable bowel syndrome, gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), chronic obstructive pulmonary disease (a group of lung diseases that makes it Residents Affected - Few difficult to breathe), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which disrupts your metabolism), increased risk for disordered eating patterns secondary to anxiety and depression; interventions included to give diet as ordered-regular textures, regular/thin consistency of fluids, provide and serve supplements as ordered, updated 12/08/2024 to give a nutritional shake three times per day, weights per protocol, encourage fluids, Registered Dietician to evaluate and make diet change recommendations as needed.

A 03/07/2024 Nutritional Screen assessment by the Registered Dietitian (RD) documented Resident 4 was 59.7 inches tall and weighed 146.6 lbs.; was eating 75-100% of their meals and there was no usual body weight listed. Resident 4 had no edema, and their weight was relatively stable with minimal fluctuations over

the past quarter to year.

A 11/09/2024 Nutritional Evaluation assessment by the RD documented Resident 4's weight was 138.6 lbs., and the resident was consuming 50-74.9% of their meals and 25-49.9% of their snacks. The RD stated weight was relatively stable with minimal fluctuations past quarter to year, down 9.8% this past year, beneficially, ongoing weight monitoring in place.

A 12/08/2024 Nutritional Evaluation assessment completed by the RD documented Resident 4 weighed 138 lbs. and their weight had been stable over the past quarter to year with a gradual downward trend considered beneficial. The resident was eating 25-49.9% of their meals. The weight loss was attributed to fluid loss post-surgery for hip fracture. The weight was relatively stable with minimal fluctuation over the past quarter to year, down 9.8% this past year. Resident's intake poor to fair since readmission.

A review of the record showed Resident 4 had lost 14.29% in 6 months and 7.9% in approximately 3 months.

The resident had the following weights listed:

1/29/25 123.6 lbs.

12/27/24 123.4 lbs.

11/5/24 134.2 lbs.

7/26/24 144.2 lbs.

Per the medication administration record, a nutritional shake was ordered on 12/13/2024 to be given three times a day. The record showed there had been no evaluation to determine whether other interventions would be beneficial for Resident 4's weight loss although they had continued weight loss from July 2024-December 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 81 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 0692 In an observation on 01/31/2025 at 12:03 PM, Resident 4 was sitting in their wheelchair with their lunch in front of them. Resident 4 was eating a roll and had not touched anything else on their tray. At 12:20 PM, Level of Harm - Actual harm Resident 4 was eating the roll and had a bite of fish. At 12:38 PM, the resident stated the fish and vegetables were not good and was eating a few bites of cake. The resident did not consume anything else on their tray Residents Affected - Few and was not given an alternate meal or a nutritional shake by staff.

In an observation on 02/03/2025 at 12:05 PM, Resident 4 was asleep in bed and had no meal tray in their room. At 12:32 PM, 1:35 PM, 2:03 PM and 2:55 PM, the resident remained asleep, and no lunch or nutritional shake was offered to the resident. At 2:03 PM, 2 nursing assistants entered the resident's room and stated Resident 4 was not feeling good.

In an interview on 02/07/2025 at 9:04 AM, Staff C, Resident Care Manager, stated weight loss interventions should have been implemented prior to 12/12/2024. Staff C stated they could have added a nutritional supplement and monitored Resident 4 to ensure they were getting adequate nutrition. Staff C added this could have prevented some of Resident 4's weight loss.

During an interview on 02/07/2025 at 10:13 AM, Staff B, Director of Nursing, stated when a resident had experienced weight loss, nutritional supplements and snacks would be encouraged, weight loss would be monitored, weight loss triggers assessed, and the RD would make a recommendation. Staff B stated nursing can also put interventions in place for weight loss. Staff B stated Resident 4 took snacks, not routinely, had no edema (swelling), and had no orders in place for weight loss and was unsure why they did not. Staff B added putting an intervention in place prior could have prevented some of Resident 4's weight loss.

Per the 12/03/2024 quarterly assessment, Resident 14 had diagnoses which included malnutrition (reduced availability of nutrients that leads to changes in the body composition and function), depression and anxiety.

The resident was severely cognitively impaired and needed set up to touching assistance with meals and had no weight loss.

Resident 14's 11/27/2024 comprehensive care plan had the following care areas implemented:

-Resident has a nutritional problem or potential nutritional problem, and will maintain adequate nutritional status as evidenced by maintaining weight and no signs and symptoms of malnutrition through the review date, this was updated on 12/10/2024; interventions included to give diet as ordered-regular textures soft and bite sized, regular/thin consistency of fluids, provide and serve diet as ordered, monitor intake and record every meal, weigh and record per provider order and facility protocol, and RD to evaluate and make diet change recommendations as needed.

A 12/02/2024 Nutritional Screen assessment by the RD documented Resident 14 was 65 inches tall and weighed 116.4 lbs.; was eating 50-74.9% of their meals and there was no usual body weight listed. Resident 14 had no edema, and their weight might fluctuate status post hospitalization for a fracture.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 81 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 0692 A 12/02/2024 Nutritional Evaluation assessment by the RD documented Resident 14's weight was 116.4 lbs. , and the resident was consuming 50-74.9% of their meals and 25-49.9% of their snacks. The RD stated Level of Harm - Actual harm weight was relatively stable with minimal fluctuations past quarter to year, down 9.8% this past year, beneficially, ongoing weight monitoring in place. The resident might benefit from gradual weight gain or Residents Affected - Few stability of weight given current body mass index and ideal body weight.

A review of the record showed Resident 14 had lost 8.51% in 1 month. The resident had the following weights listed:

12/26/24 106.5

11/27/24 116.4

A 12/11/2024 provider note stated Resident 14 was at risk for malnutrition due to dementia, poor intake, altered texture, was malnourished, and had end stage dementia and hospice was to see the patient on 12/12/2024.

Review of the record showed no evaluation was completed to determine the need for further interventions for Resident 14's significant weight loss.

In an observation on 01/31/2025 at 11:17 AM, Resident 14 was sitting in the dining room and was taking bites of their dessert. The resident had not consumed any other food on their tray. The nursing assistant explained to the resident what was on their tray, and they declined to eat. The licensed nurse in the dining room stated the resident liked Boost (a nutritional supplement). At 11:29 AM, Resident 4 was not given a nutritional supplement or alternate meal. Resident 14 was asked if they wanted to go back to their room and

they stated yes. At 11:32 AM, the nursing assistant brought the resident to the nurse and reported that they did not eat their lunch.

On 1/31/2024 at 11:36 AM, the doctor assisted Resident 14 to their room for an assessment. At 12:09 PM,

the resident was given a shower. At 12:41 PM the resident was assisted to sit in the hall and no nutritional supplement or alternate meal had been given to the resident. At 2:06 PM, the resident was asleep in their wheelchair.

During an observation on 02/03/2025 at 11:06 AM, Resident 14 was sitting in the dining room and taking bites of their food independently. At 11:11 AM a nursing assistant asked if the resident needed help to eat and moved their dessert closer to them. At 11:16 AM, the resident had consumed three quarters of a glass of milk and approximately five percent of their food. At 11:26 AM, the resident had stopped eating and had not consumed any further food. At 11:29 AM, the nursing assistant brought Resident 14 back to their hall, placed them in their room and got a stand aid to assist them to the restroom. At 11:36 AM, the nursing assistant left

the hall and did not report poor meal intake to the licensed nurse.

On 02/03/2025 at 11:49 AM, Resident 14 was assisted to bed and was not offered an alternate meal or nutritional shake.

On 02/06/2025 at 4:21 PM, Staff G, Nursing Assistant, stated when a resident had poor intake they were offered an alternate meal, the nurse was notified and would decide if a nutritional shake was needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 81 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 0692 In an interview on 02/06/2025 at 4:24 AM, Staff H, Registered Dietician, stated Resident 14 had lost 10 lbs.

in one and a half weeks, had a low body mass index and probably needed weight gain. Staff H stated the Level of Harm - Actual harm resident was evaluated by the other dietician before they started working at the facility, so it was hard to catch everything when you're stepping in, so the resident slipped through the cracks. Staff H stated it would Residents Affected - Few have been good for the nursing assistants and unit manager to bring the weight loss to their attention. Staff H added Resident 14 should have had interventions such as a nutritional supplement and nutritionally enhanced meals added. Staff H stated they should have been notified since they were new to the building.

In an interview on 02/07/2025 at 8:15 AM, Staff C stated the dietician was new and believed they checked

the weights and if not, they were discussed in their weekly nutrition at risk meeting. Staff C added interventions should have been added for Resident 14's weight loss and nursing could have obtained orders for a supplement from the provider. Staff C was unsure why Resident 14 was never seen by hospice.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 81 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50027 potential for actual harm Based on observation, interview, and record review the facility failed to ensure respiratory treatments had Residents Affected - Some provider orders, that provider orders were carried out, and care plan goals and interventions were developed for 3 of 3 sampled residents (Residents 71, 358 and 359), reviewed for respiratory care. These failures placed residents at risk for respiratory complications and a diminished quality of life.

Findings included .

Review of the facility policy titled, Quality of Care Respiratory Care dated July 2018, showed the facility would provide residents with necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan and choices. The policy included a list of respiratory therapy modalities that could be provided at the facility which included breathing techniques, CPAP (continuous positive air pressure, a treatment that used pressure to keep the airway open by way of a mask) use, and oxygenation support. Staff were to assess and monitor a resident's respiratory condition, including their response to therapy provided and any changes in respiratory conditions. The policy further showed residents who required respiratory services would have physician orders and a resident-centered respiratory care plan implemented. Oxygen therapy could be provided through various delivery systems, and the provider order was to include an indication for use, equipment to be used, oxygen levels to initiate and/or discontinue oxygen therapy.

Per the 01/29/2025 admission assessment, Resident 359 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease that made it hard to breathe) and cardiomyopathy (heart muscles too weak to pump blood). The assessment further showed Resident 359 did not receive oxygen therapy. Resident 359 was cognitively intact and able to clearly verbalize their needs.

Review of provider orders as of 02/06/2025 showed Resident 359 had no orders for oxygen therapy administration, care and/or maintenance of oxygen equipment and tubing.

Review of the January 2025 through February 2025 nursing progress notes showed Resident 359's oxygen level was 96% on 01/24/2025 and 92% on 01/30/2025, with use of oxygen via nasal cannula (tubing used for oxygen flow).

Review of the 01/28/2025 COPD care plan instructed staff to administer medications as ordered, include resident in care planning, and identify ways to reduce sources of respiratory irritations. Review of the 01/30/2025 altered respiratory status care plan instructed staff to elevate the head of the bed, monitor for signs and/or symptoms of respiratory infection, respiratory distress, and abnormal breathing patterns. No documentation was found to show Resident 359 received oxygen therapy or how to maintain oxygen equipment or tubing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 81 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 0695 In an observation on 01/28/2025 at 1:04 PM, there was an oxygen concentrator (a medical device that supplies oxygen for breathing) plugged in with an attached nasal cannula at Resident 359's bedside. There Level of Harm - Minimal harm or was an Oxygen in Use sign posted on the door. Similar observations were made on 01/29/2025 at 11:49 AM potential for actual harm and 01/31/2025 at 9:23 AM.

Residents Affected - Some In an observation and interview on 01/28/2025 at 3:46 PM, Resident 359 was in bed and the oxygen concentrator was at their bedside. Resident 359 stated they used 2 liters (L) of oxygen nightly.

In a follow-up observation and interview on 02/03/2025 at 10:43 AM, Resident 359 was in bed and had an oxygen nasal canula in their nose. Resident 359 stated they recently completed a physical therapy session and applied the oxygen afterwards. A similar observation was made on 02/05/2025 at 4:25 PM.

In an interview on 02/06/2025 at 12:35 PM, Staff T, Licensed Practical Nurse (LPN), stated residents who had lung disease would generally have orders for oxygen therapy in place to enable their breathing to perform daily activities. Staff T reviewed Resident 359's medical record. Staff T acknowledged Resident 359 had no orders for oxygen therapy.

In an interview on 02/06/2025 at 1:26 PM, Staff U, Resident Care Manager (RCM), stated Resident 359 should have had oxygen therapy orders in place along with a care plan.

Per the 01/30/2025 admission assessment, Resident 358 had diagnoses including heart failure (heart cannot pump enough blood) and sleep apnea (a sleep disorder in which breathing stopped and started repeatedly

during sleep). The assessment further showed Resident 358 used oxygen therapy and did not use a CPAP. Resident 358 was cognitively intact to verbalize their needs.

In an observation and interview on 01/28/2025, Resident 358 was sitting in their wheelchair, and a CPAP machine was on their nightstand. Resident 358 stated they were admitted to the facility on [DATE REDACTED] with their personal CPAP machine. Resident 358 explained during the admission process, an unknown staff told them not to be concerned about wearing their CPAP because it would be set up that night. Resident 358 stated their CPAP machine was assembled three days later on 01/27/2025 and they wore it for three hours.

Per review of the provider orders as of 02/07/2025 showed Resident 358 had no order for routine CPAP use, CPAP settings, cleaning and/or changing the filter.

Review of the 01/24/2025 self-care deficit care plan showed Resident 358 was dependent on staff assist to perform most activities of daily living. The 01/24/2025 altered respiratory status care plan instructed staff to elevate the head of the bed, administer oxygen therapy via nasal cannula, monitor for signs and/or symptoms of respiratory distress and changes in breathing pattern. No documentation was found for Resident 358 to wear a CPAP routinely, CPAP settings, cleaning and/or changing the machine filter.

Review of the January 2025 nursing progress notes showed no documentation Resident 358 used or had a CPAP machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 81 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 0695 In an observation on 01/28/2025 at 3:46 PM, Resident 358 was asleep in bed and their CPAP machine sitting on the nightstand. Level of Harm - Minimal harm or potential for actual harm During an interview and observation on 01/29/2025 at 11:12 AM, Resident 358 stated they forgot to use their CPAP machine last night. Resident 358 stated staff assisted them by putting on the CPAP mask and filling Residents Affected - Some the reservoir with distilled water. The CPAP machine remained on the nightstand with a jug of distilled water. Similar observations were made on 02/03/2025 at 10:17 AM and 02/05/2025 at 4:26 PM.

In an interview on 02/06/2025 at 12:14 PM, Staff V, Nursing Assistant, stated they had not observed Resident 358 with their CPAP mask in place the mornings they worked. Staff V acknowledged Resident 358 has had the CPAP machine in their room since they were admitted to the facility.

In an interview on 02/06/2025 at 12:20 PM, Staff T, LPN, stated Resident 358 utilized their CPAP machine at night since their admission and were monitored every hour when they went to bed. Staff T reviewed Resident 358's medical record. Staff T acknowledged Resident 358 had no provider orders for use of their CPAP machine, CPAP settings, cleaning and/or changing the machine filter. Staff T further stated Resident 358 should have CPAP orders implemented so staff were informed of the respiratory care needs.

In an interview on 02/06/2025 at 1:24 PM, Staff U, RCM, stated that when a resident was admitted with their own CPAP machine, staff acknowledged their settings used at home. Staff U further stated it was important to have physician orders for CPAP use so staff were able to appropriately care for the resident.

Per the 01/02/2025 quarterly assessment, Resident 71 had diagnoses including respiratory failure (serious condition where the lungs cannot get enough oxygen), COPD and sleep apnea. Resident 71 was cognitively intact and able to make decisions regarding their care.

In an observation and interview on 01/29/2025 at 9:50 AM, Resident 71 was lying in their bed and had their personal CPAP machine on their nightstand. Resident 71 stated they had not worn their CPAP machine for

the last two nights because they fell asleep before they could apply it.

In an observation and interview on 01/31/2025 at 08:49 AM, Resident 71 was laying in their bed. Resident 71 again stated they did not wear their CPAP machine last night because they were tired and fell asleep before

they could apply it.

In an observation and interview on 02/03/2025 at 10:20 AM, Resident 71 stated if they were asleep, staff did not wake them up to apply their CPAP.

In an observation and interview on 02/05/2025 at 9:50 AM, Resident 71 was laying in their bed and was hardly able to keep their eyes open. Resident 71 again stated they did not use the CPAP machine last night and were tired.

In an observation and interview on 02/6/2025 at 3:35 PM, Resident 71 was lying in their bed and more alert than previous days. Resident 71 stated they used their CPAP machine last night.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 81 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 0695 Review of the 12/05/2024 self-care deficit care plan showed Resident 71 was dependent on staff assist to perform most activities of daily living. The 12/05/2024 altered respiratory status care plan instructed staff to Level of Harm - Minimal harm or elevate the head of the bed, monitor for respiratory distress, administer medications as ordered, and use a potential for actual harm CPAP per home settings. No documentation was found for CPAP cleaning and/or changing the machine filter. Residents Affected - Some Per review of the provider orders showed an active 12/21/2024 order for Resident 71 to wear a CPAP nightly, refill the distilled water chamber at bedtime, remove the CPAP mask in the morning and cleanse with hot water and dish soap.

Record review of the medication administration record from 01/26/2025 to 02/03/2025, documented Resident 71 wore their CPAP at bedtime daily, when Resident 71 voiced it had not been worn.

During an interview on 02/06/2025 at 12:35 PM, Staff T, LPN, stated the night shift nurse monitored Resident 71 when they used the CPAP machine. Staff T reviewed Resident 71's medical records. Staff T stated documentation showed Resident 71 wore the CPAP machine nightly and they were unaware Resident 71 had not been wearing it.

In an interview on 02/06/2025 at 1:41 PM, Staff U, RCM, acknowledged Resident 71 had been sick recently and had not used their CPAP machine.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 81 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or 37544 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure consistent, ongoing Residents Affected - Few communication and collaboration with the dialysis facility for 1 of 2 sampled residents (Resident 23) reviewed for dialysis, a treatment that removed waste products and excess fluid from the bloodstream when the kidneys no longer functioned properly. In addition, the facility failed to ensure Resident 23's care plan included accurate goals and interventions related to the care and maintenance of the central venous catheter (CVC: a flexible tube that was inserted into a vein to provide an access site for dialysis).

Findings included .

The 11/21/2024 admission assessment documented Resident 23 was cognitively intact to make decisions regarding their care and had diagnoses which included diabetes and end stage kidney disease. In addition,

the assessment documented the resident received dialysis via an intravenous access site.

In an interview on 01/28/2025 at 3:27 PM, Resident 23 was observed lying in bed watching television. During

the conversation, the resident stated they received dialysis treatments and had a CVC that was used as the access site.

Resident 23 had the following active provider orders:

- monitor the dialysis fistula (an access site for dialysis that was created by connecting an artery to a vein) every shift for potential complications and signs of infection

- monitor the fistula for thrill (a vibration felt by feeling the fistula) and bruit (listening to the fistula for a swishing sound), and to notify the kidney physician if absent.

- complete and print the Pre-Dialysis Assessment and Communication form, ensure the form was sent with

the resident on Mondays and Fridays to their dialysis appointments, review and follow up as indicated upon return from the appointment, and to call the dialysis center if the form was not sent back with the resident.

Review of Resident 23's record found Pre-Dialysis assessment and Communication forms for the dates of 12/30/2024, 01/03/2025, 01/13/2025, 01/24/2025, and 02/03/2025, which showed out of 19 appointments,

the form had been returned five times. All of the returned forms documented Resident 23 had a CVC for the dialysis access site, and did not have a fistula.

Review of the Dialysis care plan documented interventions were implemented on 11/18/2024 which instructed licensed nursing staff to monitor, document, and report any signs or symptoms of infection to the dialysis access site. On 11/27/2024, interventions were added that instructed the licensed nursing staff to monitor the dialysis fistula every shift for a thrill, and bruit, and to notify the kidney physician if absent. No goals or interventions were found regarding a CVC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 81 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 0698 Review of the January 2025 Medication and Treatment Administration Records showed the licensed staff had documented every shift that they had checked the dialysis fistula for a thrill and bruit and signs of Level of Harm - Minimal harm or infection every shift as ordered. Additional review of the Medication and Treatment Records from November potential for actual harm 2024 through February 2025 found the licensed staff were documenting they had checked Resident 23's dialysis fistula for a thrill and bruit each shift. Residents Affected - Few

In a follow up interview on 01/31/2025 at 9:20 AM, Resident 23 was observed lying in bed watching television. When asked for clarification regarding the dialysis access site, Resident 23 stated they had never had a fistula, had a CVC, and pulled the collar of their shirt down to show the CVC on their right upper chest. Resident 23 stated they were avoiding getting a fistula as long as possible, they were ugly, had seen them burst open, they didn't last forever, had to be redone, and there was a man at dialysis whose arms looked like a snake was crawling down it because of the multiple fistula revisions they have had to had done.

In an interview on 02/03/2025 at 9:42 AM, Staff R, Licensed Practical Nurse, stated the Pre-Dialysis Assessment and Communication forms were filled out and sent with the resident, the nurses made sure it was returned with the resident, and a call was placed to the dialysis center if it wasn't. Staff R stated Resident 23 had a fistula when asked what type of access site the resident had, then immediately corrected and stated, no, the resident had a CVC. When asked about the documentation of the thrill and bruit, Staff R stated it had to be an error.

In an interview on 02/05/2025 at 1:29 PM, Staff B, Director of Nursing, stated the expectation was the Pre-Dialysis Assessment and Communication form was completed, returned with the resident and a call made if it was not. Staff B stated Resident 23 had a CVC for dialysis and stated the dialysis orders and care plan interventions should reflect that and acknowledged they did not.

Reference (WAC) 388-97-1900 (1), (6)(a-c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 81 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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47328

Residents Affected - Few Based on interview and record review the facility failed to ensure the facility had enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 3 of 8 sampled residents (Resident 83, 90 and 110), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life.

Findings included .

Review of the facility assessment updated December 2024, showed the facility was licensed for 119 beds with an average daily census of 88. The assessment further showed the facility provided care related to fall prevention, behavioral health needs, substance use disorders (SUD), nutrition services, pressure injury prevention and care, and infection prevention practices. The facility employed a staffing coordinator to assist with facility staffing needs. The assessment further showed the facility leadership utilized the facility assessment as a framework to ensure sufficient staff with the appropriate competencies and skill sets were available to care for residents' needs on each unit and shift (day, evening, night). The facility's budget was used as a staffing guide, but leadership may choose to adjust staffing based on resident needs. If the facility census increased or decreased the facility might add or reduce the number of staff on each shift. If the resident's acuity increased or decreased the facility might add or reduce additional staff on each unit. The facility's staffing contingency plan included use of on-call nurse managers and facility leadership to provide immediate coverage, overtime hours, incentives for staff to work, or use of agency staffing to maintain adequate staffing coverage.

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.

The 11/18/2024 provider order summary indicated Resident 90 did not receive antipsychotic medications (medication that affect the mind, emotions, and behaviors).

The 11/18/2024 nursing progress note documented Resident 90 was transported to the facility for admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 81 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 0725 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 Level of Harm - Minimal harm or 90, but the resident was too impulsive to participate in the admission process with several attempts to potential for actual harm 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 Residents Affected - Few 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.

The 11/18/2024 hospital progress notes showed Resident 90 was very pleasant, made eye contact, and did not show agitation. The hospital received report from the facility Resident 90 was agitated, impulsive, lacked judgement and behaved agressively. The resident had been sent to the care facility earlier in the day, but challenges had arisen due to the facility report of understaffing and inablity to provide Resident 90 with 1:1 supervision. The resident was started on a low dose antipsychotic medication, Seroquel.

Review of the 11/20/2024 hospital discharge medication list showed Resident 90 was to be administered Seroquel 25 milligrams (mg) twice daily after discharge.

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 from 11/22/2024 through 01/22/2025.

The 01/08/2025 provider progress note documented Resident 90 had increased behaviors, made inappropriate sexual gestures and was impulsive which caused an additional fall. The plan was to increase Seroquel to 100 mg three times daily. The provider also ordered for Resident 90 to receive Ativan (antianxiety medication) twice daily to reduce impulsiveness.

In an interview on 02/05/2025 at 2:28 PM, Resident 90's power of attorney (POA, person who can make healthcare decisions on ones behalf if unable to do so) stated Resident 90 had numerous falls at home, including a fall that resulted in a neck fracture prior to facility placement. The POA stated Resident 90 sustained falls at the facility, 1:1 monitoring was implemented, yet the resident continued to fall. The POA stated they were informed Resident 90 was administered medications to help reduce behavioral outbursts.

The POA stated it was their opinion the resident was overmedicated. The POA explained Resident 90 required one person for transfers using a walker on admission to the facility but could barely hold their head up and required three people to transfer out of their WC at discharge.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 81 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 0725 The 01/26/2025 discharge assessment documented Resident 110 was admitted on [DATE REDACTED], discharged on [DATE REDACTED], and had diagnoses which included psychoactive substance abuse (drug or substance that affected Level of Harm - Minimal harm or how the brain worked and caused changes in mood, awareness, thoughts, feelings, and behaviors), and potential for actual harm schizophrenia (mental illness that affected a person's thoughts, feelings, and actions). Resident 110 was independent with making decisions regarding daily life, had fluctuating inattention and disorganized thinking. Residents Affected - Few

The 01/24/2025 hospital transition of care orders documented Resident 110 used amphetamines (powerful addictive central nervous system stimulant) and discontinuation of its use was recommended. The resident had been hospitalized with a bone infection in both feet but left the hospital against medical advice. The note documented underlying psychotic illness (mental health condition where a person loses touch with reality) contributed to the resident leaving against medical advice and interfered with their medical decision-making capacity.

The 01/25/2025 wander risk assessment showed Resident 110 could move without assistance, did not have

a history of wandering, had no diagnosis 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.

The 01/26/2025 care plan documented Resident 110 required partial assistance to complete most of their activities of daily living and used a wheelchair for mobility. There was no documenation that Resident 110 had a substance use disorder (SUD), and no goals or interventions were developed regarding potential risks associated with a SUD such as leaving the facility without staff knowledge.

The January 2025 nursing progress notes documented Resident 110 arrived at the facility on Saturday 01/25/2025 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, had been drinking and was unable to find their way back to the facility. No documentation was found that showed what occurred with Resident 110 after the facility located them at the local hospital.

In an interview on 02/05/2025 at 4:08 PM, Staff C, Resident Care Manager, acknowledged Resident 110 had psychoactive substance abuse listed as a diagnoses but did not have a 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 1:17 PM, Staff B, Director of Nursing, 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 eloped prior to assessments being completed.

In an interview on 02/06/2025 at 1:31 PM, Staff A, Administrator, was asked if the facility had guidelines such as not admitting after a certain time of day or on the weekends because the facility team was not available to complete needed assessments to ensure adequate resident safety. Staff A acknowledged the process was being reviewed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 81 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 0725 <Resident 83>

Level of Harm - Minimal harm or According to the 12/27/2024 quarterly assessment, Resident 83 was dependent on staff assistance to potential for actual harm perform most activities of daily living. Resident 83 was cognitively intact and able to clearly verbalize their needs. Residents Affected - Few

In an interview on 01/28/2025 at 2:49 PM, Resident 83 stated they had excessively long call light wait times. Resident 83 explained they had a clock on their bedside table and had waited up to one hour and 40 minutes to have their call light answered.

During an interview on 02/04/2025 at 2:32 PM, the Ombudsman (a person who acted as an advocate for residents living in long-term care) stated residents expressed concerns about the facility's lack of staff.

In an interview on 02/05/2025 at 9:37 AM, Staff EE, Nursing Assistant, stated the facility did not have enough staff on the [NAME] unit because every resident required two staff assistance for cares.

In a confidential interview on 02/05/2025 at 10:07 AM, Confidential Staff 1, feared retaliation and wanted to remain anonymous. Confidential Staff 1 acknowledged the facility did not have enough staff, especially in the evenings and on weekends.

In a confidential interview on 02/06/2025 at 11:35 AM, Confidential Staff 2, feared retaliation and wanted to remain anonymous. Confidential Staff 2 acknowledged the facility did not have enough staff and some nights only one nurse worked.

In a confidential interview on 02/06/2025 at 2:07 PM, Confidential Staff 3, feared retaliation and wanted to remain anonymous. Confidential Staff 3 explained the nursing assistant section assignments were set and did not change based on resident acuity. Confidential Staff 3 was asked what occurred if staff did not have good teamwork. Confidential Staff 3 stated the section assignments were not adjusted.

In an interview on 02/06/2025 at 2:27 PM, Staff Y, Staffing Coordinator, explained the [NAME] unit residents required more staff assistance and the nursing assistant to resident ratio was about 1:10 on that hall.

In an interview on 02/07/2025 at 9:03 AM, Staff A, Administrator, stated Staff Y wore 4 different hats and explained Staff Y was the staffing coordinator, health unit coordinator, driver, and appointment scheduler. Staff A further stated some staff worked multiple double shifts and/or extra shifts. Staffing was reviewed with Staff A. Staff A acknowledged the facility utilized fewer nursing assistants when the facility census was decreased.

In an interview on 02/07/2025 at 9:06 AM, Staff B, Director of Nursing, stated staff had voiced the need for more staff but the staff scheduled was adequate and enough to meet resident needs.

Reference WAC 388-97-1080 (1), 1090 (1)

Refer to

F-Tag F641

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47328

Residents Affected: an assessment tool) for 9 of 11 sampled residents (Residents 3, 12, 14, 39, 82, 83, 90,

F-F641 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 81 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 17 of 81 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 18 of 81 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 19 of 81 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

F-Tag F758

Harm Level: Minimal harm or 46033

Residents Affected: administer their medications for 1 of 5 sampled residents (Resident 74) reviewed for medication

F-F758 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 81 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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 37544 potential for actual harm Based on interview and record review the facility failed to complete annual staff performance reviews yearly Residents Affected - Some as required and provide education based on the outcome of these reviews for 2 of 5 sampled staff (Staff P and Y), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life.

Findings included .

Review of the following Nursing Assistant (NA) personnel files found no documentation that showed a yearly performance evaluation had been completed following:

- Staff Y, Nursing Assistant

- Staff P, Nursing Assistant

In an interview on 02/03/2025 at 1:36 PM, Staff A, Administrator, stated they had not been aware there was not a process in place for completing yearly performance evaluations, and the facility was in the process of getting evaluations started.

Reference (WAC): 388-97-1680 (1), (2)(a-c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 81 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or 46115 potential for actual harm Based on interview and record review, the facility failed to ensure monitoring of potential adverse effects Residents Affected - Few from a blood thinning medication was done consistently for 1 of 5 sampled residents (Resident 22) reviewed for unnecessary medications. This failure placed the resident at risk for medical complications, unmet care needs and adverse side effects.

Findings included .

The 01/06/2025 quarterly assessment documented Resident 22 was able to make decisions regarding their care and had diagnoses which included heart failure and high blood pressure. In addition, the assessment documented the resident was taking a blood thinning medication.

The provider orders documented Resident 22 was prescribed a blood thinning medication (Xarelto). Additional orders included instruction to the licensed staff to monitor for adverse reactions such as bleeding, severe bruising, difficulty breathing or chest pain.

Review of the January 2025 Medication Treatment Record on 01/31/2025 found on the following dates and shifts, the monitoring documentation for adverse side effects of the blood thinning medication were blank and had not been completed:

- day shift from 01/02/2025 through 02/05/2025, and 02/08/2025 through 02/11/2025

- evening shift on 01/11/2025,

- night shift on 01/03/2025, 01/05/2025, 01/09/2025, 01/17/2025, 01/24/2025, and 01/25/2025.

In an interview on 02/05/2025 at 11:03 AM, Staff N, Registered Nurse, stated the expectation was that all charting/documentation was completed each shift as ordered and a progress note made if there were any issues or concerns. After review of the resident record, Staff N confirmed the documentation was blank as stated above.

In an interview on 02/05/2025 at 1:21 PM, Staff B, Director of Nursing, stated the expectation was that medication monitoring and any documentation was completed before the end of the shift. After review of Resident 22's record, Staff B confirmed the blood thinning medication had not been consistently monitored.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 81 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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 37544 potential for actual harm Based on interview and record review, the facility failed to ensure 3 of 5 sampled residents (Residents 22, 46 Residents Affected - Some and 71), reviewed for medication administration, received medication as ordered by the physician. Failure to administer insulin, a medication used to treat diabetes, and consistently monitor blood sugar levels, a test done that checked the level of sugar in the blood stream, and failure to follow the parameters for holding a blood pressure medication created significant medication errors, and placed the residents at risk for medical complications, unintended health consequences and diminished quality of life.

Findings included .

INSULIN AND BLOOD SUGAR MONITORING

The 01/06/2025 quarterly assessment documented Resident 22 was able to make decisions regarding their care and had diagnoses which included high blood pressure and Diabetes, a medical condition caused when

the body was unable to breakdown sugar. In addition, the assessment documented the resident received insulin, a medication used in the treatment of diabetes to keep blood sugar levels in the blood stream at normal ranges.

The provider ordered the following medications:

- On 01/23/2023, Humalog, a fast-acting insulin that started to work within 15 minutes, was to be administered three times a day,

- On 01/24/2023 blood sugar checks were to be done before meals, and

- On 11/07/2024, Lantus, a long-acting insulin, was to be administered twice a day

Review of the January 2025 Medication Administration Records (MARS) on 01/31/2025 found the following:

- On 01/02/2025, the Lantus was not given during the evening shift

- On 1/11/2025, the blood sugar checks had not been done before any of the meals, and neither the Humalog nor the Lantus had been given.

- On 01/24/2025, the blood sugar checks had not been done before breakfast or lunch nor had the Humalog been given, and the Lantus was not given during the dayshift.

There was no documentation that explained the reason for the omission of the blood sugars and administrations of the Humalog and Lantus on the dates above.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 81 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 0760 In an interview on 02/04/2025 at 11:01 AM, Staff N, Registered Nurse, (RN), stated medications needed to be administered as ordered by the physician and documented in the MAR and/or the progress notes if not Level of Harm - Minimal harm or given or there were concerns. After review of Resident 22's record, Staff N confirmed no documentation was potential for actual harm made that showed why the insulin and blood sugar orders had not been administered as ordered.

Residents Affected - Some <Resident 71>

The 01/02/2025 quarterly assessment documented Resident 71 had diagnoses that included end-stage renal (kidney) disease dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer functioned), diabetes and ketoacidosis (lack of insulin that causes the breakdown of fat for energy, which caused acid to build up in the blood). Resident 71 was cognitively intact and received insulin injections.

A review of Resident 71's active orders documented the resident was to have their blood sugar level obtained before meals and at bedtime. The resident was also to receive an injection of 13 units of Humalog insulin three times daily. On 01/15/2025, an order was given for resident 71 to receive additional insulin coverage after their meals and at bedtime. The amount of insulin to be received was based on the result of their blood sugar check.

Additional orders were given for Resident 71 to take sevelamer (lowered the amount of phosphorous in the blood) 2400 milligrams three times a day with meals, and to have dialysis sessions every Monday, Wednesday and Friday from 1:20 PM to 5:20 PM.

A review of the medication/treatment administration records (MAR/TAR) for January 2025 through February 05, 2025 documented Humalog insulin13 units injections were scheduled to be given each day at 7:30 AM, 11:30 AM, and 4:30 PM. On Mondays, Wednesdays and Fridays during the resident's dialysis treatments when Resident 71 was out of the facility, they missed their insulin on the following dates and times:

11:30 AM- 01/06/2025, 01/10/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025, 01/31/2025 and 02/05/2025.

4:30 PM-01/01/2025, 01/03/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/15/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025, 01/31/2025 and 02/05/2025.

Blood sugar checks with insulin coverages beginning 01/15/2025 were scheduled on the MARs to be checked and administered at mealtimes daily during the following timeframes of 6:00 AM to 10:00 AM, 10:00 AM to 2:00 PM, and 2:00 PM to 6:00 PM. Resident 71's blood sugar checks and insulin coverage were omitted on the following dates and times:

10:00 AM to 2:00 PM-01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025 and 01/31/2025.

2:00 PM to 6:00 PM-01/15/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025 and 01/31/2025.

Resident 71 also had doses of sevelamer omitted on the following dates in January 2025:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 81 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 0760 01/03/2025, 01/06/2025, 01/10/2025, 01/15/2025, 01/20/2025, 01/22/2025, 01/24/2025, 01/27/2025, 01/29/2025 and 01/31/2025. Level of Harm - Minimal harm or potential for actual harm In the areas on the MARS where the staff were to enter that the medications listed above had been administered, there was a code 1 entered. The key on the MAR documented that a code 1 indicated the Residents Affected - Some resident was out of the facility without their medications.

During an interview on 02/07/2025 at 9:03 AM, Resident 71 stated they brought a lunch with them to their dialysis sessions, but they did not receive any medications during their sessions.

During an interview on 02/07/2025 at 9:04 AM, Staff CC, Licensed Practical Nurse, stated they gave Resident 71 their medications and on the days the resident had dialysis sessions, the resident left the facility at around 10:20 AM and did not return until after 6:00 PM. Staff CC did not send any medications to dialysis with Resident 71 and entered the code 1 on the MAR. Staff CC stated they were unsure if the providers were aware the resident was not receiving their medications on dialysis days.

During an interview on 02/07/2025 at 9:50 AM, Staff DD, Physician Assistant, reviewed Resident 71's MARs with the surveyor. Staff DD stated there had been no communication from staff regarding the timing of the resident's insulins and sevelamer. Staff DD stated they would have expected staff to communicate with them regarding this so that medication doses could be adjusted or dosed differently if able so that doses were not omitted. Staff DD stated staff could assess Resident 71 to see if they were able to self-administer their medication at dialysis. If so, this also prevented doses from being omitted depending on the assessment.

BLOOD PRESSURE PARAMETERS

During review of Resident 22's January 2025 MARS on 01/31/2025, an order was found that documented on 11/23/2024, the physician had prescribed a medication (Metoprolol) to manage Resident 22's high blood pressure. The instructions directed the nursing staff to assess Resident 22's heart rate prior to administering

the medication. If the heart rate was below 50 beats per minute (bpm) the Metoprolol was to be held.

On 01/26/2025 and 01/27/2025, Resident 22's heart rate was documented to be below the parameter of 50 bpm, but the documentation indicated the Metoprolol was still given, and not held as directed in the order. No documentation was found that showed why the medication had not been held.

In an interview on 02/04/2025 at 10:57 AM, Staff N, Registered Nurse, reviewed Resident 22's record and confirmed no documentation was found that explained the reason for giving the Metoprolol when the heart rate was below the ordered parameters.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 81 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 0760 In an interview on 02/05/2025 at 1:21 PM, Staff B, Director of Nursing, stated the expectation was medications, insulin and blood sugar monitoring were to be done as ordered by the physician. After review of Level of Harm - Minimal harm or Resident 22's record, Staff B confirmed the blood sugars and insulins had not been administered as ordered. potential for actual harm With regards to Resident 22's Metoprolol, Staff B was able to locate progress notes on the dates in question, that documented the physician was notified of the low heart rate values, but no order was given to administer Residents Affected - Some the medication with the low heart rate. Staff B stated the Metoprolol should have been held.

The 12/04/2024 quarterly assessment documented Resident 46 was able to make decisions regarding their care and had diagnoses which included high blood pressure.

A review of the resident's January MARS showed the physician had prescribed a medication (Metoprolol) on 11/27/2024 to manage Resident 46's high blood pressure. The instructions directed the nursing staff to assess the resident's blood pressure and heart rate and if the systolic blood pressure (SBP, the top number of the blood pressure reading) was less than 120 and the heart rate was less than 60 bpm the Metoprolol was to be held.

On 01/02/2025, 01/06/2025, 01/08/2025, 01/11/2025, 01/12/2025, and 01/27/2025, Resident 46's SBP was documented to be below the parameter of 120, but the documentation indicated the Metoprolol was still given and not held as directed in the order. No documentation was found that showed why the medication had not been held.

In an interview on 02/06/2025 at 10:16 AM, Staff N, Registered Nurse, stated blood pressure medications needed to be held per the parameters and this was important because the resident could have a bad outcome.

During an interview on 02/06/2025 at 10:32 AM, Staff C, Resident Care Manager, stated the blood pressure medications should have been held and the provider should have been notified.

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

46033

46115

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 81 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 47328 Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure medications were stored under proper temperature controls in 2 of 3 sampled medication rooms (East and West) and in 1 of 3 medication storage refrigerators (East), reviewed for medication storage. This failure placed residents at risk of receiving less than the optimum dose of their medications, adverse side effects, and diminished quality of life.

Findings included .

During observation on 02/05/2024 at 1:16 PM, the [NAME] medication room was observed with Staff F, Licensed Practical Nurse. No thermometer was observed in the medication room where various medications were stored at room temperature.

During observation, interview, and record review on 02/07/2025 at 7:42 AM, the East medication room was observed with Staff B, Director of Nursing. No thermometer was observed in the medication room where various medications were stored at room temperature. Staff B acknowledged the East medication room did not have a thermometer to monitor the temperature of the room where various medications were stored. The refrigerator contained various insulins, intravenous medications and concentrated oral antianxiety medications. Staff B stated staff checked the medication room refrigerator temperatures every night shift.

Review of the February 2025 temperature log showed only one entry of 32 degrees on 02/06/2025. Review of the January 2025 temperature log showed temperature entries for 13 out of 31 days. Staff B acknowledged the medication room refrigerator temperature log had numerous omissions. Staff B stated

they expected staff to check the temperatures in the medication refrigerator because storing medications at inappropriate temperatures could potentially affect the quality of medications.

During an interview on 02/07/2025 at 10:35 AM, Staff A, Administrator, stated they expected staff to check

the medication room refrigerator temperatures because storing medications at incorrect temperatures could potentially affect medication quality. A policy on medication storage was requested at that time and again at 3:30 PM. No documentation was provided.

Reference WAC 388-97-1300 (2), -2340

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 81 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 37544 potential for actual harm Based on observation, interview and record review, the facility failed to provide appetizing and palatable food Residents Affected - Some for 5 of 9 sampled residents (Residents 18, 23, 36, 48 and 54) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, and a diminished quality of life.

Findings included .

The 01/13/2025 quarterly assessment documented Resident 18 was cognitively intact and able to make decisions regarding their care.

On 01/29/2025 at 9:05 AM, Resident 18 was observed in their room seated in their recliner. Resident 18 stated the food was not good, that the vegetables were mushy and any chicken they got was a processed patty. The resident stated they had been at the facility for years and could not remember when they had last seen a real chicken breast or real drumstick. Resident 18 stated the food was just thrown on the plate so that

it did not look appetizing. They stated they had talked about their concerns with the dietary staff but there had been no results.

The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care.

On 01/28/2025 at 3:27 PM, Resident 23 was observed lying in bed watching television. When asked about

the food, Resident 23 stated, they sent it back often, it was not good, they sent it back a lot, the eggs at breakfast were not edible, I have no idea what they do to them, but it smells and tastes terrible.

On 01/31/2025 at 9:20 AM, Resident 23 was observed lying in bed watching television. When asked how breakfast was, Resident 23 stated it was good, had sausage, but one time the meal looked like scraps, like someone had eaten and they were served the left-over plate.

The 12/16/2024 quarterly assessment documented Resident 36 was cognitively intact to make decisions regarding their care.

During an interview on 01/28/2025 at 10:26 AM, Resident 36 stated they were a lousy cook and the facility cook was even worse. The resident stated the food was inedible, too salty, and most of the time they usually did not eat the food, just had a sandwich.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 81 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 0804 On 01/31/2025 at 11:56 AM, Resident 36 stated they wanted a sandwich, the lunch did not taste like it should and they did not like it. At 12:18 PM, the resident received a sandwich and stated it was good. Level of Harm - Minimal harm or potential for actual harm <Resident 48>

Residents Affected - Some The 01/09/2025 comprehensive assessment documented Resident 48 had diagnoses which included gastroesophageal reflux disease (GERD) (a chronic digestive disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining) and esophageal ulcer (a sore that develops in the lining of the esophagus) with bleeding. The resident was cognitively intact to make decisions regarding their care.

In an observation and interview on 02/03/2025 at 12:48 PM, Resident 48 was lying in bed, eating their lunch meal (pork roast with gravy, spinach, rice, coffee, milk, and lemonade). The resident stated that the food was sometimes too salty and did not have enough flavor or seasoning.

The 10/22/2024 quarterly assessment documented Resident 54 was cognitively intact to make decisions regarding their care.

During an interview on 01/28/2025 at 10:40 AM, Resident 54 stated the food was not good and they used too much salt. Resident 54 stated they requested sandwiches, soup and fruit.

In an interview on 01/28/2025 at 11:42 AM, Resident 54's representative stated the food was extremely bad and the meat was too tough.

In an observation on 01/31/2025 at 11:59 AM, Resident 54 was served fish, vegetables and cake. Resident 54 stated they did not like the food and had requested a sandwich.

During an observation on 02/03/2025 at 11:53 AM, Resident 54 stated they did not like the meat and had requested a sandwich.

On 02/04/2025 at 12:49 PM, a test tray of the lunch meal was sampled by the survey team. The meal consisted of a chicken taco, baked apples, rice, and beans. The alternative entree was bar-be-que pork. The chicken in the taco tasted like it was canned and the rice and beans were bland without taste or flavor. The appearance of the meal was unappetizing, brown in appearance and without color. The bar-be-que pork was

the only item that tasted good and had flavor.

A subsequent test tray was obtained from the last cart being served during the breakfast meal and sampled by the survey team on 02/07/2025 at 8:36 AM. The temperature of the food was lukewarm. The meal consisted of hashbrowns, scrambled eggs, oatmeal with brown sugar and diced mangos. The hashbrowns tasted like they were seasoned with a salt substitute that was not appetizing. The scrambled eggs tasted flavorless and had large mushy curds. The oatmeal with brown sugar tasted bland and was soupy. The diced mangos were hard, unripe and had no fruit flavor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 81 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 0804 In an interview on 02/04/2025 at 11:34 AM, Staff W, Dietary Manager, stated they tasted the food while cooking or before tray line to assure that the food was palatable. Staff W stated that this was important for Level of Harm - Minimal harm or adequate meal consumption and maintaining nutrition for the healing of residents. potential for actual harm

During an interview on 02/04/2025 at 2:32 PM, a representative from the State Ombudsman office reported Residents Affected - Some to the survey team residents had expressed to their office multiple concerns related to the food and had requested Staff W to attend the Resident Council meetings so the concerns related to the temperature and taste of the food could be discussed, and it took six months before Staff W attended.

Reference WAC 388-97-1100 (1), (2)

46033

46115

50027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 81 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50027

Residents Affected - Many Based on observation, interview, and record review the facility failed to store, discard and distribute food, and monitor temperatures of foods being served in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life.

Findings included .

Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE REDACTED], showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be discarded as directed by the food manufacturer's use-by-date.

The U.S. FDA Food Code 2022 also showed that there was an increased risk of contamination when food was held, cooled and reheated at improper temperatures. Thus, temperatures of food must be taken and monitored. Records must be maintained to verify food temperatures are within the parameters required for food safety.

During a kitchen observation and interview on [DATE REDACTED] at 9:07 AM, the walk-in refrigerator contained a crate of approximately 36 pasteurized eggs with an expiration date of [DATE REDACTED]. Staff W, Dietary Manager, acknowledged that the eggs were expired and quickly disposed of the crate of eggs.

In an interview on [DATE REDACTED] at 12:00 PM, Staff W stated the eggs should have been discarded. Staff W stated that it was important for the prevention of bacterial growth and resident illness.

During an observation of a tray line service held in the dining room on [DATE REDACTED] at 10:54 AM, Staff FF, Assistant Dietary Manager, began using a digital thermometer to check the temperatures of the food items resting in the steam table. Staff FF checked the food temperatures for the food items being served from the steam table.

In an observation and interview on [DATE REDACTED] at 11:10 AM, a resident was observed eating a chef's salad in the dining room. Staff FF did not check the temperature for the chef's salad. Staff W stated the salad was brought out of the refrigerator in the kitchen.

During an observation of a tray line service held in the kitchen on [DATE REDACTED] at 11:18 AM, Staff FF unloaded the food items that were served in the dining room off a cart and onto the steam table in the kitchen. No staff checked the temperatures of the food from the steam table before the start of tray line. When prompted by

the surveyor, Staff W stated the facility did not check temperatures at the steam table in the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 81 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 0812 In an interview on [DATE REDACTED] at 11:45 AM, Staff W stated the facility did not check temperatures of foods after

the first tray line was completed in the dining room. They stated the second tray line completed in the kitchen Level of Harm - Minimal harm or consisted of randomly checking temperatures of various foods and those temperatures were not potential for actual harm documented. Staff W stated that it was important to monitor temperatures for prevention of food contamination and bacterial growth. Residents Affected - Many

Record review on [DATE REDACTED] of the temperature logs from [DATE REDACTED] through [DATE REDACTED] for both serving locations (dining room and kitchen) showed no documentation of temperatures for the kitchen tray line.

Reference: WAC [DATE REDACTED](3), -2980

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 81 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37544 potential for actual harm Based on interview and record review the facility failed to ensure arbitration (a procedure used to settle a Residents Affected - Some dispute using an independent person mutually agreed upon by both parties) agreement was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Residents 14, 60, 90), reviewed for arbitration. This failure placed residents at risk of being uninformed of their rights, loss of legal protection, loss of right to pursue legal action and a diminished quality of life.

Findings included .

The Avalon Healthcare Management Patient and Facility Arbitration Agreement stated the parties understood that any dispute would be resolved by arbitration, and not by a lawsuit or court process. The policy further stated that the parties understood and agreed that by entering the arbitration agreement, they waived their constitutional right to a jury trial, and that by signing the agreement, they acknowledge they have read, and understood that the arbitrator's decision was binding, could not be appealed, and could be enforced by a court.

The 12/03/2024 admission agreement documented Resident 14 admitted to the facility on [DATE REDACTED], was severely cognitively impaired and had diagnoses which included non-Alzheimer's dementia.

Review of Resident 14's record showed the facility's arbitration agreement was e-signed on 12/04/2024 by Resident 14, and not their legal representative.

Review of the 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.

On 02/05/2025 at 9:47 AM, Resident 14 was observed sitting in their wheelchair in the hallway. When asked how long they had lived at the facility, the resident stated they had lived there since the facility opened. When asked what the date was today, the resident stated they didn't know.

The 06/06/2025 admission assessment documented Resident 60 admitted to the facility 05/31/2024, was severely cognitively impaired and had diagnoses which included Alzheimer's dementia.

Review of Resident 60's record showed the facility's arbitration agreement was electronically signed on 06/03/2024 by the severly cognitively impaired Resident 60, and not their legal representative.

Review of the progress notes from 05/31/2025 through 02/05/2025 showed Resident 60 was cognitively impaired, oriented to self only, but able to make needs known at times to staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 81 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 0847 On 02/05/2025 at 11:53 AM, Resident 60 was observed sitting in their wheelchair in their room. When asked if the facility's arbitration agreement had been explained to them, and if they had signed the agreement, Level of Harm - Minimal harm or Resident 60 stated when they were in the Air Force, they were going to make decisions about the airplane. I potential for actual harm am not the pilot, just a person on the plane. Resident 60 pointed to their amputated left knee and stated that was all they had left, there was no fuel. Resident 60 then made a gesture with their hands and then stated I Residents Affected - Some had a tube this size, I can't find it.

The 11/26/2024 admission assessment documented Resident 90 admitted to the facility 11/20/2025, was severely cognitively impaired and had diagnoses which included non-Alzheimer's dementia.

Review of Resident 90's record showed on 11/21/2025 the facility's arbitration agreement was e-signed by

the resident and not their legal representative.

A progress note on 11/21/2024, the day Resident 90 signed the arbitration agreement, Staff AA, Physician Assistant, documented Resident 90 had dementia and believed they were in Hood River, Oregon.

In an interview on 02/05/2025 at 2:28 PM, the arbitration agreement was explained to Resident 90's power of attorney (POA, person who can make healthcare decisions when a person is unable to do so). The POA stated Resident 90 was confused and could not sign an arbitration agreement. The POA acknowledged the facility did not review the arbitration agreement with them, Resident 90's legal representative.

In an interview on 02/05/2025 at 12:07 PM, Staff Z, Admission Director stated the arbitration agreement was offered when residents admitted to the facility. When asked if the facility had a process in place or if an assessment was done prior to the agreement being offered to determine if a resident was cognitively able and/or had the mental capacity to enter into and sign an arbitration agreement, Staff Z stated they reviewed

the residents records that were received when they admitted to determine if the resident was able to understand and sign the agreement, and if they were not, then the agreement would be offered to the resident's representative and/or Power of Attorney (POA). When asked if the resident and/or representative gave up the right to go to court if they entered into an agreement, Staff Z stated they did not believe they gave up the right, but they would ask Staff A, Administrator.

In an interview on 02/05/2025 at 12:17 PM, Staff A, Administrator, confirmed arbitration was used to settle disputes and the resident and/or representative gave up the right to go to court if entered into an agreement, and it remained in effect if the resident discharged and admitted at a later date. Staff Z stated they did not know that the agreement would be valid after the resident discharged . When informed Residents 14, 60 and 90 all had severe cognitive impairments and had signed the arbitration agreements, Staff A stated the agreement should have been offered to the resident's representatives and/or POA.

No Associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 81 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37544 potential for actual harm Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions Residents Affected - Some were implemented when indicated for 2 of 4 sampled residents (Residents 46 and 54 ) reviewed that had draining wounds and that hand hygiene was completed when indicated during 1 of 2 dining observations and 1 of 2 wound treatments observed. Additionally, N95 respirator-style masks were not donned correctly in accordance with the Centers for Disease Control (CDC) guidelines by 7 Staff (R, HH, II, JJ, X, T, and KK) when reviewing infection control practices, infection prevention and control policies were not reviewed yearly as required and a water management plan was not fully developed. These failures put residents and staff at risk of becoming ill with contagious viral and bacterial infections and spreading those illnesses to others.

Findings included .

The 04/02/2024 Centers for Disease Control (CDC) publication Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant organisms (MDROs) described Enhanced Barrier Precautions as the use of gown and gloves during high-contact resident care activities to prevent the transfer of MDROs from resident to resident through contact with staff hands and clothing. High contact resident care activities included dressing, bathing, showering, changing linens, providing hygiene, changing briefs, wound care, or care for devices such as catheters or feeding tubes. Enhanced barrier precautions were intended to remain in place for the duration of the resident's stay, or until

the resolution of the wound or medical device that placed them at risk.

The 05/16/2023 CDC publication, How to use Your N95 Respirator, stated N95 respirators (a special type of tight-fitting mask that filters particles) must form a seal to the face to work properly. The document showed

the mask was to be placed under the chin, with the nose piece bar at the top, the top strap pulled over the head and placed near the crown, and the bottom strap placed at the back of the neck, below the ears. The straps were to lay flat, be untwisted, and not be crisscrossed.

At the time of the survey, the facility had an outbreak of COVID-19, a highly contagious viral illness that caused difficult breathing, fever, body aches, lethargy and serious health consequences in vulnerable populations.

On 01/28/2025 at 9:49 AM, Staff R, Licensed Practical Nurse (LPN), was observed wearing an N95 mask with both mask straps placed above the ears towards the top of the head.

On 01/28/2025 at 10:00 AM, Staff HH, LPN, was observed wearing an N95 mask with both straps positioned above the ears around the back of the head.

On 01/28/2025 at 11:04 AM, Staff R, LPN, was again observed wearing an N95 mask with both straps positioned above the ears towards the top of the head.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 81 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 0880 On 01/28/2025 at 11:42 AM , Staff II, Nursing Assistant (NA), was observed wearing a stocking hat and a neck scarf. Staff II wore an N95 mask with the top strap of the mask positioned on top of the head, over the Level of Harm - Minimal harm or stocking hat, the bottom strap of the mask was positioned over the back of the scarf. potential for actual harm

On 01/28/2025 at 12:01 PM, Staff II's N95 mask straps continued to be positioned incorrectly, with the top Residents Affected - Some strap over the stocking hat and the bottom strap lying over the back of the scarf. Several other staff members were present in the hallway and nobody corrected or redirected Staff II about the positioning of the straps.

On 01/28/2025 at 12:03 PM Staff JJ, Occupational Therapist, was observed wearing an N95 mask with the top strap positioned correctly, but the bottom strap was positioned over their long hair, and not around the back of the neck.

On 01/28/2025 at 12:16 PM, Staff X, NA, was observed wearing an N95 mask with both straps positioned above the ears on the back of their head. When asked about the positioning of the straps, Staff X stated they had received training on PPE, and knew one strap was supposed to be on the top of the head, and the bottom one behind the neck, but it was inconvenient to place the straps like that because of their hair clip.

On 01/28/2025 at 12:27 PM, Staff II donned a gown and gloves prior to entering room [ROOM NUMBER] to deliver lunch trays. Staff II removed the stocking hat and positioned the top strap correctly prior to entering

the room, but the bottom strap was still lying over the back of the neck scarf. At 12:32 PM, Staff II exited the room, doffed the gown/gloves and N95, put the stocking hat back on, donned a new N95 and positioned the top strap of the mask over the stocking hat on the top of head. Staff II stated they had received training regarding PPE and the wearing of N95 masks. When informed about the proper placement of the N95 straps, Staff II stated they were not aware that the top strap needed to be directly on the head and wearing over a hat or other items could interfere with the mask creating a seal. Staff II then positioned the straps correctly.

On 01/31/2025 at 9:32 AM, Staff X, NA, was observed walking down the hall wearing an N95 mask with both straps positioned on the top of the head. When Staff X saw the surveyor, they adjusted the bottom strap behind the neck.

On 02/03/2025 at 10:01 AM, Staff T, LPN, was observed wearing an N95 with the straps placed behind their neck. Staff T stated the straps slid down, so they wore them behind the neck to get a tight seal.

On 02/05/2025 at 11:55 AM, Staff KK, NA, was observed wearing both straps of their N95 around the top of

the head, above the ears. Staff KK stated one strap was supposed to be behind the neck, but it bothered their skin to wear it like that and started to cause a rash. Staff KK expressed understanding about the importance of wearing the straps correctly to get a better seal.

On 02/05/2025 at 2:21 PM, Staff KK was observed with their N95 mask below their chin.

In an interview on 02/05/2025 at 10:20 AM, Staff R, LPN, was again observed with both N95 straps positioned above the ears. When asked about the placement of the straps, Staff R felt the straps and stated

it was incorrect and positioned them properly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 81 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 0880 In an interview on 02/07/2025 at 9:10 AM, observations and concerns related to the improper wearing of N95 masks and not following CDC guidelines during an active COVID-19 outbreak was discussed with Staff A, Level of Harm - Minimal harm or Administrator, Staff B, Director of Nursing (DNS), and Staff LL, Corporate Registered Nurse (RN). Staff A potential for actual harm acknowledged the concerns.

Residents Affected - Some <Enhanced Barrier Precautions>

In an observation on 01/31/2025 at 8:54 PM, Resident 54 was lying in bed watching television. The resident was not wearing their foam boot to their left heel and there was yellow drainage from their heel wound on the pillowcase. There was no enhanced barrier sign on the resident's door and no PPE nearby.

Similar observations of Resident 54 without an enhanced barrier sign on the door were made on 02/03/2025 at 9:50 AM, 02/05/2025 at 11:28 AM and 02/06/2025 at 1:30 PM.

In an interview on 02/06/2025 at 2:57 PM, Staff B, DNS, stated residents with wounds needed to be on enhanced barrier precautions and this was important to stop the spread of germs.

In an observation and interview on 02/05/2025 at 11:54 AM, Resident 46 was lying in bed. The resident had bloody drainage on their shirt under their right armpit. The resident stated they had a sore under their armpit. Resident 46 did not have an enhanced barrier sign on their door and there was no PPE nearby.

Review of the January 2025 medication administration record showed a 01/17/2025 provider order to cleanse the right armpit with wound cleanser and to apply a dressing every day and as needed.

In an interview on 02/06/2025 at 2:22 PM, Staff C, Resident Care Manager, stated Resident 54 should have been on enhanced barrier precautions.

In an observation on 02/06/2025 at 1:30 PM, Staff BB, RN, put on a pair of gloves, touched Resident 54's foam boot, adjusted the resident's bed with their bed controls, obtained a pad out of the resident's bag, touched items in a bin that was filled with treatment supplies, cut the resident's pad in half, lifted the resident's left heel, opened betadine swabs and applied it to their heel while wearing the same pair of gloves. Staff BB, wearing the same pair of gloves, placed the resident's foot back into the foam boot, placed pillows under their leg, then removed their gloves, turned the light off in the room and then performed hand hygiene.

During an interview on 02/06/2025 at 1:42 PM, Staff BB stated they should have changed their gloves and performed hand hygiene before the wound care, and this was important to prevent the spread of germs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 81 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 0880 In an observation on 01/28/2025 at 11:03 AM, Staff W, Dietary Manager, passed a tray to a resident, then touched another resident's glass of juice to move it, without performing hand hygiene, passed another tray, Level of Harm - Minimal harm or then touched the glass on the serving cart, touched another resident's plate, opened the resident's ketchup, potential for actual harm picked up the salt and pepper holder and moved it to another location, then sanitized their hands.

Residents Affected - Some In an interview on 01/28/2025 at 11:27 AM, Staff W stated hand hygiene should have been completed after every tray was passed, and after touching things such as cups, clothing, and the glass on the serving cart.

During an interview on 02/07/2025 at 1:17 PM, Staff D, Infection Preventionist, stated all nurses should be able to determine who needed enhanced barrier precautions. The expectation would be for staff to follow the guidance on the enhanced barrier sign, and this was important because it breaks the chain of infection and stops the spread of germs. Staff D stated staff needed to clean their hands between every person and when

they removed their gloves.

A review of the Infection Prevention policies documented the policies were created or revised on the following dates and were not current:

-Antibiotic Stewardship (11/2017, revised 03/2019)

-Antibiotic Stewardship Program (05/2019, revised 11/2020, 04/2022)

-Infection Prevention and Control Program (11/2017, revised 06/2022)

-Infection Preventionist (09/2018)

-Influenza and Pneumococcal Immunizations (11/2017, revised 06/08/2022)

-Standard Precautions, Enhanced Barrier Precautions and Transmission-based Precautions (07/26/2022)

-Vaccination Requirement for SARS-Cov-2 (COVID-19) (01/27/2022, revised 03/21/2022, 06/29/2022)

During an interview on 02/07/2025 at 11:13 AM, Staff A, Administrator acknowledged the policies were not current.

On 02/05/2025, documents for the facility water management plan were requested. A document titled, Risk Management Plan for Legionella Control in the Operation and Management of the Water Systems of 'Facility Name' was provided. The document was a template and had not been completed with facility specific information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 81 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 0880 On 02/07/2025 at 11:13 AM, Staff A, Administrator, stated they would check to see if the completed document was in the maintenance department. Staff A returned with a binder that included hot water Level of Harm - Minimal harm or temperature checks that had been done weekly and a sample of the water chlorine test kit that the facility potential for actual harm used to test chlorine levels in their water system. After review with the surveyor, Staff A acknowledged that

the water management plan needed to be further developed so that all the elements that were required were Residents Affected - Some included. There had been no cases of Legionnaires disease since the prior survey.

Reference: WAC 388-97-1320 (2)(b), 1320 (1)(c)

46033

46115

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 81 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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46033 potential for actual harm Based on observation, interview and record review, the facility failed to ensure resident beds were in safe Residents Affected - Few operating condition for 4 of 26 beds in use on the [NAME] nursing unit observed. Specifically, bed controls had wires exposed and old electrical tape that had peeled off for 4 resident beds. This failure put residents at risk of injury and of being deprived of a home-like environment.

Findings included .

On 01/29/2025 at 9:35 AM, Resident 74 was observed in room [ROOM NUMBER]-1 seated on their bed.

The bed control was observed to have wiring exposed where the wiring entered the portion that had buttons for adjusting the position of the head or foot of the bed. The resident stated they were unsure when the wiring became exposed. There were no frayed wires present.

On 01/29/2025 at 10:18 AM, Staff K, Maintenance Director had replaced the bed in room [ROOM NUMBER]-1 and was observed pushing the bed with the exposed wiring down the hall.

On 01/29/2025 at 10:25 AM, further resident bed observations identified the following:

-The bed in room [ROOM NUMBER]-2 had two areas on the cord of the bed control that had old peeled electrical tape that had begun to come off. Under, there were exposed bed control wires.

-The bed in room [ROOM NUMBER]-1 had electrical tape that had begun to peel off near the portion that was connected to the controller and wires were exposed.

-The bed in room [ROOM NUMBER]-2 had old electrical tape that had begun to peel off and wiring was exposed.

The same beds were observed in the same condition on 01/30/2025 at 2:09 PM and 02/03/2025 at 9:28 AM.

During an interview on 02/06/2025 at 12:57 PM, Staff K stated if they did not receive a work order, they did not know if beds were in disrepair. Staff K stated they did not do regular walk around preventive inspections or audits of the equipment on the nursing units. They stated if they received a work order for a bed it was fixed.

Avalon Care Center At Northpointe

Inspection Findings

F-Tag F640

F-Tag F641

F-Tag F758

Avalon Care Center At Northpointe

Inspection Findings

F-Tag F640

F-Tag F641

F-Tag F758

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