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F-F690 for additional information

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 505322

F-F881 for additional information

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 505322 Department of Health & Human Services Printed: 09/17/2025 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 505322 B. Wing 07/25/2024

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

Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205

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 0881 Implement a program that monitors antibiotic use.

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 repeatedly implement antibiotic protocols to ensure Residents Affected - Some antibiotics were appropriately prescribed, and routinely implement a facility-wide system to monitor antibiotic use for 2 of 3 sampled residents (Resident 9 and 10), reviewed for infection control. This failure placed residents at risk of development of antibiotic-resistant organisms, adverse side effects, and diminished quality of life.

Findings included .

Review of the facility undated policy titled, Infection Prevention and Control Program showed infection surveillance tools were used to recognize the occurrence of infections, record their number and frequency, detect outbreaks, and monitor adherence to infection prevention and control practices. The policy showed McGeer Constitutional Criteria (guidelines to assess antibiotic initiation appropriateness) was used to help recognize and mange infections. Culture reports, sensitivity date, and antibiotic usage was evaluated as part of antibiotic stewardship. The policy further showed the infection preventionist would collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult

on infection risk assessment and prevention strategies; provide education and training; and implement evidenced-based infection prevention and control practices.

The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention - with regard to antibiotic stewardship showed antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance.

The website CDC.gov - with regard to urinary tract infection (UTI) showed urinary tract includes the bladder [organ in pelvis that stores urine], urethra [tube which urine leaves the body] and kidneys [remove waste and extra water from the blood as urine]. UTIs are common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract any time you take antibiotic, they can cause side effects. Side effects can include rash, dizziness, nausea, diarrhea, and yeast infections. More serious side effects can include antimicrobial-resistant infections

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 505322 Department of Health & Human Services Printed: 09/17/2025 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 505322 B. Wing 07/25/2024

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

Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205

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 0881 Review of McGeer Criteria revised 04/2024, showed residents without an indwelling catheter (tube left in the bladder that drains urine into a drainage bag) must meet criteria 1 and criteria 2 for symptomatic UTI Level of Harm - Minimal harm or infection. Criteria 1- At least one symptom acute dysuria (burning sensation during urination) OR acute pain, potential for actual harm swelling, or testicular tenderness; fever OR leukocytosis (high white blood cell count) AND at least one of the following localized urinary tract sub-criteria: acute back pain or tenderness, suprapubic (area above the pubic Residents Affected - Some bone where the bladder is typically located) tenderness, gross hematuria (visualize blood in the urine), new or marked increased incontinence, urinary urgency or frequency. In the absence of fever or leukocytosis, then at least 2 or more localizing urinary symptoms need to be met. Criteria 2- culture identified no more than 2 species of microorganisms >100,000 colony count (number of microorganisms grown) in a voided (to urinate) urine. UTI should be diagnosed when there are localizing signs and/or symptoms AND a positive urinary culture . pyuria [pus in urine] does not differentiate symptomatic UTI from asymptomatic bacteriuria [high bacterial count with one or more organisms in the urine specimen without symptoms or infection].

<Resident 9>

Review of the quarterly assessment, dated 06/25/2024, showed Resident 9 readmitted to the facility on [DATE REDACTED] with diagnoses including diabetes (disease that occurs when blood sugar is too high) and hypertension (HTN - high blood pressure). The assessment further showed Resident 9 was occasionally incontinent of urine, toileting program had not been attempted, and was independent with toileting hygiene. Resident 9 was cognitively intact and able to verbalize their needs.

Review of the 12/21/2023 bladder incontinence care plan showed Resident 9 chose not to wear incontinence briefs and instructed staff to offer Resident 9 incontinence products, check and change them every two to three hours, provide incontinence care with each episode, and monitor for signs and/or symptoms of UTI.

The antibiotic care plan revised 01/23/2024 showed Resident 9 received antibiotic for a UTI and instructed staff to administer medications as ordered by the provider, monitor for signs and/or symptoms of adverse drug effects, and monitor for potential secondary infections.

Review of provider orders showed Resident 9 had urine cultures ordered on 01/19/2024, 01/21/2024, 02/07/2024, 04/03/2024, and 04/28/2024 for signs and/or symptoms of UTI. Resident 9 was treated with antibiotic for UTIs on 01/02/2024 - 01/09/2024, 01/22/2024 - 01/27/2024, 02/08/2024 - 02/19/2024, 02/13/2024 - 02/21/2024, 04/29/2024 - 05/06/2024, and 05/21/2024 - 05/28/2024.

Review of Resident 9 urinalysis results showed the following:

- 01/19/2024: clean catch (method of collecting a sample that minimizes contamination from bacteria naturally present on the skin around the genitals) sample collected with results on 01/21/2024 showing >100, 000 colony count

- 01/21/2024: clean catch sample collected with results on 01/26/2024 showing > 100,000 colony count

- 04/03/2024: clean catch sample collected with results on 04/09/2024 showing > 100,000 colony count

- 05/15/2024: clean catch sample collected with results on 05/20/2024 showing <100,000 colony count

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 505322 Department of Health & Human Services Printed: 09/17/2025 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 505322 B. Wing 07/25/2024

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

Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205

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 0881 No documentation of urinalysis culture results were found for 02/07/2024 or 04/28/2024 urine culture orders.

Level of Harm - Minimal harm or Review of 01/02/2024 provider notes showed Resident 9 was seen for a UTI with urinary discomfort. The potential for actual harm provider indicated a urine culture was pending but started and antibiotic for seven days for a UTI.

Residents Affected - Some Review of the 02/08/2024 provider notes showed Resident 9 had painful urination even after being treated with antibiotics for a UTI. Resident 9 denied having fever, chills, urinary frequency, abdominal or pelvic pain.

The provider ordered an antibiotic for 10 days to treat a UTI.

Review of the 04/28/2024 provider notes showed Resident 9 had urinary concerns related to frequent burning sensation during urination but denied abdominal or back pain. Resident 9 had a history of recurrent UTIs. The provider ordered a urine analysis.

Review of the 05/14/2024 provider notes showed Resident 9 was seen for persistent frequent burning sensation during urination even after Resident 9 was treated with antibiotics the week prior for a UTI based

on symptoms, no urine culture was completed at that time. The provider ordered a urine analysis.

Review of the 05/21/2024 provider notes showed Resident 9's urine results were positive for a UTI. Resident 9 reported their frequent burning sensation during urination was gradually worsening. Resident 9 had a history of recurrent UTIs and had received multiple different treatments for UTIs in the last three months. The provider started an antibiotic for a UTI at that time and indicated a urine analysis would be repeated only if symptoms continue after antibiotics were completed.

In an interview on 07/25/2024 at 10:30 AM, Resident 9 acknowledged they had frequent UTIs but typically

they did not feel any pain from them until the UTI was identified. Resident 9 stated they typically felt little twinges, not super bad and requested urine cultures be obtained because they wanted to know if they had a UTI or just a twinge. Resident 9 stated they had occasional urinary incontinence, had a difficult time performing perineal hygiene independently because of range of motion issues and described the unsanitary perineal technique they used. Resident 9 acknowledged their unsanitary perineal technique could potentially be a contributing factor to their recurrent UTIs but that was the best perineal care they could perform independently.

In an interview on 07/25/2024 at 11:51 AM, Staff D, Licensed Practical Nurse (LPN), stated they were unsure what tool, protocol or criteria the facility used to determine if antibiotics were needed or appropriately prescribed. Staff D further stated they were unsure how to monitor or determine if an antibiotic was effective and would refer to the infection control specialist or providers. Staff D acknowledged residents could develop resistance to antibiotics if they were inappropriately prescribed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 505322 Department of Health & Human Services Printed: 09/17/2025 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 505322 B. Wing 07/25/2024

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

Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205

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 0881 In an interview on 07/25/2024 at 1:08 PM, Staff G, Infection Preventionist, stated the facility used McGeer Criteria to determine if an antibiotic was needed, if a UTI was suspected then a urinalysis with culture should Level of Harm - Minimal harm or be obtained to determine which antibiotic was appropriate. Staff should monitor residents for signs and/or potential for actual harm symptoms of potential side effects and monitor the infection is improving. Staff G stated obtaining repeat urinalysis or reassessing a wound infection after treatment were methods of determining if an antibiotic was Residents Affected - Some effective. Staff G further stated they tracked antibiotic prescriptions on a flow sheet for infection surveillance, reviewed treatment effectiveness after the antibiotic course was completed, tracked and trended infections but not trends had been identified. Staff G acknowledged residents were at risk of development of antibiotic-resistant organisms if antibiotics were inappropriately prescribed. Staff G was unaware of Resident 9's unsanitary perineal care technique and acknowledged that practice could contribute to UTIs. Staff G reviewed Resident 9 medical record. Staff G acknowledged Resident 9 was treated with antibiotics for UTIs frequently and should have had urinalysis with culture completed prior to being treated with antibiotics to prevent resistant microorganism development.

<Resident 10>

Review of the quarterly assessment, dated 05/22/2024, showed Resident 10 admitted to the facility on [DATE REDACTED] with diagnosis including diabetes, muscle weakness, and UTI. The assessment further showed Resident 10 was frequently incontinent of urine, toileting program had not been attempted, and was independent with toileting hygiene. Resident 10 was cognitively intact and able to verbalize their needs.

Review of the 02/22/2024 bladder incontinence care plan showed Resident 10 required staff assist for transfers onto the toilet and instructed staff to check and change Resident 10 every two hours, perform perineal care with each incontinence episode, and monitor for signs and/or symptoms of UTI.

Review of provider orders showed an 02/22/2024 for Resident 10 to be administered Oxybutynin (medication used to treat symptoms of overactive bladder) three times daily for urinary retention. Resident 10 had orders to obtain urine cultures on 03/20/2024, 03/31/2024, 04/28/2024, and 06/15/2024 for signs and/or symptoms of UTI. Resident 10 was treated with antibiotics for UTIs on 02/22/2024 - 02/27/2024, 03/25/2024 - 04/03/2024, 05/05/2024 - 05/12/2024, and 06/20/2024 - 06/30/2024.

Review of Resident 10 urinalysis results showed the following:

- 03/21/2024: clean catch sample collected with results on 03/26/2024 showing >100,000 colony count

- 04/27/2024: clean catch sample collected with results on 05/04/2024 showing >100,000 colony count

- 04/29/2024: clean catch sample collected with results on 05/04/2024 showing >100,000 colony count

- 06/16/2024: clean catch sample collected with results on 06/21/2024 showing >100,000 colony count

No documentation of urinalysis culture results were found for 03/31/2024 culture orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 505322 Department of Health & Human Services Printed: 09/17/2025 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 505322 B. Wing 07/25/2024

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

Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205

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 0881 Review of the 02/27/2024 provider progress notes showed Resident 10 completed a course of antibiotics for treatment of a UTI and their urination was normal. Level of Harm - Minimal harm or potential for actual harm Review of the 03/25/2024 provider progress notes showed Resident 10 was seen for UTI concerns related to frequent and painful urination. Resident 10 had a urine analysis sampled because they thought they had a Residents Affected - Some UTI. Resident 10 was prone to frequent UTIs because of poor health, immobility, and diabetes. Resident 10 denied abdominal pain or fever. The provide indicated urine results were still pending but ordered seven days of antibiotics to treat a UTI and would modify the antibiotic if needed after the culture results were in.

Review of the 04/28/2024 provider progress notes showed Resident 10 was seen for UTI concerns related to frequent and painful urination. Resident 10 denied abdominal or back pain. The provider ordered a urinalysis.

Review of the 06/17/2024 provider progress notes showed Resident 10 was seen for UTI concerns related to odorous urine and elevated blood sugar levels, orders were given to obtain a urinalysis, and results were still pending.

Review of the 07/09/2024 provider progress notes showed Resident 10 was seen because antibiotics were completed, and Resident 10 anticipated their urinary symptoms would predictably recur. Resident 10 has experienced chronic UTI symptoms over their lifetime with frequent treatments and was on Oxybutynin three times daily for their urinary symptoms. The provider discussed hygiene with Resident 10, but they remain a high risk for UTIs.

In an interview on 07/25/2024 at 1:40 PM, Staff E, Resident Care Manager, stated the facility used McGeer Criteria to determine if an antibiotic was needed and determined antibiotic effectiveness by routinely assessing the infection status, repeating urinalysis or obtaining additional blood work as needed. Staff E acknowledged residents were at risk of developing multidrug resistant organisms if antibiotics were inappropriately prescribed.

In an interview on 07/25/2024 at 4:43 PM, with Staff A, Administrator, and Staff B, Director of Nursing, they stated the facility used McGeer Criteria to determine if an antibiotic was needed. Staff B stated obtaining diagnostic testing like a urinalysis for a UTI helped ensure antibiotics were appropriately prescribed because

the results should identify the antibiotic/s an organism/s was susceptible to. Staff B further stated residents should be monitored for potential signs and/or symptoms of medication adverse side effects and illness the antibiotic was treating routinely assessed to determine effectiveness. Staff A stated the infection preventionist tracked and trended infections but not trends had been identified. Staff A acknowledged residents were at risk for development of multidrug resistant organisms if antibiotics were inappropriately used. Staff B stated they would not expect a urinalysis with a colony count less than 100,000 to be treated with antibiotics.

No associated WAC

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