Inspection: Manor Care Health Services-spo

F-Tag F625

Harm Level: Minimal harm or 46115

Residents Affected: administer their medications safely for 1 of 5 sampled residents (Resident 22) reviewed for

F-F625 for additional information.

In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were aware they were out of compliance with completing admission documents with the residents. Staff A stated they monitored the progress of the PIP through a report from the admissions staff on who was still outstanding. Staff A stated the PIP was not sustained.

Reference: WAC 388-97-1760 (1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 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** 40297 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure hand hygiene was followed Residents Affected - Some during medication administration and wound care for Resident 89 and during the observation of the lunch meal service, failed to serve food in a sanitary manner for an unidentified resident, failed to ensure signage was placed to inform the staff of residents (Resident 6, 88, 89, 462 and 82) who required Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, germs that are resistant to many antibiotics]), failed to sanitize equipment between resident use, and failed to timely change and maintain infection control practices for a central line (a thin, flexible tube inserted into a large vein until the tip rested in a major vein near the heart) for Resident 89.

These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences.

Findings included .

ENHANCED BARRIER PRECAUTIONS

According to a 06/28/2024 Centers for Disease Control article, EBP involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). EBP expanded the use of gown and gloves beyond anticipated blood and body fluid exposures. EBP directed staff to don (put on) gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting.

Review of the 02/23/2025 significant change assessment showed Resident 6 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment showed Resident 6 had moderately impaired cognition and an indwelling urinary catheter. Review of the medical record showed the staff treated Resident 6 for wounds to the right foot.

An observation on 04/14/2025 at 11:31 AM showed Resident 6 in their wheelchair, and the urinary catheter bag was covered. No EBP signage was observed near Resident 6's room to show the staff needed to don PPE prior to entering the room when providing high contact activities.

Review of a 03/22/2025 admission assessment showed Resident 88 admitted to the facility on [DATE REDACTED] with medically complex conditions, including an MDRO. The assessment showed the resident was cognitively intact and received dialysis (a procedure that removed waste products and excess fluid from the blood when

the kidneys failed to do so).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0880 An observation and interview on 04/14/2025 at 10:12 AM showed Resident 88 sitting at the edge of the bed.

The resident stated they went to the dialysis center and received dialysis through a central line. Resident 88 Level of Harm - Minimal harm or showed a dressing that covered the central line to the left side of their chest. No EBP signage was observed potential for actual harm near Resident 88's room to show the staff needed to don PPE prior to entering the room when providing high contact activities. Residents Affected - Some <Resident 82>

According to the 03/03/2025 quarterly assessment, Resident 82 had an indwelling urinary catheter (flexible tube inserted into the bladder to drain urine).

Review of the 11/27/2024 care plan showed Resident 82 had a urinary catheter related to urinary retention and instructed staff to maintain the tubing anchored, provide catheter care every shift, observe for signs of a bladder infection, and to keep the catheter in place until seen by a urologist (doctor that specialized in the urinary system).

Review of 02/06/2025 urologist progress notes showed Resident 82's urinary catheter was to remain in place to prevent recurrent urinary retention.

During an observation on 04/14/2025 at 9:19 AM, no EBP signage was observed to be posted outside Resident 82's room. Similar observations were made that same day at 11:53 AM and 12:36 PM.

According to the 04/03/2025 admission assessment, Resident 462 received liquid nutrition via a feeding tube (flexible tube inserted into the digestive system to deliver nutrition when unable to eat).

Review of the 03/28/2025 care plan showed Resident 462 received nutrition via tube feeding and instructed staff to administer flushes and feedings as ordered, provide oral care daily, and check the tube insertion site.

During observation on 04/21/2025 at 4:45 AM, Staff Q, Registered Nurse (RN), put on a pair of gloves without performing hand hygiene, pulled items out of their pocket including a cell phone to check the time prior to labeling a bottle of tube feed formula, adjusted the bedside table, touched Resident 462's left shoulder to get their attention, and raised the head of the bed up. Without changing gloves, performing hand hygiene, or putting a gown on, Staff Q flushed Resident 462's feeding tube, connected the tubing to the resident and began running their formula.

The above findings were shared with Staff D, Infection Preventionist, on 04/21/2025 at 9:14 AM. Staff D stated they identified residents who required EBP to be implemented during cares by reviewing the admission orders. Staff D stated residents required EBP during cares if they presented with an indwelling medical device or uncontainable wound and the requirement was communicated to the staff through signage. Staff B acknowledged EBP signage was not posted during the 04/14/2025 observations and that it should be put up upon admission [to the facility].

46115

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0880 <Resident 89>

Level of Harm - Minimal harm or The 01/23/2025 significant change assessment documented Resident 89 had diagnoses which included a potential for actual harm left leg fracture and depression. The assessment further showed Resident 89 was on isolation or quarantine for an active infectious disease process, was cognitively intact and able to make their needs known. Residents Affected - Some

A review of provider orders documented a 04/11/2025 order for Resident 89 to be administered cefazolin (antibiotic) intravenously (IV) every eight hours to treat an infection associated with an internal fixation (implants such as plates, screws or rods used to stabilize fractured bones) device in Resident 89's left leg. A 04/11/2025 order showed Resident 89 was to be on EBP related to a peripherally inserted central catheter (PICC, a long thin tube inserted into a vein in the arm and threaded up to a larger vein near the heart used for administration of medications).

The 04/13/2025 care plan documented Resident 89 had a PICC and required EBP.

During observation on 04/14/2025 at 9:31 AM, no EBP signage was observed to be posted outside of Resident 89's room and there was no plastic tote containing personal protective equipment such as gowns near the room entrance. Similar observation was made at 12:36 PM.

In an observation on 04/14/2025 at 2:26 PM, Staff LL, Registered Nurse (RN), put on gloves, wiped Resident 89's PICC with an alcohol swab, flushed the line, wiped off the IV tubing and connected it to the PICC line and had not worn a gown.

In an interview on 04/17/2025 at 8:50 AM, Resident 89 stated the staff had not always worn a gown when administering their antibiotics.

In an interview on 04/23/2025 at 1:29 PM, Staff D stated a gown needed to be worn when administering medication through a PICC line and it was important to prevent the spread of microorganisms.

HAND HYGIENE

The 01/23/2025 significant change in condition assessment documented Resident 89 had diagnoses including a left leg fracture and depression. The assessment further showed Resident 89 was on isolation or quarantine for an active infectious disease process, was cognitively intact and able to make their needs known.

A review of provider orders documented a 04/11/2025 order for Resident 89 to be administered cefazolin (antibiotic) intravenously (IV) every eight hours to treat an infection associated with an internal fixation (implants such as plates, screws or rods used to stabilize fractured bones) device in Resident 89's left leg. A 04/11/2025 order showed Resident 89 was to be on EBP related to a peripherally inserted central catheter (PICC, a type of central line).

The 04/13/2025 care plan documented Resident 89 had a PICC and required EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0880 In an observation on 04/14/2025 at 2:26 PM, Staff LL, Registered Nurse (RN) put on a pair of gloves, wiped

the PICC with alcohol, flushed the PICC line, wiped end of IV tubing and connected it to the PICC line, Level of Harm - Minimal harm or programmed the IV machine, and whiile wearing the same gloves placed a medicated patch on Resident potential for actual harm 89's back.

Residents Affected - Some In an observation on 04/17/2025 at 1:57 PM, Staff LL put on a gown and pair of gloves, picked up the IV machine cord, plugged it in, and then programmed the IV machine. Without changing gloves or performing hand hygiene, Staff LL then swabbed the PICC and IV tubing with alcohol, flushed the PICC line and reprogrammed the IV machine. Staff LL then removed their gloves and without performing hand hygiene, put

on a new pair of gloves.

In an interview on 04/17/2025 at 2:18 PM, Staff LL stated they should have removed their gloves and performed hand hygiene after plugging the IV machine in and programming it to prevent the spread of germs.

During an observation on 04/21/2025 at 4:58 AM, Staff Q, RN, did not perform hand hygiene, and put a pair of gloves, gown, and surgical mask on. With their gloved hands, Staff Q took items out of their pocket, opened the IV tubing, draped the tubing around the back of their neck, grabbed the trashcan with their right hand to move closer to the bedside, and used it to drip IV solution into when priming the tubing. Without removing gloves or performing hand hygiene, Staff Q then inserted the tubing into the IV pump, cleansed Resident 89's IV access line with alcohol, connected the tubing, and began to administer the IV medication.

In an interview on 04/23/2025 at 1:29 PM, Staff D, Infection Preventionist, stated hand hygiene needed to be performed, and gloves changed after touching things and prior to administering medications. Staff D stated hand hygiene needed to be performed prior to putting on a new pair of gloves.

WOUND CARE

The 01/23/2025 significant change assessment documented Resident 89 had diagnoses which included a left leg fracture and depression. The assessment further showed Resident 89 was on isolation or quarantine for an active infectious disease process, was cognitively intact and able to make their needs known.

A review of provider orders documented a 04/11/2025 order for Resident 89 to be administered cefazolin (antibiotic) IV every eight hours to treat an infection associated with an internal fixation device in Resident 89's left leg. A 04/11/2025 order showed Resident 89 was to be on EBP related to a PICC.

The 12/06/2024 skin impairment care plan documented Resident 89 had a surgical incision to their left knee and instructed nursing to keep the skin as clean and dry as possible and to apply treatment per the treatment administration record (TAR).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0880 In an observation on 04/17/2025 at 1:57 PM, Staff LL had not performed hand hygiene and put on a pair of gloves. Staff LL set up their treatment supplies on a plastic blue sheet, opened the clean dressings, removed Level of Harm - Minimal harm or the dressings from Resident 89's left leg, cleansed the wounds, and without removing the gloves and potential for actual harm performing hand hygiene, applied the new dressings and touched the part of the dressing with their fingers that covered Resident 89's wound. Staff LL then discarded the old dressings and supplies into the garbage, Residents Affected - Some and wearing the same gloves grabbed a marker out of their pocket and dated the dressings on the resident's left leg.

In an interview on 04/17/2025 at 2:18 PM, Staff LL stated they should have removed their gloves and performed hand hygiene prior to the dressing change, and after removing the soiled dressings and cleaning

the wounds prior to putting the new dressings on to prevent the spread of germs.

In an interview on 04/23/2025 at 1:29 PM, Staff D stated gloves needed to be changed after the old dressings were removed and hands sanitized. Staff D stated a new pair of gloves were worn to put on the new dressing and this was important to prevent the spread of infection.

SANITIZATION

In an observation on 04/22/2025 at 10:32 AM, Staff W, Nursing Assistant (NA), and an unidentified nursing assistant used the mechanical lift in room [ROOM NUMBER]. The nursing assistant pushed the mechanical lift to the tub room and closed the door without cleaning it.

In an interview on 04/22/2025 at 3:16 PM, Staff C, Assistant Director of Nursing (ADON), stated staff needed to wipe the lifts between residents to prevent the spread of germs.

In an interview on 04/22/2025 at 3:25 PM, Staff D stated staff needed to wipe the lifts between residents to prevent the spread of microorganisms.

PICC LINE DRESSING CHANGE

The 01/23/2025 significant change assessment documented Resident 89 had diagnoses which included a left leg fracture, depression, was cognitively intact and able to make their needs known.

In an observation on 04/14/2025 at 1:50 PM, Resident 89 was sitting on their bed. Resident 89 had a PICC line dressing on their right arm that was dated 04/06/2025.

A review of the provider's orders documented on 04/11/2025 PICC line dressings changes needed to be changed every Tuesday.

The 04/13/2025 care plan documented Resident 89 had a PICC and the dressing was to be changed per the order.

In an observation and interview on 04/16/2025 at 9:02 AM, Resident 89 was sitting on their bed. The resident's PICC line dressing was dated 04/16/2025. Resident 89 stated the dressing was changed yesterday but was not placed correctly so it had to be re-done. The resident went nine days between dressing changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0880 In an interview on 04/22/2025 at 12:07 PM, Staff C stated PICC line dressing changes needed to be completed every seven days and this was important for infection control. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/24/2025 at 12:47 PM, Staff D stated Resident 89's PICC line dressing should have been changed within seven days from the last dressing change and this was important to prevent infections. Residents Affected - Some 47328

DINING OBSERVATION

During observation on 04/14/2025 at 12:26 PM, Staff MM, NA, did not perform hand hygiene and delivered a tray to a resident in the small assisted dining room. Staff MM adjusted the resident's wheelchair (WC) closer to the table, placed a new clothing protector on the resident, did not perform hand hygiene, then sat down to start assisting the resident with their meal. Staff MM pulled the resident up in their WC by grabbing the back of their pants, did not perform hand hygiene, and sat down to continue assisting the resident with their meal. Staff MM pulled down the surgical mask they were wearing, blew on the resident's food to cool it down, and asked the resident is that better? as they placed the food into the resident's mouth.

In an interview on 04/22/2025 at 2:54 PM, Staff Y, NA, stated hand hygiene was using alcohol-based (ABHR) hand rub when entering/exiting resident rooms or touching anything soiled. Staff Y stated staff should perform hand hygiene when indicated to prevent the spread of germs. Staff Y further stated staff should not blow on a resident's food to cool it down because it could spread germs.

In an interview on 04/22/2025 at 2:57 PM, Staff H, Licensed Practical Nurse (LPN), explained hand hygiene was washing hands with soap and water for 20 seconds or using ABHR and should be performed before/after resident cares and before/after dispensing/administering medications. Staff H stated staff should perform hand hygiene when indicated to prevent the spread of infection from person to person. Staff H acknowledged staff should not blow on a resident's food to cool it down as that could spread germs.

In an interview on 04/22/2025 at 3:16 PM, Staff C explained hand hygiene was washing hands with soap and water or using ABHR before/after resident cares, before applying gloves, and after glove removal. Staff C stated staff should perform hand hygiene when indicated to prevent the spread of germs and infections. Staff C acknowledged staff should not blow on a resident's food because staff could pass germs onto a resident's food.

In an interview on 04/22/2025 at 3:25 PM, Staff D stated hand hygiene was washing hands with soap and water or using ABHR before entering a resident's room, after exiting a resident's room, between providing care to different residents, between delivering different resident meal trays, and after adjusting residents in their WCs. Staff D stated staff should perform hand hygiene when indicated to prevent the spread of microorganisms. Staff D acknowledged staff should not blow on a resident's food to cool it down because it was an infection control issue.

In an interview on 04/22/2025 at 3:31 PM, Staff A, Administrator, stated they expected staff to change gloves and perform hand hygiene when indicated. Staff A acknowledged staff should not blow on residents' food to cool it down because that was a potential infection control issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0880 Reference WAC 388-97-1320 (1)(a), -1320 (2)(b), -1320 (1)(c).

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 Page103of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 40297 potential for actual harm Based on interview and record review, the facility failed to follow an established Antibiotic Stewardship Residents Affected - Some Program (ASP) to promote the appropriate use of antibiotics (ABT) for newly admitted residents or those prescribed an ABT by community providers for 3 of 3 months (January, February, and March 2025) reviewed for infection control practices. This failure increased resident risk for multi-drug-resistant organisms (MDRO, germs that are resistant to many antibiotics) and had the potential for adverse outcomes with inappropriate and/or unnecessary use of ABT.

Findings included .

The 08/2023 facility policy titled Administrative Infection Control Processes documented the elements of the Infection Prevention and Control program included antibiotic stewardship. The staff used surveillance data to determine whether ABT usage patterns required change. The policy documented the facility used McGeer Criteria, a set of standardized definitions that helped identify potential infections and guided appropriate ABT use.

A review of Monthly Infection Surveillance Logs for January, February, and March 2025 with Staff D, Infection Preventionist, occurred on 04/21/2025 at 8:44 AM. Staff D clarified that residents identified with CA [community acquired] infections, admitted from the hospital with an ABT or were prescribed the ABT by a community provider.

Review of the January 2025 Monthly Infection Surveillance Log with Staff D showed 28 residents identified with CA infections received an ABT. The log showed no answer to the question, If ABT used, McGeer's minimum criteria met?, for eight of the 28 residents.

Review of the February 2025 Monthly Infection Surveillance Log with Staff D showed 24 residents identified with CA infections received an ABT. The log showed no answer to the question, If ABT used, McGeer's minimum criteria met?, for nine of the 24 residents, N/A [not applicable] for four other residents, and No for one resident.

Review of the March 2025 Monthly Infection Surveillance Log with Staff D showed 35 residents identified with CA infections received ABT. The log showed no answer to the question, If ABT used, McGeer's minimum criteria met?, for 31 of the 35 residents, No for one resident, and N/A for two other residents.

On 04/21/2025 at 8:44 AM, Staff D acknowledged the ASP was not implemented for new admissions to the facility or residents prescribed an ABT by community providers. Staff D stated they did not apply the ASP process because, I am under the impression the hospital ensures McGeer is being followed on their end. No further information was provided.

No Associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 potential for actual harm Based on interview and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 88 Residents Affected - Few and 6) reviewed for infection control practices, received vaccinations for influenza and pneumonia as consented to. This failure placed the residents at risk of contracting pneumonia and influenza and potential complications associated with those illnesses.

Findings included .

Review of the 08/10/2023 facility policy titled Influenza Vaccine documented the facility offered residents an influenza vaccine within 5 working days of their admission to the facility between October 31st and March 31st (generally accepted as influenza season) each year.

Review of the undated facility policy titled Pneumococcal Vaccine documented that before or upon admission, the staff assessed residents for eligibility to receive the pneumococcal vaccine series and, if indicated, offered the vaccine within 30 days of admission to the facility, unless previously received or medically contraindicated.

The 03/22/2025 admission assessment documented Resident 88 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment documented the resident had not received the influenza vaccine, the pneumococcal vaccine was not up to date, and neither vaccine was offered by the facility.

Review of the medical record showed no documentation the facility screened Resident 88 for influenza and pneumococcal vaccination eligibility or offered them. The above findings were shared with Staff D, Infection Preventionist, on 04/22/2025 at 10:55 AM. Staff D stated they would grab consent.

On 04/22/2025 at 1:10 PM, Staff D provided an undated but signed Vaccine Consent Form which showed Resident 88 requested both the influenza and pneumococcal vaccines. Staff D stated the consent was completed on 03/16/2025 and the pneumococcal vaccine was ordered just today. Staff D acknowledged it was past the 30 days for staff to offer Resident 88 the pneumococcal vaccine. No further information was provided to show what efforts the facility made to show they provided Resident 88 the influenza vaccine

during the remaining influenza season.

The significant change assessment dated [DATE REDACTED] documented Resident 6 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment documented the resident did not receive the influenza vaccine during the influenza vaccination season because it was not offered.

An undated but signed Vaccine Consent form documented Resident 6 requested vaccination for influenza.

The Vaccine Consent Form was scanned into the electronic medical record on 02/03/2025. Review of the February, March and April 2025 Medication Administration Records had no documentation Resident 6 received the influenza vaccination during the remaining influenza season as requested.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0883 The above findings were shared with Staff D on 04/22/2025 at 1:10 PM. Staff D acknowledged Resident 6 should have but did not receive the influenza vaccine as consented to. Level of Harm - Minimal harm or potential for actual harm Reference: WAC 388-97-1340 (1) (2) (3)

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page106of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 42802 potential for actual harm Based on observation, interview and record review, the facility failed to ensure equipment was maintained in Residents Affected - Few a safe operational condition for 1 of 4 sampled residents (Resident 17) reviewed for environment. This failure placed the resident at risk of possible injury.

Findings included .

According to the 03/26/2025 admission assessment, Resident 17 was cognitively intact to make decisions regarding their care and able to make their needs known.

On 04/15/2025 at 11:11 AM, Resident 17's call light/television (TV) cord was observed with various colored wire cords exposed near the control. The resident stated they told staff and asked if it could be replaced, but nothing had been done about it.

Similar observations of the call light/TV cord with exposed wires were made on 04/17/2025 at 11:30 AM, 04/18/2025 at 1:45 PM, 04/21/2025 at 7:35 AM, and on 04/22/2025 at 9:22 AM.

During an interview on 04/23/2025 at 9:26 AM, Staff G, Maintenance Director, stated if a call light was not working, there was usually a spare one in a drawer in the nurses station. For any non-urgent maintenance issues, staff filled out a work order on the computer. Staff G was informed of the observations of Resident 17's call light/TV cord with exposed wires.

During a follow-up interview on 04/23/2025 at 10:36 AM, Staff G stated they replaced the call light in Resident 17's room. They verified that it was the first work order they received about the call light. Staff G stated that even though the break in the plastic did not go though the individual coating of the wires, it was still a safety issue and should have been replaced when first noticed.

During an interview on 04/23/2025 at 10:55 AM, Staff C, Assistant Director of Nursing, stated they expected staff to let maintenance know when they noted any issues, and if it was urgent, they should inform management to contact Staff G. Staff C further clarified that Resident 17's call light should have been replaced as soon as staff noticed or were informed of it.

Reference: WAC 388-97-2100

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page107of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 47328 potential for actual harm Based on observation, interview and record review, the facility failed to repeatedly ensure residents' call Residents Affected - Some lights were readily accessible for 2 of 4 sampled residents (Resident 21 and 65), reviewed for resident call systems. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and a diminished quality of life.

Findings included .

The 03/29/2025 quarterly assessment documented Resident 21 had diagnoses that included muscle weakness and left below the knee amputation. Resident 21 was dependent on staff assistance to perform most activities of daily living (ADLs). Resident 21 had moderate cognitive impairment and was able to clearly verbalize their needs.

The 01/09/2025 care plan documented Resident 21 was at risk for falls related to lower extremity weakness, impaired physical mobility, and a history of falls. Staff were instructed to anticipate Resident 21's needs, provide education and remind the resident to use their call light to request assistance with ADLs.

On 04/14/2025 at 9:09 AM, Resident 21's room was observed. The right side of the bed was placed against

the wall in a high position. The call light cord ran across the top of the over bed light fixture, the soft touch call light pad dangled down the wall, unreachable from the left side of the bed if sitting in a wheelchair. Similar observations were made at 10:09 AM, on 04/15/2025 at 8:45 AM, 10:37 AM, 12:06 PM, and 3:23 PM,

on 04/16/2025 at 8:46 AM, 12:06 PM, and 2:38 PM, and on 04/21/2025 at 7:49 AM.

On 04/21/2025 at 10:24 AM, Resident 21 was observed seated in their wheelchair on the left side of their bed watching television. The call light cord ran across the top of the overbed light fixture as previously observed. Resident 21 stated they were unable to reach the call light. They stated they would have to wait for staff to walk past their room and yell out for help if they needed assistance.

During an interview on 04/21/2025 at 10:42 AM, Staff O, Registered Nurse, observed Resident 21's call light cord running across the top of the over bed light fixture and dangling down the wall. Staff O acknowledged Resident 21's call light should be within their reach so they could call for help when needed.

The 02/11/2025 admission assessment documented Resident 65 had diagnoses that included syncope (to faint) and collapse. Resident 65 sustained a fall in the month prior to admission and had a non-injury fall once admitted .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page108of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0919 The 01/30/2025 hospital history and physical documented Resident 65 experienced a fall at home and was down for approximately an hour. Resident 65 had a history of falls, needed assistance with walking, had a Level of Harm - Minimal harm or soft-spoken voice, and spoke minimally, which was their baseline level of functioning. potential for actual harm

The 02/06/2025 care plan documented Resident 65 was at risk for falls related to cognitive and functional Residents Affected - Some impairments, weakness, recent hospitalization , unsteady gait, and incontinence. Staff were instructed to anticipate Resident 65's needs, have the bed against the wall in the lowest position, place common items within reach, and educate the resident on safe transfers.

The facility Incident Log documented Resident 65 sustained falls on 02/05/2024 at 4:50 PM (1 hour and 50 minutes after their admission), 02/13/2025, 02/28/2025, 03/12/2025, and 3/14/2025.

On 04/14/2025 at 9:08 AM, Resident 65's room was observed. The right side of their bed was against the wall. The call light was pinned to the cord that came out of the wall, unreachable from the left side of the bed if sitting in a wheelchair. Similar observations were made at 10:09 AM, and on 04/15/2025 at 8:47 AM, and 10:37 AM.

On 04/16/2025 at 8:47 AM, Resident 65's bed was observed in a high position. The call light was on the floor behind the bed. Similar observations were made at 12:06 PM, and 2:38 PM, on 04/17/2025 at 8:37 AM, and

on 04/21/2025 at 7:48 AM and 10:25 AM.

On 04/21/2025 at 10:37 AM, Staff P, Nursing Assistant, observed the call light on the floor with the surveyor and stated the call light needed to be left where the resident could call for assistance when they needed to.

During an interview on 04/21/2025 at 10:54 AM, Staff A, Administrator, stated they expected their staff to leave resident call lights where residents could use them to call for assistance.

Reference WAC 388-97-2280 (1)(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page109of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115

Residents Affected - Few Based on observation and interview, the facility failed to ensure a sanitary, comfortable and homelike environment for 1 of 7 sampled residents (Resident 87) reviewed for environment. This failure placed the resident at risk of an unpleasant, uncomfortable living environment and a decreased quality of life.

Findings included .

The 03/24/2025 quarterly assessment documented Resident 87 had diagnoses including heart failure, high blood pressure and depression. Resident 87 was cognitively intact and able to make their needs known.

In an observation on 04/14/2025 at 1:33 PM, upon entrance to shared room [ROOM NUMBER], there was a very strong foul odor that resembled sweat and urine. The odor became stronger as you passed Resident 87's side of the room. Resident 87 shared a room with Resident 22.

The 04/01/2025 significant change in condition assessment documented Resident 22 had diagnoses including diabetes, high blood pressure and depression. Resident 22 had moderately cognitive impairments and was able to make their needs known.

In an observation and interview on 04/14/2025 at 1:33 PM, Resident 22 was lying in bed and their hair appeared greasy. Resident 22 stated they received a shower once a week when they allowed it. Resident 22's tray table was unclean with multiple napkins, a washcloth, container of ice cream that looked like it had been there for quite some time, the floor had food and fluid on it that had spilled.

Subsequent observations of the foul odor in room [ROOM NUMBER] were made on 04/15/2025 at 12:12 PM, 04/16/2025 at 9:11 AM, 12:03 PM, and 2:52 PM, 04/17/2025 at 8:56 AM and 12:35 PM, and 04/18/2025 at 9:00 AM.

In an interview on 04/17/2025 at 8:59 AM, Resident 87 was asked if the foul odor in the room bothered them, and they stated yes and they had mentioned it numerous times to the staff, but nothing was done.

In an interview on 04/23/2025 at 12:15 PM, Staff OO, Licensed Practical Nurse, stated Resident 22 did not take showers very often and there was a foul odor in the room at times. Staff OO stated they smelled the odor when they entered the room to provide medications.

In an interview on 04/23/2025 at 12:20 PM, Staff PP, Environmental Service Director, stated room [ROOM NUMBER] had a foul odor and they had replaced Resident 22's mattress a few times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page110of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0921 In an interview on 04/23/2025 at 12:23 PM, Staff V, Social Service Director, stated room [ROOM NUMBER] had a foul odor as Resident 22 refused their showers. Staff V stated they had not spoken to Resident 87 Level of Harm - Minimal harm or regarding the foul odor in the room to determine if the condition of the room or the foul odor was bothersome potential for actual harm to them.

Residents Affected - Few In an interview on 04/23/2025 at 1:47 PM, Staff C, Assistant Director of Nursing, stated Resident 22 refused cares and had a foul odor in their room off and on. Staff C stated they did not have a conversation with Resident 87 regarding the foul odor in the room.

In an observation on 04/23/2025 at 1:54 PM, when Staff V informed Resident 87 they were being moved to a new room, Resident 87 stated that was great and thanked Staff V.

Reference WAC 388-97-3220 (1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page111of111 505322

F-Tag F656

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297

Residents Affected: Some and routinely met professional standards of practice for 12 of 13 sampled residents (Resident 6, 262, 69, 16,

F-F656 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 potential for actual harm Based on observation, interview, and record review the facility failed to ensure services provided consistently Residents Affected - Some and routinely met professional standards of practice for 12 of 13 sampled residents (Resident 6, 262, 69, 16, 41, 83, 312, 63, 65, 311, 79, and 85), reviewed for skin conditions, constipation and accidents. Failure of staff to monitor wounds, follow and/or clarify physician orders when indicated, develop and implement an effective fall prevention policy and consistently monitor residents for injury after falls, placed residents at risk for a delay in treatment, injury, hospitalization , and a diminished quality of life.

Findings included .

The American Nurses Association (ANA) is a national professional organization that represents the interests of registered nurses in the United States and sets and promotes high standards of nursing practice to ensure quality and ethical care for patients. The ANA developed the document, Nursing: Scope and Standards of Practice, with its fourth edition released in 2021. The resource informs and guides nurses in providing safe, quality, and competent patient care. The resource outlined and described 18 standards of practice for nursing professionals to follow.

Review of the Nursing: Scope and Standards of Practice resource showed the first six standards included:

1. Assessment: effectively collect data and resident information that is relative to their condition or situation.

2. Diagnosis: analyze the data gathered during the assessment phrase, to determine potential or actual diagnoses.

3. Outcomes Identification: effectively predict outcomes for the resident.

4. Planning: After identifying a diagnosis and outcomes, develop a plan or strategy to attain the best possible outcome for the resident in need.

5. Implementation: Implement the identified plan. This may be done by coordinating care for the residents, such as administering treatment, or implementing/following provider orders.

6. Evaluation: After implementation, a nurse must monitor and evaluate the patient's progress towards the expected outcome or health goals.

FAILURE TO ASSESS AND IMPLEMENT TREATMENT FOR NON-PRESSURE SKIN CONDITIONS

Review of an undated facility policy titled, Skin Tears, Abrasions, and Bruises Management showed, the nurses completed weekly skin observations and documented their findings in the medical record. The documentation included the location of the skin condition and its description, to include the size, along with treatment orders and interventions to promote healing. The policy instructed the nurses to evaluate the effectiveness of the treatment weekly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 <Resident 6>

Level of Harm - Minimal harm or Review of a 02/23/2025 significant change in condition assessment showed Resident 6 admitted to the potential for actual harm facility on [DATE REDACTED] with medically complex conditions, to include Sjogren's syndrome (a chronic autoimmune disease that can cause dry skin). The assessment showed the resident had moderately impaired cognition Residents Affected - Some and had no lesions, skin tears, or abrasions.

An observation on 04/14/2025 at 11:28 AM showed Resident 6 sitting in a wheelchair in a resident lounge area. An undated dressing was observed towards the top of the resident's head, partially lifted on the right side and exposed an open area of an undetermined size. The exposed area was not actively draining and seemed to have a dry, red wound bed, like an abrasion. Resident 6 stated the staff, Change the dressing if I need it every day.

Observations on 04/16/2025 at 09:25 AM and 04/17/2025 at 8:39 AM showed Resident 6 up in a wheelchair and out of their room, with no dressing present. Observed was a dry abrasion, approximately 1.5 centimeters (cm, a unit of measurement) by 2 cm. No active drainage or signs of infection were observed. Review of the April 2025 Treatment Administration Records (TAR) showed no instructions to monitor or care for the abrasion to Resident 6's head.

A 03/06/2025 progress note documented Resident 6 had opened several scabbed wounds by scratching on [their] forehead and right leg resulting in bleeding. Antibiotic antibiotic ointment and skin prep was applied to

the wounds and dressed with bordered dressings. Another 03/06/2025 progress note showed the staff identified abrasions to the right lower leg and to the right side of the scalp. Review of the March 2025 Treatment Administration Records (TAR) showed no orders for the application of the antibiotic ointment and bordered dressings to the wounds on the forehead or right leg.

Review of a 03/13/2025 Wound Consultant note showed, the staff assessed Resident 6 had, bruises and abrasions from falls and scratching [themselves]. The consultant instructed the staff to apply one or more ounces of emollient [moisturizing] cream to all the skin at least two times a day. Subsequent notes by the Wound Consultant on 03/20/2025, 03/27/2025, 04/03/2025, and 04/10/2025 showed the same instructions.

Review of the March and April 2025 TAR or care plan showed no documentation the nurses implemented

the Wound Consultant's specific instruction.

Review of the progress notes from 03/21/2025 to 04/12/2025 showed the staff identified various skin conditions as follows:

- On 03/21/2025, an abrasion to the forehead

- On 03/24/2025, skin tears and abrasions

- On 03/26/2025, abrasions to knees

- On 03/28/2025, skin abrasions

- On 04/12/2025, a skin tear that is not covered; skin found to be open, size is about 8cm in length with moderate amount of blood; Per the documentation, the resident was sent to the hospital, returned to the facility at 8:15 PM, and had obtained 9 stitches and 5 steri-strips [adhesive strips].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 Review of provider notes showed they also identified the following various skin conditions:

Level of Harm - Minimal harm or - On 02/19/2025 and 03/17/2025 - abrasions to both knees and scalp potential for actual harm -On 03/06/2025, 03/11/2025, 03/14/2025, 3/27/2025, 03/28/2025, 4/17/2025 - Wound on scalp or Scabbed Residents Affected - Some wound on scalp.

Review of the medical record showed the nurses completed weekly Skin Observation assessments on 02/17/2025, 02/24/2025, 03/03/2025, 03/06/2025, 03/11/2025, 03/13/2025, 04/10/2025, and 04/17/2025. The medical record showed no documentation that showed the nurses assessed or evaluated the status or progress of the multiple identified non-pressure skin conditions, to include the substantial skin tear of unknown location, or developed and implemented measures to ensure adequate healing and/or prevent complications associated with the non-pressure skin conditions. Review of the physician orders showed no instructions to care for the substantial skin tear of unknown location that required the resident's transfer to

the hospital for invasive treatment on 04/12/2025.

The above findings were shared with Staff C, Assistant Director of Nursing (ADON), on 04/18/2025 at 11:21 AM. Staff C acknowledged the nurses should have, but did not procure or implement provider orders for the management of non-pressure skin conditions, assessed or evaluated the status or progress of non-pressure skin conditions, or developed and implemented measures to ensure adequate healing and prevent complications associated with the non-pressure skin conditions.

According to the 02/12/2025 quarterly assessment, Resident 63 was dependent on staff assistance to perform personal hygiene which included washing/drying their face. Resident 63 had moderate cognitive impairment and was able to clearly verbalize their needs.

Review of the 02/04/2025 weekly skin assessment observation showed Resident 63 had dry skin.

Review of the 02/11/2025 weekly skin assessment observation showed Resident 63 had extremely dry skin.

Review of Resident 63's care plan showed no documentation or interventions to address Resident 63's extremely dry skin.

During observation and interview on 04/14/2025 at 9:00 AM, Resident 63 had thick white dry skin flakes covering their entire forehead, down both sides of their face, inside both ear crevices, down both sides of their neck, and behind both ears. Resident 63 stated they had Psoriatic [skin condition that resulted in red patches covered with silvery scales] Arthritis [joint pain, stiffness, and swelling]. Resident 63 stated they were experiencing a bad flare up and explained their skin itched and was irritated. Resident 63 stated they had a cream to help but they had to request it and I never seem to get it. Resident 63 further stated it took their skin

a while to calm back down after a flare up. Similar observations were made at 11:31 AM, 1:20 PM, on 04/15/2025 at 8:58 AM and 12:03 PM, on 04/16/2025 at 12:14 PM, and on 04/18/2025 at 8:43 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 In an interview on 04/22/2025 at 1:18 PM, Staff C reviewed Resident 63's medical record. Staff C acknowledged Resident 63 had extremely dry skin and no treatment for psoriasis. Staff C stated they Level of Harm - Minimal harm or expected staff to follow up on skin issues as needed. potential for actual harm <Resident 16> Residents Affected - Some According to the 03/11/2025 assessment, Resident 16 was cognitively intact and able to clearly verbalize their needs.

Review of the 04/07/2025 facility unwitnessed fall report showed Resident 16 attempted to self-transfer but their legs gave out and fell . Resident 16 sustained a skin tear to the back of their left hand that was closed with steri-strips (thin strips of tape used to close small cuts).

Review of April 2025 nursing progress notes showed on 04/07/2025 Resident 16 fell and sustained a skin tear to the back of their left hand that was closed with steri-strips. On 04/08/2025 the left hand steri-strips were getting a little dirty and were covered with gauze. No documentation of skin tear monitoring or assessment for signs and/or symptoms of infection was found until 04/15/2025. On 04/15/2025 the left-hand dressing was dislodged, the wound was cleansed, assessed, and redressed. Resident 16 informed the staff

the skin tear was an injury from their recent fall.

Review of provider orders as of 04/14/2025, seven days after Resident 16 sustained a fall, showed no provider orders to monitor the left-hand skin tear for signs and/or symptoms of infection or to change the bandage.

During observation and interview on 04/14/2025 at 11:18 AM, Resident 16 stated they sustained a skin tear to their left hand when they attempted to self-transfer recently and fell . Resident 16 pointed to a white undated bandage on the back of their left hand with a dark blood drainage stain spot observed through the bandage. Resident 16 stated the bandage had not been changed for a week and thought the skin tear was worsening because it was becoming painful, warm, and continued to bleed. Similar observation was made

on 04/15/2025 at 8:52 AM.

In an interview on 04/22/2025 at 12:02 PM, Staff H, Licensed Practical Nurse (LPN), explained if a resident fell and sustained a skin tear the provider would be notified and orders to monitor and/or skin treatment orders implemented. Staff H stated skin issues could worsen or get infected if they were not monitored. Staff H reviewed Resident 16's medical record. Staff H acknowledged Resident 16 experienced a fall on 04/07/2025, sustained a skin tear to the back of their left hand, and staff should have implemented orders to monitor the skin tear.

In an interview on 04/22/2025 at 12:19 PM, Staff C, ADON, stated skin issues could worsen or get infected if

they were not consistently monitored. Staff C reviewed Resident 16's medical record. Staff C acknowledged Resident 16 sustained a skin tear from a fall on 04/07/2025, but treatment orders were not implemented until 04/16/2025, nine days later. Staff C stated they expected staff to follow-up on skin issues.

In an interview on 04/22/2025 at 2:01 PM, Staff A, Administrator, stated they expected staff to follow up on skin issues.

FAILURE TO ASSESS AND IMPLEMENT ORDERS FOR CONSTIPATION

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 Review of provider standing orders showed directions to address constipation before and after 48 hours of not experiencing a bowel movement (BM). The protocol was time-specific regarding administration of the Level of Harm - Minimal harm or different laxatives. potential for actual harm

The standing orders showed that after 48 hours of no BM, the nurses were instructed to administer Lactulose Residents Affected - Some every two hours as needed and if the resident did not have a BM after six hours, then Milk of Magnesia (MOM). If the resident did not have a BM after six hours of receiving the MOM, the nurses were to administer

a Bisacodyl suppository. If the suppository proved ineffective after six hours, the nurses were ordered to administer a Fleets enema once and to notify the provider if they wished to repeat it. The orders instructed

the nurses to notify the provider if a resident did not have a BM greater than 3 days and to let them know of all medications that were already attempted.

Review of a 04/03/2025 admission assessment showed Resident 262 admitted to the facility on [DATE REDACTED] with medically complex conditions, which included Parkinsonism (a neurological disorder) and chronic pain syndrome. The assessment showed the resident was cognitively intact and presented with a bowel pattern of constipation.

An observation and interview on 04/18/2025 at 1:04 PM showed Resident 262 sitting up in a chair in their room. Resident 262 said they independently walked to the bathroom. The resident said they had a BM one every 4 or 5 days here [in the facility] which was a change from home where they had a BM, almost every day. The resident shared that at home they took a a big gulp of Milk of Magnesia about once a week and, Apparently [staff] don't know about Milk of Magnesia here. The resident referred to being offered a liquid twice a day that they thought was for the management of constipation but, I wonder about it because I'm still not pooping. Maybe I should mention it to [the staff]. That would make me go poop. I'd like that. When asked if the staff inquired if they had a bowel movement, Resident 262 stated, No, I don't think anybody has asked that.

Review of the April 2025 Medication Administration Records (MAR) showed physician orders for routine or scheduled administration of medications that had the side effect of constipation, to include amiodarone (a cardiac agent), bupropion (an antianxiety agent), iron tablets, semaglitude (for diabetes), and carbidopa-levidopa (for Parkinsons). The MAR showed that both scheduled senna tablets and gavilax (both over the counter [OTC] medications used to treat constipation) were discontinued on 04/07/2025. The MAR showed no as needed orders for medications to treat episodes of constipation.

Review of a 03/29/2025 care plan showed the staff assessed and determined the resident was at risk for constipation related to medications. The care plan showed, if the resident experiences constipation it will be resolved thru the review period. The interventions directed the nurses to administer medications as ordered, implement bowel protocol when indicated, observe for signs and symptoms of constipation or extended abdomen that may indicate constipation, and track and record bowel movements.

Review of a Bowel Elimination Record from 03/28/2025 to 04/18/2025 showed Resident 262 did not have a BM recorded for three days from 03/28/2025 to 03/30/2025, for six days from 04/04/2025 to 04/09/2025, and for three days from 04/11/2025 to 04/13/2025 and from 04/15/2025 to 04/17/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 The above findings were shared with Staff C on 04/18/2025 at 1:30 PM. Staff C clarified that the bowel protocol the care plan referred to was the provider's standing orders and the nurses had to manually input Level of Harm - Minimal harm or those orders into the electronic medical record for their use. Staff C acknowledged the medical record potential for actual harm showed no documentation the nurses assessed Resident 262 or implemented the standing orders for constipation, as per professional standards of practice, to include notifying the provider when Resident 262 Residents Affected - Some did not have a BM greater than 3 days.

46115

The 03/07/2025 significant change in condition assessment documented Resident 69 had diagnoses which included constipation and high blood pressure. The resident was cognitively intact and able to make their needs known.

In an interview on 04/14/2025 at 10:04 AM, Resident 69 stated they had constipation and MOM helped.

The 12/09/2025 care plan instructed nursing to monitor for signs and symptoms of constipation, implement bowel protocol when indicated, administer medications as ordered, and track and record bowel movements.

The care plan documented if the resident experienced constipation it would be resolved through the review period.

The bowel record from 03/01/2025 to 04/18/2025 documented Resident 69 did not have a BM on the following dates:

03/05/2025 to 03/12/2025, eight days

03/21/2025 to 03/24/2025, four days

04/14/2025 to 04/19/2025, six days

Review of the March and April 2025 MARs showed Resident 69 had as needed Bisacodyl to treat episodes of constipation and none was administered.

The 02/01/2025 quarterly assessment documented Resident 38 had diagnoses which included diabetes and heart failure. The resident was cognitively intact and able to make their needs known.

The 10/30/2024 care plan instructed nursing to monitor signs and/or symptoms of constipation, implement bowel protocol when indicated, administer medications as ordered, and track and record bowel movements.

The care plan documented if the resident experienced constipation it would be resolved through review period.

The bowel record from 03/01/2025 to 04/18/2025 documented Resident 38 did not have a BM on the following dates:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 03/18/2025 to 03/27/2025, ten days

Level of Harm - Minimal harm or 04/01/2025 to 04/04/2025, four days potential for actual harm 04/06/2025 to 04/12/2025, seven days Residents Affected - Some

Review of the March and April 2025 MARs showed Resident 38 had no as needed medications to treat episodes of constipation.

In an interview on 04/22/2025 at 9:00 AM, Staff X, Licensed Practical Nurse, stated the bowel protocol was started on day three of no BM and they were to administer DOSS (a stool softener), Senna (a laxative) and Miralax (a stimulant). Staff X stated small bowel movements did not count. Staff X stated it was important to follow the protocol, so blockage and pain did not occur.

In an interview on 04/22/2025 at 1:30 PM, Staff C stated they had standing orders for the bowel protocol from a group of their providers, and they had a provider that ordered MOM on day three of no BM, if no results a suppository was given, and if no results the next day an enema was given. Staff C stated the bowel protocol should have been followed for the above residents or a progress note made stating they spoke to

the residents and inquired if they had a BM. Staff C stated it was important to follow the bowel protocol to prevent pain and blockage.

According to the 03/11/2025 assessment, Resident 16 was always incontinent of bowel and their bowel patterns showed constipation was present. Resident 16 was cognitively intact and able to clearly verbalize their needs.

Review of the 02/21/2025 care plan showed Resident 16 was at risk for constipation and instructed staff to administer medications as ordered, track BMs, observe for signs of constipation, and implement the bowel protocol when indicated.

Review of provider orders showed a 02/11/2025 order for Resident 16 to be administered MOM every 24 hours as needed for constipation, MiraLAX to be administered every 24 hours as needed for constipation, and a Bisacodyl suppository daily as needed for bowel care.

Review of the bowel elimination record from 03/19/2025 to 04/17/2025 showed Resident 16 did not have a BM for three days from 03/27/2025 to 03/29/2025, for four days from 04/01/2025 to 04/03/2025, for four days from 04/05/2025 to 04/08/2025, and for four days from 04/11/2025 to 04/14/2025.

Review of the March 2025 through April 2025 MAR showed Resident 16 was not administered any as needed bowel medication from 03/24/2025 through 04/16/2025.

According to the 02/13/2025 admission assessment, Resident 41 was continent of bowel, was cognitively intact and able to clearly verbalize their needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 Review of the 02/05/2025 continence care plan showed Resident 41 was usually continent of bowel and instructed staff to record BMs, provide staff assistance with toileting, and provide toileting/incontinence Level of Harm - Minimal harm or supplies as needed. potential for actual harm

Review of provider orders showed a 02/04/2025 order for Resident 41 to be administered MiraLAX every 24 Residents Affected - Some hours as needed for constipation.

Review of the bowel elimination record from 03/20/2025 to 04/18/2025 showed Resident 41 did not have a BM for five days from 03/30/2025 to 04/03/2025 and for four days from 04/06/2025 to 04/09/2025.

Review of the April 2025 MAR record showed Resident 41 was not administered MiraLAX for constipation as needed.

According to the 03/30/2025 quarterly assessment, Resident 85 was always incontinent of bowel and their bowel patterns showed constipation was present. Resident 85 was cognitively intact and able to clearly verbalize their needs.

Review of the 01/14/2025 opioid (class of drugs used to reduce moderate to severe pain) use care plan showed Resident 85 was at risk for complications and instructed staff to administer medications as ordered, record/track bowel movements, and implement the bowel regimen protocol.

Review of provider orders showed a 12/30/2024 order for Resident 85 to be administered a bisacodyl suppository every 24 hours as needed for constipation, and a 02/17/2025 order for Resident 85 to be administered MOM every 24 hours for constipation lasting more than 48 hours.

Review of 12/18/2024, 12/30/2024, 02/06/2025, 03/01/2025, and 03/17/2025 provider progress notes showed Resident 85 struggled with recurrent constipation going up to several days before having a hard BM.

Review of February 2025 nursing progress notes showed on 02/23/2025 Resident 85 had an incident of hard impacted stool. Several large hard stools were passed after Resident 85 was administered a Bisacodyl suppository. Resident 85 will require education on bowel maintenance when taking scheduled [opioid] medication.

Review of the bowel elimination record from 03/18/2025 to 04/16/2025 showed Resident 85 did not have a BM for 10 days 03/20/2025 to 03/29/2025, for four days from 04/04/2025 to 04/07/2025, and for five days from 04/12/2025 to 04/16/2025.

Review of the March 2025 through April 2025 MAR showed Resident 85 was not administered MiraLAX or a Bisacodyl suppository for constipation as needed.

In an interview on 04/22/2025 at 9:23 AM, Resident 85 stated the facility did not monitor or track BMS and often went 9-10 days without a BM. Resident 85 further stated it was painful to have a BM after 10 days, staff did not offer bowel interventions and often had to request a suppository or enema.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 In an interview on 04/22/2025 at 9:43 AM, Staff F, Resident Care Manager, stated residents were at risk for bowel blockages if the bowel protocol was not implemented when indicated and staff should document bowel Level of Harm - Minimal harm or interventions attempted and/or refused. Staff F reviewed Resident 85's medical record. Staff F potential for actual harm acknowledged Resident 85 went 9-10 days without a BM and staff should have implemented the bowel protocol. Residents Affected - Some

In an interview on 04/22/2025 at 10:34 AM, Staff A, Administrator, stated they expected staff to implement

the bowel protocol when indicated.

47328

FAILURE TO IMPLEMENT FALL PRECAUTIONS

Review of the facility policy titled, Fall Safety- Everyone is at Risk of Falling dated October 2022, showed anyone could fall regardless of age, gender, or illness. The policy instructed staff to be alert to situations that could lead to falls and included some potential situations to avoid and interventions to implement. The Falling Leaves program consisted of a leaf sticker placed next to a high fall risk resident's door name tag. The sticker was to notify staff the identified resident required frequent rounding to help reduce falls. The policy did not instruct staff how to assess fall risk, what steps to take when a fall occurred, or how to monitor residents when falls were sustained.

Review of an undated facility incident report form instructed staff to use the format as a guide on what steps were required after a resident sustained a fall. Staff were to place the resident on alert charting: every shift for 72 hours, or longer if not resolved. The form additionally instructed staff to complete a neurological evaluation (neuro and/or neuro checks, a series of tests that assess mental status, reflexes, movement, and pupil reaction to evaluate brain and nervous system function) if a resident hit their head or the fall was unwitnessed by staff.

Review of the Neurological Evaluation Flow Sheet used by the facility to assess for any changes instructed staff to complete a neuro evaluation with vital signs every 30 minutes for two hours, then every hour for four hours, then every 8 hours for nine hours (72 hours), compare vital signs over time and pay close attention to respiratory patterns. The form included a graph to document the required information on.

According to the 02/11/2025 admission assessment, Resident 65 admitted to the facility on [DATE REDACTED] with diagnoses including Dementia, syncope (to faint) and collapse. The assessment further showed Resident 65 sustained a fall in the month prior to admission and a non-injury fall since their admission. Resident 65 had severe cognitive impairment, disorganized thinking and inattention.

Review of the 01/30/2025 hospital history and physical showed Resident 65 experienced a fall at home and was down for approximately an hour. The notes further showed Resident 65 had a history of falls, needed assistance with walking, had a soft-spoken voice, and spoke minimally per their baseline.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 Review of the 02/05/2025 admission assessment showed Resident 65 arrived to the facility at 3:00 PM, had cognitive impairment, was confused, oriented to self only, and unable to make their needs known. The Level of Harm - Minimal harm or assessment further showed Resident 65 had post fall injuries including significant bruising, four lacerations, potential for actual harm and an eyebrow abrasion.

Residents Affected - Some Review of the 02/06/2025 care plan showed Resident 65 was at risk for falls related to cognitive and functional impairments, weakness, recent hospitalization , unsteady gait, and incontinence. The care plan instructed staff to anticipate Resident 65's needs, have the bed against the wall in the lowest position, non-skid strips at bedside, educate resident on safe transfers, provide and use non-skid socks while out of bed. An intervention implemented on 02/13/2025 showed Resident 65 was added to the Falling Leaves program. Revisions on 03/03/2025 instructed staff that resident was to be in high visibility areas when up in

the wheelchair (WC), and on 03/13/2025 a fall mat was to be placed to the left side of the bed.

Review of the February 2025 through March 2025 facility incident reporting log showed fall entries related to Resident 65 were made on 02/05/2024, 02/13/2025, 02/28/2025, 03/12/2025, and 03/14/2025.

Review of Resident 65's fall reports showed:

- Unwitnessed fall on 02/05/2025 at 4:50 PM (1 hour and 50 minutes after their admission), staff entered Resident 65's room to answer their call light and found them lying on the floor. Resident 65 was restless, continued to attempt to self-transfer out of bed. Resident 65 had aphasia (disorder that made it hard to understand and speak) and could not explain the situation. Interventions implemented were to place the bed against the wall in the lowest position and provide the resident with non-skid socks. No documentation of neuro checks was found.

- Unwitnessed fall on 02/13/2025, Resident 65 was found on the floor next to their roommate's bed. The mattress on the floor next to [Resident 65's] bed had been moved away from the bed about 4-5 inches and appeared the resident self-transferred. Intervention implemented was to add Resident 65 to the Falling Leaves program. The attached neurological evaluation flow sheet vital signs section showed only five of 12 sets of vital signs were documented.

- Unwitnessed fall on 02/28/2025, Resident 65 slid out of their WC, was confused, unable to state what happened and neuro checks were started, however, no documentation of neuro checks were found.

- Unwitnessed fall on 03/12/2025, Resident 65 was found sitting on the floor next to their bed with the fall mat again pushed away from the bed, neuro checks were initiated. The incident summary showed Resident 65's care plan remained appropriate. No documentation of intervention implemented, or neuro checks was found.

- Unwitnessed fall on 03/14/2025, Resident 65 was found lying on the floor next to their WC near the nurses' station, and neuro checks were initiated. Intervention implemented was a therapy referral for WC evaluation.

The attached neuro sheet showed omissions in documentation for four of 12 neuro assessments and eight of 12 sets of vital signs.

Review of February 2025 through March 2025 nursing progress notes showed Resident 65 was inconsistently monitored for latent injuries after falls occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0658 In an interview on 04/24/2025 at 10:34 AM, Staff H, Licensed Practical Nurse (LPN), stated residents were assessed for fall risk upon admission. Staff H explained when a fall occurred, an incident report was Level of Harm - Minimal harm or completed, the resident assessed for injuries, placed on alert to monitor for potential latent injuries, provider potential for actual harm notified, and interventions implemented. Staff H further stated all unwitnessed falls and falls with head injury needed to have neuro checks completed and documented on the paper form. A fall intervention needed to Residents Affected - Some be implemented when a fall occurred to prevent further falls and/or injury. Staff H acknowledged a resident's health and safety was in jeopardy if a resident was not consistently monitored after a fall occurred.

In an interview on 04/24/2025 at 10:40 AM, Staff C, ADON, explained neuro checks were to be completed for unwitnessed falls or falls with head injury. Staff C stated staff were to document neuro checks on the paper neurological evaluation flow sheet when implemented. Staff C further stated residents were monitored for latent injuries via the neuro check flow sheet and nursing progress notes, if a resident was not monitored then staff would not know if or when a resident had a worsening injury, pain, or change of condition. Staff C reviewed Resident 65's fall reports and acknowledged there were omissions in Resident 65's neuro check monitoring, and staff should have monitored neuros consistently.

The 03/07/2025 significant change assessment documented Resident 69 had diagnoses including high blood pressure, anxiety and repeated falls. Resident 69 was cognitively intact and was able to make their needs known.

The 12/10/2024 risk for falls care plan documented Resident 69 was at risk for falls related to weakness, poor vision, incontinence and functional impairments. The care plan had multiple fall interventions in place.

Review of the September 2024 through March 2025 facility incident log showed Resident 69 sustained a fall

on 09/19/2025.

A 09/19/2024 progress note documented Resident 69 reported they fell in their room and had gotten themselves up off the floor. The resident stated they landed on their right side. The nurse stated they initiated neuros.

The neuro monitoring sheet revealed 10 omissions and documented the resident was asleep. Review of Resident 69's record revealed there were no further progress notes regarding the fall.

The 04/04/2025 admission assessment documented Resident 311 had diagnoses including cancer, high blood pressure and diabetes. Resident 311 had moderate cognitive impairments and was able to make their needs known.

The 12/10/2024 risk for falls care plan documented Resident 311 was at risk for falls related to deconditioning, pain and medications. The care plan had multiple fall interventions in place. <br[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 safety Based on observation, interview, and record review the facility failed to consistently and accurately assess Residents Affected - Many residents smoking abilities and implement safety interventions to prevent smoking related injuries for 3 of 3 sampled residents (Resident 73, 86 and 461), reviewed for smoking. The failure to accurately assess residents' smoking abilities and implement safety interventions to prevent smoking related injuries represented an immediate jeopardy (IJ).

On 04/15/2025 at 5:21 PM, the facility was notified of the identified IJ related to

F-Tag F657

F-F657 for additional information.

In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were unaware there were issues with care conferences not being offered or held. Staff A asked how they were out of compliance, and it was explained that 12 residents were reviewed and only one resident had a care conference for those that were scheduled

in February 2025. Staff A stated the PIP included looking at the scheduled care conferences daily and asking if they had been completed and the staff said they were. Staff A did not check to see that the care conferences had been completed.

-Admission Processes

See

F-Tag F658

F-F658 for additional information. Similar deficiencies were cited during the annual recertification survey dated 01/19/2024 and during a complaint investigation on 05/29/2024.

In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were not aware there were concerns with monitoring after falls occurred. Staff A stated the previous Director of Nursing (DNS) completed a PIP in December 2024 in which they performed audits and educated the staff. Staff A stated the DNS felt the PIP was successful as they reduced their number of falls from 28 to 23 and they no longer needed to do a full QAPI on falls.

-Care Conferences

See

F-Tag F689

Harm Level: Immediate Review of a 01/24/2025 hospital document showed Resident 73 fell asleep easily during the interview but

Residents Affected: Many

F-F689 CFR S483.25 Accidents and Supervision. Onsite verification by surveyors on 04/17/2025 showed, the facility removed the immediacy by placing Resident 73 on one-to-one surveillance, secured the resident's smoking paraphernalia, re-assessed the resident's ability to smoke, and revised the care plan to show the level of assistance and supervision the resident required to smoke safely. The facility closed access to unsupervised patio areas. The facility added a fire blanket and an outdoor ashtray to the designated smoking area. The facility interviewed other residents and staff to identify other residents who smoked and completed smoking safety evaluations of all the residents in the facility and for any residents identified as a smoker/tobacco user, to include development or revision of their care plans to show individualized interventions and supervision levels related to smoking preference. The facility completed a facility-wide sweep to remove unauthorized smoking materials. The facility notified the residents of the smoking policy. The facility educated the staff on

the smoking policy, and identifying, managing, and reporting unsafe smoking behaviors. Immediacy was removed 04/16/2025.

Findings included .

Review of a facility admission agreement showed smoking or vaping was prohibited within and on the grounds of the facility. The agreement informed the residents that possessing smoking related items, like cigarettes and lighters, was strictly prohibited. Residents were informed that the facility would provide information and assistance with exploring smoking cessation interventions and products if they had a history of smoking or tobacco use prior to admission to the facility and if so desired. Violation of the Smoke-Free Facility policy endangered the health and safety of the residents in the facility and was ground for discharge.

Review of the facility policy titled, Smoking Prohibited for Residents But Allowed For Staff dated October 2021, showed if staff found a resident with smoking materials, they were to be given to the nurse who secured them. The policy further showed staff would notify the provider for each incident of policy violation, document incident in the medical record, and investigated by the facility leadership team to evaluate the scope and potential endangerment to other residents and staff. The results of the investigation determined

the course of action to protect other residents and staff from endangerment, to include re-education of the resident, removal of smoking materials, discussion about smoking cessation support, evaluation of the resident's ability to smoke safely without staff assistance or supervision in a location out of the facility and off

the facility grounds, and/or discharge from the facility.

During the entrance conference on 04/14/2025 at 8:42 AM, Staff A, Administrator, stated the facility was a non-smoking facility and there were no residents that smoked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 <Resident 73>

Level of Harm - Immediate Review of a 01/24/2025 hospital document showed Resident 73 fell asleep easily during the interview but jeopardy to resident health or awakens easily again. The document showed the resident smoked cigarettes on some days. safety

Review of a 02/03/2025 facility provider note showed Resident 73 was, Current smoker some days. Residents Affected - Many

Review of a 02/07/2025 facility admission assessment showed Resident 73 admitted to the facility from the hospital on 02/01/2025 with medically complex conditions, including Parkinson's disease (a neurological disorder) and diabetes. The assessment showed Resident 73's speech was unclear, was cognitively intact, experienced fluctuating altered levels of consciousness and required staff assistance during transfers and walking. The assessment showed Resident 73 did not use tobacco.

Review of progress notes showed on 02/17/2025, the staff observed Resident 73, smoking outside in the parking lot. Social worker went out to speak to resident and remind [them] that we are a non-smoking facility. [The resident] was agreeable and put out [their] cigarette.

Review of a 02/17/2025 Smoking - Resident Safety Evaluation, signed off as completed on 03/05/2025 (16 days later), showed the staff identified Resident 73 used tobacco products, allowed the resident to smoke, and used Cigarettes / Cigars. The staff assessed Resident 73 was unable to hold or extinguish a cigarette safely or use an ashtray to extinguish the cigarette. The staff concluded, Resident is not a safe smoker at

this time. [They] agreed to Nicotine patches and to not smoke at this time. Family notified and nicotine patch order placed.

Review of a 03/03/2025 progress note showed, the facility informed the resident, that this is a non-smoking facility as was noted to be smoking at one point. Smoking materials obtained until safety can be established.

Review of a 03/04/2025 Tobacco Use care plan showed, Resident 73 preferred to smoke cigarettes. The goal was for the resident to follow non-smoking policy. The interventions included, Instruct the resident about smoking risks and hazards and about smoking cessation aids that are available, Notify social services or nurse manager if patient is found to be smoking, and smoking assessment as needed. The interventions were dated 03/04/2025 and 03/05/2025. The care plan showed no documentation the facility developed interventions to keep the resident safe from smoking related injuries or that compensated for their inability to manage smoking supplies. The care plan showed no documentation where smoking supplies were kept.

Review of 03/03/2025, 03/06/2025 and 03/14/2025 facility provider notes showed once more Resident 73 was, Current smoker some days.

Review of March and April 2025 Medications Administration Records (MAR) showed no documentation the provider prescribed nicotine patches for Resident 73 prior to 04/15/2025, as indicated in the 02/17/2025 resident smoking safety evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 An observation on 04/15/2025 at 2:23 PM, by the entire survey team, showed Resident 73 self-propelling in their wheelchair in the patio area with a lit cigarette in their hand. The resident attempted to enter the Level of Harm - Immediate conference room where surveyors were with the lit cigarette, but was unable to open the door. Resident 73 jeopardy to resident health or then wheeled over to the barbecue area under the [NAME] and sat next to a propane tank with the lit safety cigarette. At 2:34 PM, a surveyor entered the patio area, and it smelled of cigarette smoke. No fire blanket or ashtrays were observed. Resident 73 stated that they liked to smoke three times a day, and when asked if Residents Affected - Many there was an ashtray outside, they said, No. Observation of a white plastic fold-up table showed black streaks on its surface resembling the stubbing of a cigarette (to put out a cigarette by pressing the lit end against a surface, often done using a surface like an ashtray or the ground). Resident 73 again attempted to get into the conference room but was unable to do so. The resident then self-propelled across to the other side of the patio to enter another side of the building. A staff member was observed to escort Resident 73 back in the building.

In an interview on 04/15/2025 at 3:23 PM, Staff Q, Registered Nurse (RN), stated that the facility was a non-smoking establishment, and smoking was allowed out on the street or off the premises. Staff Q became aware if a resident actively smoked and the assistance required by checking the resident's roster (a basic information sheet used by the staff). Staff Q stated that they did not have any resident smoking materials secured. Staff Q stated that they were unaware of any residents who smoked in the facility but that if they did see a resident smoke, they would stop the resident and notify the Unit Manager.

In an interview on 04/15/2025 at 3:29 PM, Staff R, Nursing Assistant (NA), stated that they became aware of resident information by review of the Kardex (a summary of the care plan). Staff R stated, We are non-smoking so I am unsure if there are smokers [in the facility] but if they did smoke, they would have to go off property. Staff R stated that there was no designated place for a resident to smoke on facility premises. Staff R stated if they saw a resident violate the facility smoking policy they would, stop it from happening and let the nurse supervisor know and report it up above. Go through the chain [of command] not just the nurse. Staff R stated that smoking materials would be kept in a lock box with the Social Services department.

In a confidential interview on 04/15/2025 at 3:36 PM, an Anonymous Staff stated, Not a lot of residents here smoke and As long as [the resident] is on the sidewalk, that's considered off property. The staff stated if they saw a resident violate the facility smoking policy they would, Ask them if they can go to the sidewalk and educate them on the policy. I'd let my Unit Managers know or the ADON [Assistant Director of Nursing]. The staff identified Resident 73 was the only resident they were aware of that currently smoked and stated the resident kept their smoking materials in their jacket and never has it out in the open. The Anonymous Staff was unaware how long Resident 73 smoked since admission to the facility.

An observation and interview on 04/15/2025 between 3:36 PM and 4:00 PM showed, Resident 73 lying in bed. Resident 73 stated that they kept their cigarettes in their pocket along with the lighter and smoked more than twice a day and off the property. Additionally, Resident 73 stated that when the front doors to the facility were locked after 7:00 PM or 8:00 PM, I have to wait until someone sees me to let me in because the doors are locked. Resident 73 stated that their preferred smoking time began at noon or after lunch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 The above findings were shared with Staff A, Administrator, in an interview on 04/15/2025 at 5:21 PM. Staff

A confirmed the patio was not a smoking area and that, North [Hall] staff said they were not aware of [any] Level of Harm - Immediate smoker [in the facility]. Staff A stated that when staff escorted Resident 73 back to the facility, the resident jeopardy to resident health or had a faint smell of smoke. Staff A stated the resident was known to have paraphernalia on [them] which was safety relinquished to the facility and the resident, will not tell us how [they] got the smokes and lighter [afterwards and] we are assuming the family brought it in or visitors. Staff A stated that since Resident 73 refused to Residents Affected - Many relinquish the cigarettes and lighter they were placed on a one-to-one surveillance after the 04/15/2025

observations in the patio.

In an interview on 04/24/2025 at 9:45 AM, Staff C, ADON, described the process on how the facility identified residents who smoked and ensured their safety. Staff C stated that hospital paperwork was reviewed, and part of the facility's admission assessment completed by the nurse asked about smoking preferences. Once

a resident was identified as currently smoking, We care plan if they are an active smoker and let them know

we are a non-smoking facility and if they prefer to smoke, come up with a smoking plan and establish locations to smoke and smoking times. Staff C stated the facility identified concerns related to smoking, At initial assessment if admitting, observations of the resident, communication at Stand Up [a daily Inter-disciplinary meeting], and review of the 24-hour report [progress notes]. Staff C stated that when a resident was identified as unsafe to smoke or noncompliant with the smoking policy, the facility should ensure the resident, does not have smoking paraphernalia in their room, provide a smoking apron and supervision, and re-do their smoking assessment.

On 04/28/2025 at 8:13 AM in a follow up telephone conversation, the facility provided additional information. Staff C stated the facility should have added instructions to the care plan to direct the staff on the level of supervision and amount of assistance Resident 73 required during smoking after completion of the 02/17/2025 Smoking Safety Evaluation, to include staying with the resident while they smoked. Staff C stated that the additional safety interventions did not show in the care plan because the evaluation concluded a smoking cessation program (nicotine patches) would be started. Staff C acknowledged upon review of the medical record that the nicotine patches never started as mentioned in the 02/17/2025 smoking evaluation.

47328

According to the 01/03/2025 quarterly assessment, Resident 461 admitted to the facility on [DATE REDACTED] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that makes it difficult to breathe). The assessment further showed Resident 461 was cognitively intact, did not exhibit behaviors and was able to clearly verbalize their needs.

Review of the 07/04/2024 hospital history and physical provided to the facility during the admisson process showed Resident 461 smoked tobacco and had a tobacco abuse diagnosis.

Review of the 07/11/2024 resident safety assessment showed Resident 461 used tobacco products including cigarettes/cigars and the facility did not allow smoking. A nicotine patch was listed as a smoking cessation intervention. Resident 461 was identified as safe to smoke with supervision.

Review of provider orders showed a 07/12/2024 order for Resident 461 to use a nicotine patch daily for nicotine dependence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 Review of the July 2024 through September 2024 MAR showed Resident 461 began to refuse the nicotine patch on 08/10/2024. The nicotine patch was discontinued on 09/11/2024. Level of Harm - Immediate jeopardy to resident health or Review of the 08/21/2024 care plan showed Resident 461 smoked and was agreeable to smoke off safety premises. Interventions instructed staff to educate the resident about smoking risks and hazards, smoking cessation aids available, educate the resident about the facility smoking policy to include smoking off Residents Affected - Many premises only, notify the charge nurse immediately if the resident was suspected of violating the facility smoking policy, and monitor clothing and skin for signs of cigarette burns.

Review of the 08/22/2024 resident safety assessment showed Resident 461 used tobacco products including cigarettes/cigars and the facility allowed resident smoking. The assessment further showed Resident 461 was offered a nicotine patch but refused it and requested to smoke. Resident 461 was educated on not smoking in their room and to store cigarettes and lighter in a safe location. Resident 461 was identified as safe to smoke without supervision.

Review of the 10/11/2024 resident safety assessment showed Resident 461 used tobacco products including cigarettes/cigars, resident declined smoking cessation interventions, and the facility allowed resident smoking. Resident 461 was identified as safe to smoke without supervision.

No documentation was found that showed Resident 461's smoking materials were stored securely for safety

after additional record review.

Review of August 2024 through December 2024 nursing progress notes showed the following:

- 08/21/2024, Resident 461 stated they had five packs of cigarettes, knew how to wean themselves off, and did not need a nicotine patch.

- 08/22/2024 the facility non-smoking policy was reviewed with Resident 461, they were no longer wearing

the nicotine patch and continued to smoke on the facility property, no additional smoking safety interventions were implemented at that time.

- 12/27/2024 Resident 461 continued to demonstrate unsafe behavior of smoking on the facility property. When Resident 461 was reminded smoking was not permitted on the premises, Resident 461 stated they were not leaving the premises and would continue to smoke on the property. A 30-day notice was discussed with Resident 461 related to their health had improved sufficiently so they no longer needed services provided by the facility and their continued smoking on the property endangered other facility residents. No additional smoking safety interventions were implemented at that time.

- 12/29/2024 the fire alarm was set off at approximately 2:30 AM, staff smelled smoke in Resident 461's bathroom, Resident 461 denied smoking indoors and refused to hand over their cigarettes or lighter, frequent checks for safety were implemented. At noon, Resident 461 was placed on 1:1 monitoring due to safety concerns. Resident 461 again refused to give staff their lighter and stated, I'm going to smoke no matter what.

- 12/30/2024 Resident 461 was provided a discharge notice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 Review of the 12/29/2024 fire alarm detailed activity report showed at 2:18 AM the fire alarm was activated,

the fire department was dispatched, facility staff were contacted by the fire alarm monitoring company, the Level of Harm - Immediate fire alarm was cleared and restored. jeopardy to resident health or safety Review of the 12/30/2024 nursing home transfer or discharge notice showed Resident 461's health improved sufficiently so that they no longer needed services provided by the facility and the safety of other individuals Residents Affected - Many in the facility was endangered due to the status of the resident. A brief explanation showed Resident 461 was independent with all activities of daily living and left the facility daily in their car or motorcycle. Resident 461 continues to smoke on property and has been found smoking in [their] room.

In an interview on 04/21/2025 at 9:29 AM, Staff G, Maintenance Director, acknowledged the fire alarm went off on 12/29/2024 because Resident 461 smoked in their bathroom. Staff G further stated Resident 461 was placed on 1:1 monitoring after that incident and did not smoke indoors after that. Staff G explained Resident 461 was a challenging resident and would ignore staff when asked to do things.

In an interview on 04/21/2025 at 9:36 AM, Staff C, ADON, stated Resident 461 smoked, they were offered a nicotine patch but refused it and chose to smoke. Staff C explained on 12/29/2024, Resident 461 exercised their right to smoke in their bathroom and was placed on 1:1 monitoring after that incident. Staff C stated Resident 461 was not safe to smoke independently, they were self directed and did what they wanted to do.

In an interview on 04/23/2025 at 2:44 PM, Staff A stated Resident 461 would smoke in the facility parking lot and refused to quit smoking. Staff A explained on 12/29/2024 the fire alarm went off, staff thought Resident 461 had smoked in their room, but Resident 461 denied it and refused to give staff their smoking paraphernalia. Staff A stated Resident 461 was placed on 1:1 monitoring after the 12/29/2024 fire alarm incident and was given a 30-day notice.

According to the 03/31/2025 quarterly assessment, Resident 86 admitted to the facility on [DATE REDACTED] with diagnoses including weakness. Resident 86 had severe cognitive impairment and was able to verbalize their needs.

Review of the 11/06/2024 hospital history and physical that was provided to the facility during the admission process showed Resident 86 smoked cigarettes every day.

Review of the 11/12/2024 safety assessment showed Resident 86 did not use tobacco products and the facility did not allow resident smoking.

Review of the 11/19/2024 tobacco use care plan showed Resident 86 preferred to smoke cigarettes daily. Interventions instructed staff to educate the resident about smoking risks and hazards, smoking cessation aids available, remind the resident the facility was non-smoking, there was no smoking on the facility property, and to complete a smoking assessment as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0689 In an interview on 04/16/2025 at 9:24 AM, Resident 86 stated they used to smoke but had not smoked in a while. Resident 86 further stated staff had not spoken to them about smoking and they were unaware the Level of Harm - Immediate facility was a non-smoking building. jeopardy to resident health or safety In a follow-up interview on 04/24/2025 at 9:55 AM, Staff A stated they expected staff to accurately assess residents for tobacco use and safe smoking abilities when a resident chose to smoke. Staff A further stated Residents Affected - Many they also expected staff to implement smoking safety interventions as needed for resident safety.

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

Refer to

F-Tag F806

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297

Residents Affected: Some food for 8 of 9 sampled residents (Residents 262, 63, 89, 56, 3, 15, 47, and 16) reviewed for food. This

F-F806 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 46115

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure resident food preferences were honored for 3 of 13 sampled residents (Residents 15, 63 and 89) reviewed for food preferences. This failure placed the residents at risk of unintended weight loss, less pleasure in dining and diminished quality of life.

Findings included .

The 01/01/2025 quarterly assessment documented Resident 15 was cognitively intact and was able to make their needs known.

On 04/16/2025 at 12:05 AM, Resident 15's meal was observed. They were served barbequed ribs and mashed potatoes. Resident 15 stated they were upset. They had ordered the shrimp scampi and filled out their menu twice. Resident 15 attempted to eat the ribs and stated they were going return their meal.

On 04/17/2025 at 12:13 AM, Resident 15's meal included a chicken patty, green beans and mashed potatoes. Resident 15 stated they had ordered the alternate menu choice but their menu must have been lost. They stated they had filled out their menu twice and had given it to an aide. They were going to request

a sandwich.

On 04/18/2025 at 8:47 AM, Resident 15 stated they were frustrated because they were supposed to get boiled eggs but was served scrambled eggs.

On 04/18/2025 at 12:34 PM, Resident 15 had pudding and fluids on their meal tray. They stated they had been given fish and that was not what they ordered. Resident 15's visitor stated Resident 15 did not eat rice, but it was served to them. Resident 15 stated they were tired of getting sent the wrong things despite filling out the menus.

The 01/23/2025 significant change in condition assessment documented Resident 89 was cognitively intact and was able to make their needs known.

On 04/18/2025 at 8:49 AM, Resident 89 stated they did not get their yogurt and milk and got orange juice instead of apple juice.

On 04/18/2025 at 12:32 PM, Resident 89 stated they were upset because they did not get yogurt again. Resident 89's tray card instructed staff to send yogurt on the meal trays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0806 On 04/21/2025 at 8:39 AM, Resident 89 stated they did not get any apple juice and were given oatmeal. Resident 89's tray card instructed staff to send cold cereal, apple juice, toast and milk for breakfast. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/23/2025 at 1:13 PM, Staff JJ, Regional Food Service Manager, stated residents sent their menus to the kitchen then staff wrote the menu requests on meal tickets. Staff JJ stated it was Residents Affected - Few important to provide the residents their requests because this was their home, and staff were there to serve

the residents.

During an interview on 04/23/2025 at 1:26 PM, Staff II, Nursing Assistant, stated they had to take meals back to the kitchen because residents were served the wrong things.

The 02/12/2025 quarterly assessment documented Resident 63 had diagnoses that included failure to thrive. Resident 63 had moderate cognitive impairment and was able to clearly verbalize their needs and received a therapeutic diet.

The 03/14/2025 dietary profile documented Resident 63's food dislikes including sweet potatoes, potatoes, and scrambled eggs.

On 04/18/2025 at 8:43 AM, Resident 63 was observed lying in bed with their breakfast tray in front of them.

The plate contained an uneaten scoop of scrambled eggs and hashbrowns. Resident 63 stated they did not like scrambled eggs or potatoes and only ate a piece of sausage and their oatmeal. Resident 63 stated they were not offered alternative options. Review of the breakfast tray card documented Resident 63 disliked scrambled eggs and potatoes.

During an interview on 04/22/2025 at 1:22 PM, Staff C, Assistant Director of Nursing, stated resident food preferences were obtained by completing a dietary profile assessment and the preferences were printed on

the tray cards. Residents were also able to circle meal options on provided menus. Staff C stated they expected staff to honor a resident's food preferences.

During an interview on 04/24/2025 at 8:34 AM, Staff GG, Dietary Manager, acknowledged staff returned meals to the kitchen because it was not what residents ordered. Staff GG stated at times residents were not provided menus, or the menus were not returned to the kitchen timely. At other times, menu selections contradicted information on the tray cards. Staff GG stated they were unsure why the named residents received foods they did not want or disliked. It was possible kitchen staff hurried, did not look at the menu items closely, or were new employees.

Reference: WAC 388-97-1120 (2)(a), -1100 (1), -1140 (6)

47328

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 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** 42802

Residents Affected - Some Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety. Specifically, some foods were not labeled with the date opened or type of food item, labeled with a resident name (in the nourishment refrigerators) or discarded when expired. Additionally, the facility failed to maintain a clean kitchen environment, ensure dietary personnel wore appropriate hair coverings that fully covered their hair and performed hand hygiene when indicated. These failures placed residents at risk for food borne illness and diminished quality of life.

Findings included .

Review of the facility policy titled Food Brought by Family/Visitors dated February 2019 documented, perishable foods must be stored in the refrigerator. The policy instructed staff to label containers with the resident's name, and a use by date as appropriate.

During the initial kitchen tour on [DATE REDACTED] at 9:02 AM with Staff GG, Kitchen Manager, the following was observed:

Food crumbs and debris were noted in the following areas:

1) Shelves of a rolling cart near hot service area with jelly and butter packages

2) Shelves of a rolling cart with cold cereal packages

3) Top shelf of the cart with the toaster

4) Shelf under the coffee station that contained bins with peanut butter and honey

5) Flat surfaces around one of two stoves with drips of an unknown, dried substance down the right side of

the a stove.

6) The floor under the stove and 2 ovens had food debris and crumbs.

7) The floor of the walk-in freezer had crumbs covering the rubber mats, two vanilla ice cream cups and a clear plastic wrapper on the back left corner of the floor, under the shelving unit.

Staff VV, [NAME] was wearing a hairnet and beard covering. Staff VV had a full beard about 2 inches long.

The beard net only covered their chin which left the hair of their upper lip, cheeks and neck uncovered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0812 1) Three opened, large bags of shredded cheese, about half full on a shelf in the refrigerator. There was no date that showed when the bags were opened. Level of Harm - Minimal harm or potential for actual harm 2) A full pitcher of white liquid with a date of ,d+[DATE REDACTED]. There was no label that showed what the white liquid was. Per Staff GG, it was a health shake. Residents Affected - Some 3) Opened, partially used spice containers on a shelf over the food prep area had seasoning salt, garlic powder, garlic salt, dill, lemon pepper, steak seasoning, thyme, parsley, paprika, poultry seasoning and pepper. The poultry seasoning was dated ,d+[DATE REDACTED] in black marker, and the pepper was dated ,d+[DATE REDACTED].

It was not clear if that meant day/month or month/year. None of the other nine spice containers were clearly marked with the date opened. The seasoning salt container had an unknown dried substance dripped on the cover.

4) On the same spice shelf, there was an opened bag of rock hard brown sugar with plastic wrap over an opened corner of the bag. There was no date that showed when it was opened.

5) On a rolling shelf next to refrigerators, a large opened container of caramel sauce and white chocolate sauce was observed, both undated with an open date. The caramel sauce container did not have a cap, had dried caramel drips down the sides of the whole container, and it was past the manufacturer expiration date of [DATE REDACTED]. The container of white chocolate sauce was also past the manufacturer expiration date of [DATE REDACTED]. There were three shaker containers (approximately one cup each) that contained colored powder granules; two had shakers were covered and one was uncovered. These containers were not labeled with a date or contents. The shelf had spills of a sticky, dried red substance, that some of the containers were stuck to.

During a concurrent interview on [DATE REDACTED] at 9:02 AM, Staff GG acknowledged that the sauces should be discarded since they were expired. Staff GG further stated all foods should be dated when opened, so that

they would know when to throw them out but was unsure how long spices were ok to use for once opened. Staff GG explained the powder in the shaker containers was jello powder used to sprinkle over desserts using a [NAME]. Staff GG acknowledged items should be properly labeled with the contents and an open or discard date.

On [DATE REDACTED] from 10:52 AM to 12:14 PM, during the lunch meal preparation in the kitchen the following was observed:

Staff VV's beard was about half covered, as described on the initial visit to the kitchen on [DATE REDACTED]. During the meal observation, Staff VV checked food temperatures, served all of the food onto plates and placed the plates on a shelf for Staff WW, Dietary Aide, to put onto trays.

Staff WW had a short neat beard that you could not see skin though and did not wear a beard covering. Staff WW was on the other side of the steam table, put the insulated bases and plate covers on the food filled plate, placed them on the trays and into the rolling meal carts.

Staff JJ, Regional Food Service Director, had a beard that was about half an inch long and did not wear a beard covering. Staff JJ was on the far side of the kitchen, past the red line on the floor near the entrance that indicated hair coverings were required past that point.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0812 <Hand Hygiene>

Level of Harm - Minimal harm or Staff WW did not wear gloves while in the kitchen. During the meal preparation, they opened cart doors, potential for actual harm moved carts, filled cups with coffee or hot water for tea. At 11:49 AM, Staff WW scratch their face and adjust their headphones and did not perform hand hygiene before returning to place the food filled plates on the Residents Affected - Some insulated bases, covering them and placing them on the tray.

During an interview on [DATE REDACTED] at 2:12 PM, Staff GG, Kitchen Manager, explained the red line near the kitchen entrance was a visual reminder for staff that they could not go past the red line without a hairnet or cap. Staff GG stated they had not received clear guidance on beard coverings but acknowledged beard coverings/nets should also be worn past that red line. Staff GG acknowledged Staff WW should have washed their hands after touching their face and headphones and before returning to their tasks. Staff GG was informed of the unclean areas of kitchen observed earlier. Staff GG acknowledged surfaces should be cleaned and acknowledged there was no cleaning schedule/log sheet for those tasks at this time.

NOURISHMENT REFRIGERATORS

During an inspection of the North hall nourishment refrigerator on [DATE REDACTED] at 5:15 AM, the following was observed:

1) Three strawberry Ensure and 4 Premier Protein Shakes labeled with room numbers but no resident name.

2) One container from Olive Garden labeled with a last name and room number, but no date.

3) A partially used container of roasted red pepper hummus, without a resident name, room number or date.

During an inspection of the South hall nourishment refrigerator on [DATE REDACTED] at 7:40 AM, the following was observed:

1) Two opened containers of Simply Orange juice with a room number, but no resident name or open date.

2) A pitcher of clear yellow liquid, about a quarter full, without a date or label identifying the liquid contents.

During an interview on [DATE REDACTED] at 3:47 PM, Staff HH, Registered Dietician, stated any staff that past the red line in the kitchen should have appropriate hair and beard coverings on. Staff HH was informed of the surveyor's observations including staff in kitchen without full coverage of beards, incidents of missing hand hygiene, incomplete labeling/dating of foods, and crumbs/spills on surfaces in the kitchen. Staff HH acknowledged the findings did not meet their expectations for food service safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0812 Reference WAC [DATE REDACTED](3) and WAC [DATE REDACTED]

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 92 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0843 Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Level of Harm - Minimal harm or potential for actual harm 40297

Residents Affected - Many Based on interview and record review, the facility failed to establish and maintain a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed hospital transfers, lack of access to hospital level of care and diminished quality of life.

Findings included .

On 04/23/2025 at 11:17 AM, Staff A, Administrator, and Staff E, Regional Director of Clinical Operations, were asked to provide the facility-hospital transfer agreements.

In an interview on 04/23/2025 at 1:11 PM, Staff E acknowledged the facility did not have a transfer agreement with any local hospital.

Reference: WAC 388-97-1620(6)(a)

Refer to

F-Tag F867

Harm Level: Minimal harm or

Residents Affected: Few Based on interview and record review, the facility failed to ensure care plan revisions were completed and

F-F867 for additional information

42802

46115

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 42802 potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident's CPAP machine (a Residents Affected - Few machine connected to a mask, that kept airways open while sleeping) was functional and failed to accurately document its use for 1 of 1 sampled resident (Resident 17) investigated for respiratory care. This failure placed the resident at risk of worsening health complications.

Findings included .

According to the 03/26/2025 admission assessment, Resident 17 had diagnoses which included heart failure (where the heart cannot pump enough blood for the body's needs), Chronic Obstructive Pulmonary Disease (COPD, a lung disease that causes chronic respiratory symptoms and airflow limitations) and obstructive sleep apnea (OSA, a condition where the airway becomes blocked during sleep, causing pauses in breathing). The resident was alert and able to make their needs known.

A review of the medical record showed the following provider orders for use of their CPAP machine:

1) CPAP home setting, to be worn at bedtime every evening and night shift, started on 03/20/2025.

2) CPAP on at bedtime, started on 03/20/205.

3) CPAP mask cleaning every morning on day shift, started on 03/21/2025.

4) Change CPAP tubing on night shift, every month on the 19th, started on 04/19/2025.

Resident 17's Respiratory care plan, initiated on 04/02/2025, documented they were at risk for respiratory complications due to OSA. One of the interventions was to assist the resident as needed to administer/setup their CPAP machine.

Review of the March 2025 Treatment Administration Record (TAR) documented the following:

1) CPAP home setting every evening and night, initialed by nurse as done on evening and night shift from 3/20/25 through 03/31/2025.

2) CPAP on at bedtime, initialed by the nurse as done on night shift from 3/20/25 through 03/31/2025.

3) CPAP mask cleaning every morning on day shift, initialed by the nurse as done on from 3/21/25 through 03/31/2025.

Review of the April 2025 TAR documented the following:

1) CPAP home setting every evening and night, initialed by nurse as done on evening and night shift from 04/01/2025 through 04/14/2025. The only exception was the 04/09/2025 evening shift slot was blank.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0695 2) CPAP on at bedtime, initialed by the nurse as done from 04/01/2025 through 04/14/2025. The only exception was the 04/09/2025 slot was blank. Level of Harm - Minimal harm or potential for actual harm 3) CPAP mask cleaning every morning on day shift, initialed by the nurse as done from 04/01/2025 through 04/15/2025. The only exceptions were the 04/09/2025 and 04/11/2025 slots were blank. Residents Affected - Few

A 03/22/2025 nursing progress note at 7:36 PM documented CPAP use noted.

A 03/31/2025 nursing progress note at 1:20 PM documented CPAP use noted. Details as follows: set to home settings, tolerating well.

Review of the nursing progress notes showed no mention of the CPAP not functioning, not in use or the resident stating that it was not working.

Review of the provider notes on 03/21/2025, 03/24/2025, 03/26/2025 and 04/12/2025 documented the resident had not used their CPAP for over 6 months.

During an interview on 04/15/2025 at 11:17 AM, Resident 17 stated they brought their CPAP from home, but

it was not working. They were informed by the staff that they did not repair them and they had not helped them to replace the CPAP. Resident 17 further stated since they were unable to use it, they had difficulty falling sleep and woke up in the night and were unable to fall back asleep.

During an interview on 04/23/2025 at 9:25 AM, Staff NN, Central Supply, stated if a resident needed a CPAP, it was easy to obtain. They would get a doctor's order with the settings and correct size mask and fax

it over to the supply company to rent one and it usually arrived the same day. Staff NN further stated no one had asked about renting a CPAP for Resident 17.

During an interview on 04/23/2025 at 9:55 AM, Staff BB, Licensed Practical Nurse (LPN) stated that they would ask Resident 17 if they needed help with their CPAP and many times they would say they could do it themselves at bedtime. Staff BB further stated they were not aware that Resident 17's CPAP was not working, or they would have told management.

During an interview on 04/23/2025 at 10:55 AM, Staff C, Assistant Director of Nursing, stated they were not informed that Resident 17's CPAP was not working. Staff C stated that staff should have noted that the resident was not using the CPAP and followed up on it.

During an interview on 04/23/2025 at 11:52 AM, Staff C and Staff E, Regional Director of Clinical Operations, acknowledged that staff were not following up on the use and function of the CPAP and the discrepancy of

the documentation was failed practice.

Reference: WAC 388-97-1060(3)(j)(vi)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0696 Provide appropriate care/assistance for a resident with a prosthesis.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled resident Residents Affected - Few (Resident 31) reviewed for prosthesis (an artificial limb designed to replace the function of an amputated or missing arm or leg) received the care and assistance required to be able to use the prosthesis. This failure placed the resident at risk for decreased mobility and balance, delayed discharge from the facility to the community, and a diminished quality of life.

Findings included .

An undated facility policy titled, Artificial Limb - Prosthesis showed, staff would assist the resident in caring for their prosthesis to encourage resident function and safety. The policy showed the use of the prosthesis would be addressed in the resident's plan of care. Care instructions included washing, rinsing, and drying the socket (the device that joins the residual limb [stump] to the prosthesis) every day, inspecting the prosthesis for loose or worn parts at least once each week, reporting the findings to the nurse, avoiding the use of any creams, ointments, or preparations that contained alcohol, and following the manufacturers guidelines for any special care of the prosthesis. The policy instructed the staff to ensure the limb sock (a sock worn over a residual limb to improve fit and comfort within a prosthesis) was free of wrinkles, fit well, cleaned daily with cool water and mild soap, and completely dry before reusing. The staff were not to pad the limb or prosthesis with towels or washcloths as any uneven distribution of pressure could cause pressure sores and infection to

the residual limb.

Review of a 02/22/2025 quarterly assessment showed Resident 31 admitted to the facility on [DATE REDACTED] with the primary medical condition of an amputation (the surgical removal of all or part of a limb, typically an arm or leg). The assessment showed the resident was cognitively intact, no rejection of care, and was dependent on

the staff or required assistance for Activities of Daily Living. The assessment showed no prosthesis in use

during the assessment reference period.

An observation and interview on 04/14/2025 at 1:40 PM showed Resident 31 sitting up in a wheelchair in their room. A leg prosthesis was lying on the windowsill. Observation of Resident 31's left leg showed a covered stump. Resident 31 said the prosthesis was not in use since they were not making progress with therapy and wanted to walk so they could discharge from the facility. The resident showed a business card of

the clinic who built the leg prosthesis.

An observation and interview on 04/21/2025 at 9:37 AM showed Resident 31 in bed, with the leg prosthesis standing upright on the windowsill. Resident 31 said the staff do not apply the leg prosthesis but applied a shrinker [a type of compression stocking that is worn to help shape and reduce swelling in the residual limb]

in the morning and removed it at night.

Review of a 09/06/2024 Quarterly Discharge Plan Review showed Resident 31, wants to remain in the facility until [the resident] receives [their] prosthetic leg and then wants to find an alternative placement. A subsequent review on 12/05/2024 showed the resident, wants to remain in the facility long term.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0696 In an interview 04/21/2025 at 7:36 AM, Staff V, Social Services Director, stated Resident 31 wanted to stay

in the facility and was waiting to receive their prosthetic leg. When asked to elaborate what was meant by Level of Harm - Minimal harm or waiting to receive their prosthetic leg, Staff V stated, The appointments to get the prosthetic leg going and potential for actual harm once they got the prosthetic leg maybe reconsider other alternative placements [for living].

Residents Affected - Few Review of the 12/12/2024 progress note showed Resident 31 received their prosthesis and stood with therapy earlier this week. On 12/19/2024 it showed the resident continued to work with therapy with their prosthesis. A 12/23/2024 note showed, continues to make improvements with [their] prosthesis with therapy.

On 01/28/2025, the notes showed the facility notified the resident of their last day with therapy services, and Resident 31 was upset as wanting to use [their] prosthetic leg more and the Resident agreed that [they] will get out of bed to increase [their] stamina and attempt to put [their] leg on. Review of progress notes showed no rejection of care from 12/12/2024 to 04/20/2025.

Review of 12/06/2024 note from the prosthesis clinic showed Resident 31 received their prosthesis. The notes showed the clinic provided information on the function of the prosthesis, its care and cleaning, how and when to report problems related to the prosthesis or changes in physical condition, benefits and precautions to take, usage and break-in period, removing and applying the prosthesis, fitting issues, skin inspection, and other safety issues.

Review of 12/27/2024 note from the prosthesis clinic showed the resident informed the clinic staff they were able to wear the prosthesis daily for short amounts of time, but mostly laying in bed with the prosthesis on, but has done some standing with a forearm walker. The resident complained of some discomfort when wearing the prosthesis when in bed or sitting, and the clinic staff discussed with the resident that wearing the prosthesis for a prolonged period of sitting or lying down changed the pressure in the socket and was the reason for the discomfort. The clinic educated the resident to ensure the full prosthesis was supported to decrease gravity pull. The notes showed the resident increased the limb sock thickness and currently wearing 5 ply [a thickness or layer] with good fit. In this visit, the clinic staff re-educated Resident 31 on applying the prosthesis and cleaning the liner, including written instructions.

Review of 01/29/2025 note from the prosthesis clinic showed the clinic became aware all therapy was stopped as Resident 31 needed, to work on upper body strength from wheelchair and leg exercises from bed. The notes showed the resident wore the prosthesis for 30 minutes, three times a week while sitting, and

a shrinker when not wearing the prosthesis.

Review of the provider orders showed no directions on the care or management of the prosthesis, including application of the shrinker or limb sock. Review of the provider notes on 12/31/2024, 01/10/2025, 01/30/2025, 02/03/2025, 02/06/2025, 02/27/2025, 03/08/2025, 03/13/2025, 03/21/2025, 03/27/2025, and 04/09/2025 made no mention of a prosthesis in existence or use.

Review of a 01/30/2025 Physical Therapy (PT) discharge summary showed Resident 31 was able to apply and remove the left leg prosthesis with minimum assistance. The summary showed the resident would not commit to being out of bed beyond trying to stand during their therapy session and would not wear the prosthesis limb except during the therapy treatment time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0696 In an interview on 04/23/2025 at 8:39 AM, Staff FF, PT, stated Resident 31 would not wear the prosthesis except during therapy treatment time because, It's kind of a behavior thing. It was a lot of work to get out of Level of Harm - Minimal harm or bed. It was painful for [the resident], too, to a certain degree. Staff FF stated the resident was, not receptive potential for actual harm to being out of bed for a longer period of time. Staff FF stated that prosthesis wear-time is gradual, starting at one to two hours a day, up to eight hours a day, and off at night. Staff FF said since discharge from therapy, I Residents Affected - Few have not seen [the resident] with the prosthetic on.

In an interview on 04/23/2025 at 8:30 AM, Staff M, Nursing Assistant, stated Resident 31 was transferred out of bed by use of a mechanical lift once a day and never saw the resident walk. Staff M stated they never put

the prosthesis on Resident 31's stump and, I don't think [they] really use it during the day. Staff M stated they applied the shrinker in the morning and staff usually take it off at night.

In an interview on 04/23/2025 at 8:34 AM, Staff X, Licensed Practical Nurse, stated, Never really seen [the resident] walk and occasionally [they] will ask for the prosthetic to be put on and the aides could do that. Staff X stated the aides also applied the shrinker.

Review of a 06/11/2024 care plan showed, The resident has an amputation of left lower extremity and that

The resident's wound will heal and progress without complications. The care plan showed no documentation that acknowledged the presence of the prosthesis, instructions on wear time, how to ensure proper fit to prevent skin breakdown, the care of the prosthesis, or the use of the shrinker and limb sock.

On 04/21/2025 at 8:16 AM, a Collateral Contact (CC) from the clinic who built Resident 31's prosthesis was interviewed. The CC stated the prosthesis was issued on 12/06/2024. The CC stated the facility notify was supposed to notify the clinic when they identified issues with the fit of the prosthesis, pain, impaired skin integrity, or if any components were loose or feeling unstable when the resident wore the prosthesis. The CC stated the prosthesis should be worn daily by the resident, as long as no sores or not painful, and the shrinker also worn daily as it helps with swelling and phantom pain (when you feel pain in your missing body part after an amputation). The CC stated that the risk of the prosthesis not being worn daily was, not training your body to use it which can keep you wheelchair bound.

The above findings were shared with Staff F, Unit Manager, on 04/21/2025 at 9:55 AM. Staff F stated they were not aware of any refusals with the prosthetic as Resident 31 was very eager to have it. Staff F stated, I believe [the resident] puts on the shrinker [themselves]. At first the nursing staff was helping [them]. Staff F acknowledged the care plan did not reflect the status of the stump and stated, I believe that area is healed. Staff F acknowledged the medical record showed no direction on the care of the prosthesis and associated components, including instructions from the prosthesis clinic, its care and cleaning, how and when to report problems related to the prosthesis, wear-time, skin inspection, and other safety issues.

Reference WAC 388-97-1060 (3)(j)(ix).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 potential for actual harm Based on observation, interview and record review, the facility failed to ensure it obtained all Residents Affected - Few treatment-related documentation from the dialysis center and the medical records showed the accurate dialysis access site and location of the dialysis center for 1 of 1 sampled resident (Resident 88) reviewed for dialysis (a procedure that removed waste products and excess fluid from the blood when the kidneys failed to do so). This failure placed the resident at risk for delayed treatment and post-dialysis complications.

Findings included .

Review of a 03/22/2025 admission assessment showed Resident 88 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment showed the resident was cognitively intact and received dialysis services.

Review of 03/16/2025 hospital transfer orders showed a dialysis access site to the left subclavian (a large blood vessel located beneath the collarbone used for central line [a flexible tube inserted into a large vein near the heart placement used to deliver medications, fluids, nutrition, or blood products] placement).

An observation and interview on 04/14/2025 at 10:12 AM showed Resident 88 sitting at the edge of the bed.

The resident stated that they went to the dialysis center on Tuesdays, Thursdays and Saturdays from 2:00 PM to 7:30 PM. Observed to the resident's chest was a dressing that, according to Resident 88, covered a central line catheter. Resident 88 stated that the facility did not communicate with the dialysis center adding, I have to make sure I have all my records with me, so they [dialysis] know what's been happening.

Review of Resident 88's medical record showed no presence of dialysis logs. Dialysis logs document key information about each dialysis treatment session. These sheets serve as a record of the resident's condition, the treatment settings, and any events or complications that occurred during the dialysis session.

This information was crucial for monitoring the resident's progress, optimizing treatment, and ensuring resident safety.

Review of the 03/16/2025 dialysis care plan showed the location of the dialysis center, treatment days, and access site corresponded to the observation of and interview with Resident 88 on 04/14/2025.

Review of an April 2025 Order Summary showed a particular dialysis center with a pick-up time and scheduled dialysis days on Mondays, Wednesdays, and Fridays different to Resident 88's interview and care plan. Additionally, the orders directed the staff to, Check AV [arteriovenous, between an artery and a vein] Fistula [a surgically created connection usually in the arm] for bruit and thrill every shift, and if the fistula was bleeding, to apply pressure. A bruit was a sound heard with a stethoscope, while thrill was a vibration felt by hand, both caused by blood flow through the fistula. These assessments helped ensure the fistula was functioning properly and allowed for early intervention if issues arose. Central lines inserted into veins do not produce a bruit or thrill.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0698 The above information was shared with Staff F, Resident Care Manager, on 04/21/2025 at 9:58 AM. Staff F confirmed Resident 88 had a central line and acknowledged the provider orders that showed an AV fistula Level of Harm - Minimal harm or and corresponding assessments, and the dialysis center location and days were inaccurate and, should be potential for actual harm clarified and corrected. Staff F stated, I have yet to see [dialysis logs] come [to the facility]. No further information was provided. Residents Affected - Few 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 61 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 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 - Many Based on observation, interview and record review, the facility failed to repeatedly ensure the facility had enough staff to provide care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 9 of 17 sampled residents (Resident 16, 46, 61, 64, 65, 15, 22, 63 and 85), 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 reviewed 09/01/2023 showed the assessment was conducted annually to determine and update the capacity to meet the needs of and competently care for the residents during day-to-day operations. The assessment further showed the facility was licensed for 125 beds, had an average daily census of 84 which included 55 long-term care residents and 29 short term skilled (received higher level of medical care and/or rehabilitation services) residents. The facility had between two to five admissions during the week and two to three admissions on weekends. The facility provided care to residents who required specialized care, had mobility impairments, required assistance completing activities of daily living (ADLS) such as toileting, and were incontinent (unintentional leakage of urine or stool). The assessment showed on average the facility cared for 78 residents with urinary incontinence, 44 residents with bowel incontinence, and 15 residents that required a toileting program. The assessment further showed

the facility had adequate staffing, staffing was reviewed daily to ensure that adequate staff was available to meet the needs of facility residents, the facility employed a full-time staffing coordinator (during weekdays) and used contracted/agency staff when facility staff was unable to meet the needs of [facility] residents.

According to the 02/11/2025 significant change assessment, Resident 65 admitted to the facility on [DATE REDACTED] with diagnoses including syncope (to faint) and collapse. The assessment further showed Resident 65 required substantial staff assistance for toileting hygiene, was frequently incontinent of urine and always incontinent of bowel. Resident 65 had severe cognitive impairment.

Review of the 02/06/2025 rehabilitation care plan showed Resident 65 required maximum assistance from two staff for transfers and was dependent for toileting. The 02/06/2025 risk for falls care plan instructed staff to anticipate Resident 65's needs, ensure appropriate footwear, place common items within reach, keep the bed against the wall, and ensure Resident 65 was in areas of high visibility when up in their wheelchair.

Review of the 02/15/2025 allegation of neglect incident investigation showed at 6:54 PM it was reported Resident 65 was not changed.

Review of the February 2025 through March 2025 facility incident log showed Resident 65 sustained falls on 02/05/2025 (1 hours and 50 minutes after admission), 02/13/2025, 02/28/2025, 03/12/2025, and 03/14/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 <Resident 46>

Level of Harm - Minimal harm or According to the 03/29/2025 significant change assessment, Resident 46 required moderate staff assistance potential for actual harm to complete most of their ADLS which included toileting hygiene. The assessment further showed Resident 46 had severe cognitive impairment and was frequently incontinent of bowel and bladder. Residents Affected - Many

Review of the 01/08/2025 continence care plan showed Resident 46 was frequently incontinent of bowel and bladder and instructed staff to assist with toileting, apply barrier cream, provide toileting hygiene, monitor for signs of a bladder infection, and check and change incontinence brief every two hours. The 01/08/2025 risk for fall care plan instructed staff to keep items within reach, do not leave in the bathroom unattended, ensure proper footwear, and encourage Resident 46 to stay in areas of high visibility when up in their chair.

Review of the 03/25/2025 allegation of neglect incident investigation showed at 7:00 AM it was reported Resident 46 had not been checked and/or changed during the night shift. The investigation included a 03/25/2025 staff statement that showed Resident 46 had not been changed by night shift and was soiled through brief when checked on day shift.

In an interview on 04/15/2025 at 9:31 AM, Resident 46's family member stated the facility needed more staff, Resident 46 did not get help needed, and had a few falls.

Review of the November 2024 through March 2025 facility incident log showed Resident 46 sustained falls

on 11/06/2024, 12/12/2024, 01/08/2025, 02/06/2025, 02/24/2025, 03/07/2025, 03/09/2025, and on 03/17/2025.

According to the 03/25/2025 annual assessment, Resident 64 was frequently incontinent of urine and was dependent on staff assistance for toileting. Resident 64 was cognitively intact.

Review of the 01/07/2025 continence care plan showed Resident 64 was frequently incontinent of bowel and bladder and instructed staff to provide maximal assistance with toileting, apply barrier cream, and check and change their incontinence brief frequently as needed.

Review of the 02/13/2025 Resident Council (group of facility residents that met normally to discuss care and/or concerns) Meeting Minutes showed the Council voiced concerns related to excessively long call light wait times.

Review of the 03/26/2025 allegation of neglect incident investigation showed it was reported Resident 64 had not been changed. The investigation included a 03/26/2025 staff statement that showed Resident 64 was unhappy and yelling because staff had not checked or changed them. Resident 64 did not have their call light, their bed and brief was completely soaked with a wet brown ring of urine.

In an interview on 04/14/2025 at 11:14 AM, Resident 64 stated there were excessively long call light wait times, sometimes up to an hour.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 According to the 02/12/2025 quarterly assessment, Resident 63 was always incontinent of bowel and bladder, and dependent on staff assistance for toileting hygiene and bed mobility. Resident 63 had moderate Level of Harm - Minimal harm or cognitive impairment and was able to clearly verbalize their needs. potential for actual harm

Review of the 01/03/2025 respiratory care plan showed Resident 63 utilized supplemental oxygen and Residents Affected - Many instructed staff to administer oxygen as ordered, obtain vital signs as needed, and monitor for signs and/or symptoms of respiratory complications. The 02/11/2025 continence care plan showed Resident 63 was frequently incontinent of bowel and bladder and instructed staff to apply barrier cream, provide maximal assistance with toileting, provide the bed pan as requested, and check/change Resident 63's incontinence brief as needed.

In an interview on 04/14/2025 at 1:22 PM, Resident 63 stated the facility did not have enough staff because

they experienced excessively long call light wait times and seldom got changed on time. Resident 63 further stated they were unable to get up or walk, they wore oxygen but sometimes was unable to get to their call light or oxygen.

According to the 03/11/2025 significant change assessment, Resident 16 required substantial staff assistance for toileting hygiene and was always incontinent of bowel and bladder. The assessment further showed Resident 16 was cognitively intact and able to clearly verbalize their needs.

Review of the 03/17/2025 rehabilitation care plan showed Resident 16 required substantial/maximal assistance with bed mobility and toileting. The 03/17/2025 continence care plan showed Resident 16 was usually continent of bladder and instructed staff to apply barrier creams and observe for signs and/or symptoms of a bladder infection. The 04/10/2025 interventions instructed staff to provide assistance with toileting, provide the bed pan upon request, provide toileting hygiene as needed, record bowel movements, and check and change the incontinence brief while in bed.

Review of the 04/01/2025 allegation of neglect incident investigation showed at 2:15 PM Resident 16 reported they had not been changed since that morning and their bed was found to be wet with odor. The investigation included a 04/01/2025 2:18 PM staff statement that showed Resident 16's bed was found to be saturated when [Resident 16] got up. [Resident 16's] brief found to be completely soaked through and heavy.

In an interview on 04/14/2025 at 11:08 AM, Resident 16 stated they were incontinent, did not know how much or when they urinated, and needed to be routinely checked and changed. Resident 16 stated the facility had been short staffed for a while. Resident 16 explained they could tell the facility was short staffed because they did not receive care when needed and have had to wait up to an hour for assistance, which occurred three weeks ago. Resident 16 further stated, I wish they could do something to level out this staffing issue, it is not the resident's fault they don't have enough staff, they got to be able to hire some more people.

Review of the 04/07/2025 unwitnessed fall investigation showed Resident 16 attempted to self-transfer but their legs gave out and they sustained a fall with a left-hand skin tear.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 In a follow-up interview on 04/14/2025 at 11:18 AM Resident 16 stated they recently fell and sustained a skin tear to their left hand. Resident 16 explained I did not want to keep waiting for [staff] to help me, I wanted to Level of Harm - Minimal harm or get in bed, so I did it myself. potential for actual harm <Resident 61> Residents Affected - Many According to the 02/26/2025 quarterly assessment, Resident 61 was dependent on staff assistance for toileting hygiene, was frequently incontinent of urine and always incontinent of bowel. Resident 61 was cognitively intact and able to clearly verbalize their needs.

Review of the 06/12/2024 self-care deficit care plan showed Resident 61 required extensive staff assistance for bed mobility and personal hygiene. The 09/20/2024 care plan showed Resident 61 required long-term care and instructed staff to render appropriate nursing care. The care plan showed no documentation Resident 61 was incontinent of bowel and bladder.

Review of the 04/01/2025 allegation of neglect incident investigation showed at 2:15 PM Resident 61 reported they had not been changed all day. The investigation included an undated handwritten staff statement that showed Resident 61 stated they had not been changed since 7:30 AM and their bed was soaked.

In an interview on 04/14/2025 at 9:47 AM, Resident 61 stated the facility absolutely did not have enough staff, day shift was extremely short staffed, and weekends were worse than other days. Resident 61 explained they had excessive long call light wait times and has had to wait up to 45 minutes to be changed, which happened a few weeks ago on day shift.

Review of the October 2024 through April 2025 facility incident log showed the following:

- October: 10/01/2024 allegation of abuse, 10/06/2024 four different allegations of neglect, 10/09/2024 allegation of neglect, and 10/15/2024 injury of unknown origin.

- November: 11/02/2024 allegation of neglect, 11/05/2024 allegation of abuse, and 11/29/2024 allegation of abuse.

- December: 12/09/2024 allegation of abuse, 12/17/2024 allegation of misappropriation, 12/23/2024 three different allegations of neglect, 12/25/2024 allegation of abuse, and 12/31/2024 allegation of abuse.

- January: 01/01/2024 allegation of neglect, 01/02/2024 one allegation of abuse and one allegation of neglect, 01/10/2025 two different allegations of neglect, 01/21/2025 allegation of abuse, 01/23/2025 allegation of neglect, 01/24/2025 allegation of neglect, 01/29/2025 allegation of neglect, 01/30/2025 allegation of misappropriation, and 01/31/2025 allegation of neglect.

- February: 02/12/2025 allegation of abuse and two residents were involved in resident-to-resident altercation, 02/15/2025 five different allegations of neglect, 02/21/2025 allegation of neglect, 02/22/2025 allegation of abuse, 02/26/2025 two residents were involved in a resident-to-resident altercation, and 02/27/2025 allegation of neglect

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 - March: 03/06/2025 allegation of neglect, 03/09/2025 three different allegations of neglect, 03/20/2025 two residents were involved in a resident-to-resident altercation, 03/22/2025 allegation of neglect, and Level of Harm - Minimal harm or 03/25/2025 two different allegations of neglect. potential for actual harm - April: 04/01/2025 two different allegations of neglect and one allegation of misappropriation, 04/07/2025 Residents Affected - Many allegation of neglect, 04/13/2025 allegation of abuse, and 04/17/2025 two different allegations of neglect.

In a follow-up interview on 04/18/2025 at 10:52 AM, Resident 61 again stated, the facility is so short staffed, but that does not even begin to describe it.

According to the 04/01/2025 significant change assessment, Resident 22 had diagnoses which included diabetes. Resident 22 had moderate cognitive impairment and was able to clearly verbalize their needs.

Review of provider orders showed an active 11/09/2023 order for staff to monitor for signs and/or symptoms of low blood sugar and implement the facility low blood sugar protocol as needed.

Review of the 01/20/2025 diabetes care plan showed Resident 22 was at risk for blood sugar fluctuations and instructed staff to administer medications as ordered, provide diabetic foot care, and observe for signs and/or symptoms of high or low blood sugars.

In an interview on 04/14/2025 at 1:33 PM, Resident 22 stated they had excessively long call light wait times and has had to wait an hour or longer for their call light to be answered. Resident 22 explained they were diabetic, they had a low blood sugar during the night and it took staff 45 minutes to get them a glass of juice. Resident 22 voiced concern because they did not want staff to take forever if and/or when their blood sugar dropped again.

According to the 03/20/2025 quarterly assessment, Resident 15 was frequently incontinent of bowel and bladder and was dependent on staff assistance for toileting hygiene and bed mobility. Resident 15 was cognitively intact and able to clearly verbalize their needs.

Review of the 03/24/2023 self-care deficit care plan showed Resident 15 was dependent on Hoyer (full body mechanical lift) for transfers and required moderate staff assistance for toileting. The 03/24/2023 elimination care plan showed Resident 15 was usually continent of bowel and bladder and instructed staff to encourage Resident 15 to get out of bed daily, monitor bowel movements, and implement the bowel protocol as needed.

In an interview on 04/14/2025 at 1:59 PM, Resident 15 stated they were not impressed with resident care because the facility was totally understaffed especially when residents required a lot of care. Resident 15 explained they can never find [staff] if we need help and had waited up to three hours to have their brief changed, which happened at least once a week. Resident 15 further stated when they talked to staff about their excessive long call light times, Resident 15 was told they are shorthanded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 <Resident 85>

Level of Harm - Minimal harm or According to the 03/30/2025 quarterly assessment, Resident 85 was dependent on staff assistance for potential for actual harm toileting hygiene and bed mobility. The assessment further showed Resident 85 was always continent of bowel and occasionally incontinent of bladder. Resident 85 was cognitively intact and able to clearly Residents Affected - Many verbalize their needs.

Review of the 10/31/2024 care plan showed Resident 85 was administered diuretics (medication used to help rid the body of excess fluid). The 01/14/2025 rehabilitation care plan showed Resident 85 required extensive assistance for bed mobility and was dependent for transfers and toilet use.

During observation on 04/14/2025 at 11:47 AM, Resident 85 was wheeled into their room by an unidentified female staff and then walked out of the room. With an upset and loud tone of voice, Resident 85 began to yell out, that girl took off! you need to find her! I need to go pee! At 11:48 AM Resident 85's roommate walked out into the hall in search of staff to assist Resident 85. At 11:50 AM, as an unidentified male staff walked past Resident 85's room, Resident 85 again yelled out, I am going to pee my pants! The lady that brought me in here disappeared!

In an interview on 04/14/2025 at 1:44 PM, Resident 85 stated they had been out of the facility from 6:45 AM until 11:30 AM at a doctor appointment in Idaho and really needed to urinate. Resident 85 stated they did not like to be incontinent of urine. Resident 85 further stated the facility was short staffed and they were stuck in bed when there was not enough staff to get them up, because two staff were required to use the Hoyer, even though their record showed they needed to be up daily. Resident 85 preferred to be up in their wheelchair by 10 AM. Resident 85 stated they had excessively long call light wait times, waiting up to 50 minutes to be toileted.

Review of provider orders showed an active 03/17/2024 order for Resident 85 to be out of bed and in their wheelchair twice daily for at least an hour.

Review of the Medication Administration Record from 03/17/2025 through 03/31/2025 showed Resident 85 was not gotten out of bed and into their wheelchair 10 out of 29 times, only three refusals were documented.

Review of 04/01/2025 through 04/15/2025 showed Resident 85 was not gotten out of bed and into their wheelchair 19 out 30 times, only three refusals were documented.

During observation on 04/16/2025 at 11:54 AM 38 out of 60 residents on the North (100 hall, long-term care) were observed eating lunch in bed.

Review of the 04/17/2025 allegation of neglect incident investigation showed Resident 85 was upset because they were not gotten out of bed. The investigation included a 04/17/2025 staff statement that showed Resident 85 reported they were very upset because they requested to get out of bed but was told most of the Hoyers were not working, only one Hoyer was in working order, but other residents needed to get up and Resident 85 was not gotten out of bed as requested.

During observation and interview on 04/17/2025 at 1:37 PM, Resident 85 was observed lying in bed. Resident 85 stated staff did not get them out of bed today because staff told them there was only one functioning Hoyer lift and all staff were fighting to use it. Resident 85 stated I am stuck in bed for the day. I am not happy. I do not like to be in bed all day long. My preference is to be up in my chair for a while.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 In an interview on 04/17/2025 at 2:33 PM, the Resident Council stated the facility did not have enough staff,

they experienced excessively long call light waiting times, up to an hour. The Resident Council explained Level of Harm - Minimal harm or sometimes staff were also unable to find a second staff to assist with cares, when cares required two staff. potential for actual harm

In a follow-up interview on 04/22/2025 at 9:34 AM, Resident 85 again stated they were stuck in bed all day Residents Affected - Many yesterday because staff told them they were shorthanded, I was pissed.

During a confidential interview on 04/18/2025 at 10:25 AM, Confidential Staff A, stated the facility did not have enough staff, the North (100 hall, long-term care) unit was heavy care, and normally staffed with only four nursing assistants but that was not enough staff, it was hard to get things done.

Review of the 04/19/2025 facility census showed Residents 15, 16, 22, 46, 61, 63, 64, 65, and 85 all resided

on the North 100 long-term care hall.

In an interview on 04/22/2025 at 9:30 AM, Staff W, Nursing Assistant (NA), stated the facility was short staffed most of the time and they typically cared for about 15 residents.

During observation on 04/22/2025 at 9:32 AM, Staff KK, NA, was observed asking several NAs for assistance to change the resident in room [ROOM NUMBER] but was unable to get help. Staff W told Staff KK to ask a manager for help because they needed to help a resident who asked for help. At 9:47 AM Staff KK was observed asking Staff LL, Registered Nurse, for help but Staff LL stated, I am sorry, I can't help you, I am running way behind and asked Staff KK to let them know when they changed the resident in room [ROOM NUMBER] because they needed to apply cream to them. Staff KK replied, that is what I have been trying to do, I have been trying to get help. At 9:49 AM Staff KK told the resident they would change them alone, since they were unable to find staff to help.

In an interview on 04/23/2025 at 12:07 PM, Staff N, Staffing Coordinator, stated they used a HPD (hours per resident day, minimum staffing requirements) spreadsheet that was based on census, not based on acuity as

a guide to see how many staff were needed. A copy of the spreadsheet was requested at that time. Staff N explained if the facility needed to provide 1:1 monitoring for a resident they would make an exception to the budget and cover the 1:1 needs. Staff N stated if the facility acuity increased they would have to pull staff from the other units and adjust section assignments to better staff the more acute unit. Staff N explained the North 100 hall was the easier unit, it was more consistent because the residents were long-term care and the South hall was the more acute unit because that was where residents admitted to and were typically more ill. Staff N was asked what would happen with staffing if the census increased. Staff N stated if the census increased they would have to schedule more agency staffing because the facility did not have enough facility staff. Staff N further stated the facility used agency staffing seven days a week, for both NAs and nurses. Staff N further stated the facility had a high staff turnover rate and needed more staff. Staff N acknowledged staff voiced staffing concerns related to the need for more staff, residents with excessively long call light wait times, and residents not changed timely.

In an interview on 04/23/2025 at 12:43 PM, Staff A, Administrator, had a copy of the HPD spreadsheet used by Staff N as a guide for staffing. Staff A stated the form was just a quick and fast tool used to see if the facility had enough staff, based on census. Staff A did not provide a copy of the spreadsheet as requested.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0725 In a follow-up interview on 04/24/2025 at 8:34 AM, Staff A, explained the facility reassessed staffing every shift and attempted to balance staffing, census, and acuity. Staff A stated they used agency staffing daily and Level of Harm - Minimal harm or staff would bring staffing concerns to them, if there were any. Staff A stated if/when residents reported potential for actual harm excessively long call light wait times, it was reported as an allegation of neglect. Staff A acknowledged the facility had an increased number of allegations of abuse and/or neglect. Staff A stated, I am not short staffed. Residents Affected - Many Reference WAC 388-97-1080 (1), 1090 (1)

Refer to

F-Tag F887

Harm Level: Minimal harm or 47328

Residents Affected: Some as required and provide education based on the outcome of these reviews for 3 of 5 sampled staff (Staff K,

F-F887, WAC 1380 and 1480 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 47328 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 3 of 5 sampled staff (Staff K, L, and M), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and a diminished quality of life.

Findings included .

Review of Staff K's, Nursing Assistant, personnel file showed they were hired on 04/01/2023. No documentation of a performance evaluation was found.

Review of Staff L's, Nursing Assistant, personnel file showed they were hired on 11/29/2023. No documentation of a performance evaluation was found.

Review of Staff M'S, Nursing Assistant, personnel file showed they were hired on 12/06/2023. No documentation of a performance evaluation was found.

In an interview on 04/23/2025 at 3:18 PM, Staff A, Administrator, acknowledged Staff K, L, and M did not have performance evaluations on file. Staff A stated they expected staff to complete performance evaluations yearly, as required.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 47328 potential for actual harm Based on observation, interview, and record review the facility failed to consistently post nurse staffing Residents Affected - Some information on a daily basis, as required for 4 of 4 months (January, February, March and April 2025), reviewed. This failure resulted in residents, families and visitors not being fully informed of the facility's current staffing levels and resident census information.

Findings included .

During an observation on 04/14/2025 at 10:19 AM, daily staffing information was not posted in a prominent place readily accessible to residents, families, and/or visitors. Similar observations were made at 1:15 PM,

on 04/15/2025 at 8:28 AM, 9:50 AM, and 11:21 AM, on 04/16/2025 at 8:23 AM, 12:04 PM, 2:33 PM, on 04/17/2025 at 8:21 AM, on 04/18/2025 at 8:35 AM, 10:45 AM, and 3:17 PM, on 04/21/2025 at 4:17 AM and 7:45 AM.

During observation and interview on 04/21/2025 at 8:21 AM, Staff N, Staffing Coordinator, stated nurse managers were to post the daily head count staffing information. Staff N walked the surveyor to Staff C, Assistant Director of Nursing's office. Staff N asked Staff C for the head count sheets. Staff C pulled out a blank daily staffing sheet and stated they thought Staff N had been posting the daily staffing information. Daily staffing sheets from January 2025 through 04/21/2025 were requested at that time.

During an interview on 04/21/2025 at 8:36 AM, Staff N provided the daily staff posting sheets they had on file. Staff N acknowledged there were no daily staffing sheets after 03/14/2025.

Review of the daily staffing sheets provided showed no daily staffing information for the following dates:

- January: 01/03/2025, 01/07/2025-01/12/2025, 01/14/2025, 01/16/2025-01/19/2025, 01/21/2025, and 01/28/2025-01/29/2025

- February: 02/03/2025, 02/07/2025-02/10/2025, 02/11/2025, 02/14/2025-02/16/2025, 02/18/2025-02/20/2025, 02/24/2025-02/26/2025, and 02/28/2025

- March: 03/01/2025-03/09/2025, 03/11/2025-03/13/2025. No documentation was found after 03/14/2025.

In an interview on 04/21/2025 at 8:43 AM, Staff A, Administrator, stated they expected staff to post the daily staffing, as required.

No associated WAC

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 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 37544 Residents Affected - Some Based on observation, interview, and record review, the facility failed to consistently ensure 2 of 3 sampled medication carts (Med Bridge unit carts 1 and 2) were free from expired medications, and medications were labeled and disposed of properly when unused. In addition, the facility failed to consistently ensure controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenic) were securely stored and monitored for loss or diversion as required for 1 of 2 sampled medication rooms (Med Bridge unit) reviewed for medication storage, and failed to ensure medications were stored securely for Resident 95 who was observed to have medicaiton in their room.

Findings included .

MEDICATION CARTS

An observation of the Med Bridge Unit Cart 1 on 04/24/2025 at 9:09 AM showed opened insulins of Humalog Lispro dated 03/21/2025 and Novolin R dated 3/18/2025. Staff H, Licensed Practical Nurse (LPN), acknowledged the insulins were beyond the expiration date of 28 days and that they should have been discarded.

An observation on 04/24/2025 at 11:27 AM of Med Bridge Unit Cart 2 with Staff C, Assistant Director of Nursing (ADON), showed the top left drawer had a medication cup with Resident 82's name hand written on

it that contained six unknown medications, and the top center drawer of the cart contained an unlabeled/unopened bottle of nitroglycerin tablets, used for chest pain, and a plastic bag that contained an unopened EpiPen, an injectable medication used to treat life threatening allergic reactions. The plastic bag had Resident 46's name hand written on it, but aside from the bag, no other pharmacy label that included the resident's name, date, or other information was present on either the bottle of nitroglycerin or the EpiPen. Staff C stated medications needed to be labeled, and believed both medications had been pulled from the emergency cart, and should have been returned when it was determined they were not needed.

40297

SAFE STORAGE OF RESIDENT MEDICATION

An observation and interview on 04/14/2025 at 12:57 PM showed, 2 tablets of Imodium AD (anti-diarrhea) 2 mg (milligrams, a measurement) sat on Resident 95's bedside stand. The resident said, I have some. I haven't used them here. Last used them probably in late August.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0761 An observation and interview on 04/15/2025 at 11:30 AM showed, Resident 95 awake and in bed and the two Imodium AD tablets on the bedside stand. At this time, Staff X, Licensed Practical Nurse (LPN), Level of Harm - Minimal harm or confirmed the presence of the medication on the bedside stand and said that they should not be unsecured potential for actual harm in the room. Resident 95 stated their family member brought them and that they had some more in their coin purse. Resident 95 then took out five more tablets, this time of generic Imodium (loperamide) 2mg. Staff F Residents Affected - Some stated, The family should know not to bring in medications and if we find them, we take them or have family come pick them up. Staff X confirmed there were no physician orders for the use of Imodium or loperamide, or to keep medications at bedside.

46115

MEDICATION ROOM

An observation on 04/24/2025 at 9:02 AM of the medication storage room on the Med Bridge unit with Staff C, showed two of the three emergency medication kits were not sealed and contained a controlled medication that was used to treat anxiety (Ativan). The first kit contained two vials of injectable Ativan and three bottles of oral liquid, and the second kit contained two vials of injectable Ativan and two bottles of oral liquid. When asked if the Ativan vials/bottles were counted by the nurses to ensure not being diverted, Staff C stated the kits should have seals and the Ativan was not counted.

Additional observations of the medication room showed a locked medication safe was used to store medications that needed to be destroyed, including controlled medications. The safe was a drop box style with an opening that allowed the medications to be dropped into. Staff C stated medications were put in the safe until they could be destroyed and/or returned to pharmacy and there were only two keys to unlock the safe and they were kept by the nurse managers.

On 04/24/2025 at 9:51 AM, when Staff C was asked if the controlled medications were counted to ensure diversion was not occurring during the waiting period to be destroyed, Staff C stated the count was not done once the medication had been placed in the safe.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure nutritional assessments were completed accurately and timely for 4 out of 5 sampled residents (Residents 60, 88, 313, and 263), accurate and timely weights were obtained after a significant weight loss occurred (Resident 60), and the required nutritional supplements were available and/or provided (Residents 88 and 313). These failures placed the residents at risk for weight loss, unmet nutritional needs, and a diminished quality of life.

Findings included .

Review of a 05/25/2023 facility policy titled, Weight Assessment and Intervention showed, the facility strived to prevent, monitor and intervene for undesirable weight loss for the residents. The policy defined a significant weight change as, 5% [percent] in one month, 7.5% in 3 months, and 10% in 6 months, and anything above these percentages considered a severe weight change. The policy instructed the staff to weigh residents upon admission and if no weight concerns were identified, then measured monthly. If an inaccurate weight was suspected or a 5% or more weight change identified, the facility reweighed the resident for confirmation. The facility notified the provider of significant weight changes once verified. The policy instructed the staff to investigate and analyze an unplanned significant weight change.

Review of a 03/16/2025 admission assessment showed Resident 60 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment showed Resident 60 weighed 162 pounds (lb) and experienced no weight loss.

An observation and interview on 04/18/2025 at 1:11 PM showed Resident 60 in bed. Resident 60 said they did not know if they had lost weight or what their current weight was since their admission to the facility. When asked if the facility involved them in decisions about their diet, food preferences, and where to eat, the resident said, Not really. Resident 60 said they did not necessarily want to lose weight, that their weight prior to coming to the facility was 161 lb, and no staff reviewed their current weight with them.

Review of 03/09/2025 hospital records showed Resident 60 weighed 162 lb. Another hospital record dated 03/10/2025 showed the resident weighed 168.6 lb.

Review of a provider order showed the staff were ordered to weigh Resident 60 on the day of admission, then weekly for the next three weeks, then monthly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 Review of the March 2025 Medication Administration Record (MAR) showed no documentation the staff obtained a weight on 03/10/2025 or 03/11/2025 as ordered by the provider. Additionally, the nurses Level of Harm - Minimal harm or documented Resident 60 refused to be weighed on 03/12/2025, NA [not applicable] for 03/24/2025, and potential for actual harm refused again on 03/31/2025. The progress notes for March 2025 showed no documentation about why the resident refused to be weighed and what the staff did to address the reason for the refusals and obtain a Residents Affected - Some weight.

Review of the Weight Summary section in the electronic medical record (EMR) showed the staff obtained Resident 60's first weight on 03/17/2025, seven days after admission. The weight obtained was 149.4 lb, a severe weight loss of almost 8% in one week and under 30 days compared to the hospital weights. Record

review showed no documentation the staff re-weighed Resident 60 to confirm the severe weight loss, or completed weekly weights as ordered on or around 03/24/2025 and 03/31/2025.

Review of a 03/17/2025 Nutritional at Risk Assessment completed by Staff HH, Registered Dietitian (RD), showed it was an initial assessment and acknowledged the 03/17/2025 weight of 149.4 lb. as the most recent weight. The assessment showed Staff HH assessed Resident 60 with a moderate decrease in food intake over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties. The assessment asked if there was weight loss during the last three months, to which Staff HH answered, does not know. The assessment concluded that Resident 60 was at risk of malnutrition due to two or more medical conditions and established a goal to maintain weight. Approaches to achieve weight maintenance included monitoring significant weight loss. Staff HH documented they, Need updated weight.

The assessment showed no documentation Staff HH reconciled the hospital or resident's reported weight of 161 lb against the facility's weight of 149.4 lb and ruled out severe or significant weight loss.

Review of provider notes showed on 03/12/2025, Patient's current weight not recorded. Hospital weight 168 lb. The 03/17/2025 and 03/26/2025 notes showed the provider acknowledged the 03/17/2025 weight of 149. 4 lb. Record review showed no documentation the provider identified or reconciled severe or significant weight loss or was notified of it by the facility.

Review of March 2025 Nutrition and Hydration meeting notes scanned into the EMR showed:

- 03/20/2025, Staff HH reviewed Resident 60 because they were a new admit and acknowledged the 03/17/2025 weight of 149.4 lb and no weekly weight was available. Staff HH concluded there was no weight trigger or meal refusals. The summary showed that the staff would obtain the second weekly weight in a few days. This document was signed by Staff HH and Staff C, Assistant Director of Nursing (ADON). The notes showed no documentation Staff HH reconciled the resident's reported weight of 161 lb or the hospital weights supporting the resident's weight range in the 160 lb.

- 03/27/2025, Staff HH reviewed Resident 60 because they were a new admit, weight of 149.4 # [lb] 3/17/25 and, No change this week as an updated weight is needed. The summary showed, will review next week, no new interventions and provider aware. The notes showed no documentation Staff HH reconciled the resident's reported weight of 161 lb or the hospital weights supporting the resident's weight range in the 160 lb.

Review of the April 2025 MAR showed the staff weighed Resident 60 on 04/07/2025 at 149.4 lb, a sustained severe and significant weight loss of about 8% in under 30 days. Record review showed no documentation

the staff re-weighed the resident to confirm or reconcile the weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 Review of April 2025 Nutrition and Hydration meeting notes scanned into the EMR showed:

Level of Harm - Minimal harm or - 04/03/2025, Staff HH reviewed Resident 60 and documented the resident was, refusing weights, reattempts potential for actual harm made to obtain a weight, intake variable but adequate, no supplements, no new interventions, provider aware, and no meal refusals. The review showed no documentation to demonstrate why Resident 60 refused Residents Affected - Some to be weighed and how the facility addressed those refusals. Staff HH requested a weight from the staff.

- 04/10/2025, Staff HH reviewed Resident 60 and noted, no new weights as resident is known to refuse weights, meds [medications] and cares. Intake remains variable, however, [the resident] is likely meeting [their] needs. The review showed no documentation Staff HH investigated and analyzed why the resident refused to be weighed and how the facility addressed those refusals. The notes showed no documentation Staff HH acknowledged or reconciled the sustained severe and significant weight loss of 149.4 lb.

A 04/07/2025 and 04/17/2025 provider notes showed, Patient's current weight 149 lb. The notes showed no documentation a reconciliation or confirmation of Resident 60's Hospital weight [of] 168 lb, mentioned in the 03/12/2025 provider notes, occurred.

In an interview on 04/18/2025 at 1:54 PM, Staff QQ, Nursing Assistant (NA) said they managed resident refusals by reapproaching the resident and letting the nurse know. Staff QQ said Resident 60 refused meals because the resident, is just not hungry. The meal doesn't look good to her. Staff QQ said the floor NA weighed residents and Resident 60 did not like to get out of bed because, I think [they are] depressed. Staff QQ said they notified the nurse when Resident 60 refused to be weighed.

In an interview on 04/18/2025 at 2:30 PM, Staff C described how the facility identified weight concerns for a newly admitted resident. Staff C said they and Staff HH attended a Nutrition and Hydration meeting every Thursday. Staff C said staff obtained weights on admission, then weekly after that, and go on to monthly weights if stable. Staff C said the facility determined a change in weight from the time of admission occurred, by reviewing hospital records of weights, interviewing the resident, and Staff HH went to meet the resident. Staff C said, If [the resident is] of sound cognition they will usually give you a baseline of what [their weight] is. Staff C said they expected the provider and resident representative to be notified of a significant weight change. Staff C said they did not know why Resident 60 refused to be weighed. Staff C acknowledged Resident 60's weights from the hospital upon record review and that a significant weight change should have been identified in the 03/20/2025 nutrition meeting with Staff HH.

In an interview on 04/18/2025 at 02:01 PM, Staff HH stated they provided services at the facility Monday through Friday. Staff HH said they identified weight concerns for a newly admitted resident by completing an overview of their admit paperwork upon admission and participate in their initial care conference. Staff HH said they evaluated new residents weekly and determined weight changes from the time of admission by reviewing weight measurements obtained by the staff. Staff HH said, Sometimes I don't consider a hospital weight to be reliable and not having a current weight, makes it harder to gather a baseline for new admit. I can't always come up with a proper intervention if there needs to be one. Staff HH stated that when they identified a significant weight loss, We evaluate the reason for that weight loss and Yes, I notify family and providers. Staff HH said it was unknown to them why Resident 60 refused to be weighed by the staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 On 04/18/2025 at 2:21 PM, Staff HH calculated Resident 60 experienced a significant weight loss of 8%, from the 03/09/2025 hospital weight of 162 lb to the facility weight of 149.4 lb on 03/17/2025 and 04/07/2025. Level of Harm - Minimal harm or Staff HH said, Because we did not have the hospital weights in the [weight summary section of the EMR, the potential for actual harm resident] did not trigger for the significant weight loss. When asked if they reviewed Resident 60's hospital records on their first assessment of the resident's nutritional status, Staff HH stated, Yes, I did a comparison. Residents Affected - Some I noted in my assessment that I needed weights.

Review of a 03/22/2025 admission assessment showed Resident 88 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment showed the resident was cognitively intact and received dialysis (a procedure that removed waste products and excess fluid from the blood when the kidneys failed to do so) services.

Review of March 2025 Medication Administration Record (MAR) showed an order that instructed the nurses to provide Resident 88 Nepro (a therapeutic liquid nutrition specifically designed for dialysis patients to help meet their unique nutritional needs, offering higher protein content and lower levels of potassium and phosphorus) prior to dialysis on Mondays, Wednesdays and Fridays. The order showed kitchen staff would stock the North Nutrition Room refrigerator with the supplement. The Nepro was scheduled for administration at 5:00 AM. The order asked the nurses to document the amount consumed in mL [milliliter, a measurement], if possible, and to document refusals of the supplement. Review of administration documentation showed a 9 [Other/See progress notes] on 03/10/2025, 03/21/2025 and 03/24/2025, a 3 [absent from facility/hospitalized ] on 03/12/2025, a 2 [refused] on 03/19/2025, and left blank on 03/14/2025. Further review of the MAR showed the days of the Nepro administration changed to Tuesdays, Thursdays, and Saturdays, with a 9 documented on 03/27/2025 and 237 mL on 03/29/2025.

Review of progress notes associated with the March 2025 MAR Nepro order showed the nurses documented

on 03/10/2025, Resident 88 experienced a transfer to the hospital, on 03/21/2025 is going Saturday to dialysis, on 3/24/2025 change in dialysis day and time, and on 03/27/2025, dialysis is later in the day. There was no documentation that showed why Resident 88 refused Nepro on 03/19/2025.

Review of the April 2025 MAR showed an order that instructed the nurses to provide Resident 88 Nepro prior to dialysis on Tuesdays, Thursdays, and Saturdays at 5:00 AM. The order showed kitchen staff would stock

the North Nutrition Room refrigerator with the supplement. Every administration from 04/01/2025 to 04/17/2025 was signed by a nurse and 9 [Other/See progress notes].

Review of progress notes associated with the April 2025 MAR Nepro order showed on 04/01/2025 no documentation of the amount of Nepro Resident 88 consumed. On 04/03/2025 and 04/05/2025, the nurses documented no intake due to, takes own later in the day. On 04/08/2025 the nurse documented, dialysis is later in the day. On 04/10/2025, the nurse documented, takes later. On 04/15/2025 the nurse documented, Takes [their] own later in the day due to dialysis scheduled later. On 04/17/2025 the nurse documented, drinks own later in the day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 An observation and interview on 04/21/2025 at 5:02 AM showed Resident 88 sitting on the edge of the bed. When asked about their knowledge of the Nepro supplement, the resident stated, Oh it was just horrible. It Level of Harm - Minimal harm or tasted horrible. I didn't like it at all. I wouldn't wish it on my worst enemy. It was really watered down. It made potential for actual harm me sick to my stomach. Resident 88 said they bought their own supplement locally, their significant other brought it to the facility, and the resident would then take it to dialysis with them. Resident 88 identified the Residents Affected - Some supplement they took with them on dialysis days as Ensure Plus (a general-purpose nutritional supplement for those with increased nutritional needs). Resident 88 said Staff HH saw them physically, Just once, a month ago, about 35 days ago.

Review of March 2025 Nutrition and Hydration notes showed Staff HH acknowledged the staff sent the Nepro with Resident 88 to the dialysis center on Mondays, Wednesdays, and Fridays (03/20/2025 and 04/03/2025), 100% of the Nepro was given to the resident on dialysis days (03/27/2025), and the resident accepted the Nepro three times a week 100% of the time. There was no documentation that showed Staff HH ascertained how much of the Nepro Resident 88 consumed when the nurses documented 9 or the extent of Resident 88's refusal of the supplement.

An observation of the North Nutrition refrigerator and interview with Staff TT, Licensed Practical Nurse on 04/21/2025 at 4:14 AM, showed no presence of Nepro. Staff TT stated Resident 88 chose to buy their own supplement, and staff stored the supplement then gave it to the resident whenever they asked for it. Staff TT stated the supplement Resident 88 purchased was, I think it's an Ensure Plus. Staff TT stated the Nepro, That was the one [they] didn't like. That's why I chart [the resident] refuses. Staff TT said Resident 88 did not like the taste of Nepro and that's why they chose to buy another supplement. When asked about night nurses documenting in the MAR that they gave Resident 88 their supplement at 5:00 AM, Staff TT stated, I'm not here to say if [they] drank it. Staff TT said the resident told staff they did not like the taste of Nepro.

In an interview and observation of the facility dry food storage area on 04/21/2025 at 5:14 AM, Staff GG, Dietary Manager, showed the availability of Nepro. Staff GG stated one resident in the facility was on Nepro. Staff GG said they knew which supplements to provide the residents with when the nurses ordered them or by instructions in the meal ticket. Staff GG stated a doctor's order of the supplement required of the nurse to, come to the kitchen to get them. Staff GG showed a Dialysis Sack Lunch schedule with the name of two residents, of which Resident 88 was one of them. The schedule showed their dialysis days, when to be ready for dialysis transport pick-up, the type of diet, and what to provide with their sack lunches. The schedule showed it was created by Staff HH. There was no documentation in the schedule that showed Resident 88 required Nepro prior to dialysis.

In an interview on 04/21/2025 at 6:57 AM, Staff RR, Registered Nurse (RN), stated they were unsure what Resident 88's dialysis sack lunch included. Staff RR stated Resident 88's significant other, was bringing [the resident] the Boost [a general nutritional drink] and stopped supplying the Boost and was doing the Ensure. Ensure is not very good for dialysis patients so they switched [Resident 88] to the Nepro. Staff RR stated the resident was, now on the Nepro and that just started this week. Staff RR stated that they saw Resident 88 take the Boost to dialysis.

In an interview on 04/21/2025 at 7:12 AM, Staff SS, NA, stated they were unsure if Resident 88 took a bottle of supplement with them to the dialysis center because, [the resident] packs a bag [themselves] of stuff [they] take. But I do know for sure [the resident has] bought some Glucerna [a liquid supplement specifically designed for individuals with diabetes or prediabetes to help manage blood sugar levels] and takes with [them] to dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 The above findings were shared with Staff F, Resident Care Manager, on 04/21/2025 at 10:18 AM. Staff F stated if a resident refused a supplement, they expected documentation in the medical record of the refusal Level of Harm - Minimal harm or and provider notification and identify if there is a trend and, see what's driving the refusals. Staff F stated that potential for actual harm Nepro was, a supplement for dialysis patients and had no knowledge Resident 88 did not like to drink the Nepro. Staff F was asked how the facility determined consumption of the Nepro when the night shift nurses Residents Affected - Some documented the resident consumed it later in the day or drinks their own and stated, by [Staff HH] looking [in

the medical record]. Staff F acknowledged the medical record showed no documentation the facility identified and addressed Resident 88's refusal of the Nepro.

The above findings were shared with Staff HH on 04/21/2025 at 10:25 AM. Staff HH stated that when a resident had orders for a supplement, they checked the MAR to verify and make sure the nurses documented the amount of supplement consumed. Staff HH stated they, lean on what's documented in the MAR to estimate percentage consumed. Staff HH stated they were unaware Resident 88 did not like and was not consuming Nepro.

42802

According to an admission assessment dated [DATE REDACTED], Resident 263 was admitted with diagnoses which included surgical aftercare following a hip fracture, cirrhosis (a chronic condition which scar tissue replaced healthy liver tissue) and ascites (an abnormal buildup of fluid in the abdomen, often caused by late-stage cirrhosis of the liver.) The resident was alert and able to make their needs known.

A physician note, dated 04/02/2025, documented that the resident had required weekly paracentesis (a medical procedure in which a tube was inserted into the abdomen, to drain excess fluid).

Review of the medical record showed the resident had admission orders for weekly weights for three weeks, then monthly for four weeks. The resident's weight dropped from 142.7 lb. on 03/31/2025 to 116.2 lb. on 04/15/2025, a loss of 26.5 lb. in 15 days, which indicated a significant and severe weight loss.

A Nutrition and Hydration meeting note dated 04/10/2025, documented the significant weight change and that their food/fluid intake had been adequate. Per the note, Staff HH attended.

A further review of the medical record showed no comprehensive nutritional assessment was completed by Staff HH as required.

During an interview on 04/23/2025 at 3:47 PM, Staff HH stated they completed the comprehensive assessment within one week of admission, or sooner if their admission paperwork showed a concern. Staff HH acknowledged they had done Resident 263's full assessment as they were behind on them.

37544

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 The 03/31/2025 admission assessment documented Resident 313 had severe cognitive impairment and diagnoses which included dementia, malnutrition, and adult failure to thrive. In addition, the assessment Level of Harm - Minimal harm or documented the Resident 313 received hospice services. potential for actual harm

On 04/15/2025 at 9:51 AM, Resident 313 was observed in their room lying in bed watching television. The Residents Affected - Some resident was very thin in appearance and a glass of untouched vanilla protein drink was sitting on the bedside tray table. When asked about their care, Resident 313 stated they had been at the facility for a long time, but was unable to give details or the date.

In an interview on 04/15/2025 at 10:29 AM, Resident 313's representative stated the resident's appetite was very poor and that was to be expected, but they would drink Ensure, a brand that makes nutritional drinks. When asked if Ensure was provided, the representative stated they had been told the facility used a different kind of nutritional drink, and it was their understanding Ensure was not available, so they purchased and brought it in for Resident 313.

Review of Resident 313's record found the following information:

- The meal monitor records from 03/25/2025 through 04/16/2025 documented Resident 313 refused meals

on 12 out of the 25 days they resided at the facility.

- The care plan had nutritional interventions implemented on 03/30/2025, but did not include resident specific goals or interventions related to the resident's diagnoses of malnutrition or adult failure to thrive. The interventions were generic and not resident centered, nor did they provide instruction and/or information to

the nursing staff to inform them of Resident 313's dietary likes/dislikes or preferences.

- The admission nutrition assessment was completed on 04/16/2025, 22 days after the resident was admitted to the facility. The assessment showed Resident 313 was offered and refused the facility's house nutritional drink, but aside from monitoring food intake at meals and encouraging food and fluid intake, no other nutritional interventions or considerations were offered or implemented. The assessment documented Resident 313's dietary preferences and dislikes were included on the dietary profile and referred nursing staff to the profile for details, however, no dietary profile was found in Resident 313's record.

- Review of the progress notes from 03/25/2025 through 04/15/2025 found no documentation related to the nutritional or dietary needs for Resident 313.

In an interview on 04/18/2025 at 10:29 AM, Staff P, NA, stated they encouraged Resident 313 to eat, they often refused meals, but liked chocolate, water and juice, so they tried to make sure it was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0801 In an interview on 04/22/2025 at 11:33 AM, Staff HH stated they attempted to complete nutritional assessments within a week of a resident's admission to the facility, but was behind on getting them Level of Harm - Minimal harm or completed. When asked what nutritional interventions were offered for Resident 313, Staff HH stated the potential for actual harm house supplement was offered, but was refused. When asked if there were other nutritional interventions such as offering ice cream or NEM (nutritionally enhanced meals which contain more nutrients than a normal Residents Affected - Some meal), Staff HH stated yes, once they spoke to Resident 313's representative, they would have a better idea of what to offer. When asked if they had spoken to Resident 313's representative, Staff HH stated no, but now that they were aware they would.

Reference: WAC 388-97-1160(1)

Refer to

F-Tag F919

Harm Level: Minimal harm or

Residents Affected: Many Based on interview and record review the facility failed to designate a Registered Nurse (RN) to serve as the

F-F919 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of111 505322 Department of Health & Human Services Printed: 08/28/2025 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 04/24/2025

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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 47328

Residents Affected - Many Based on interview and record review the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DNS) on a full-time basis, as required. This failure placed all residents at risk of lack of RN oversight for care provided, unmet care needs, and a diminished quality of life.

Findings included .

In an interview on 04/14/2025 at 8:34 AM, Staff A, Administrator, identified Staff B as the interim Director of Nursing. Staff A stated the facility had no nurse staffing waivers in place.

Review of the facility staff list provided on 04/15/2025 showed Staff B was the MDS (Minimum Data Set, standardized resident assessment tool) RN/DNS. Staff C was identified as Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON).

In an interview on 04/18/2025 at 11:29 AM, Staff C, explained they reviewed the facility incident reports after

they were completed by floor staff, they tried to implement other interventions, but did not always have a chance to complete reviews.

In an interview on 04/23/2025 at 11:16 AM, Staff B, Interim Director of Nursing, stated they were the MDS Coordinator. Staff B explained they became the interim DNS in February 2025 but Staff C, LPN/ADON, handled most of the DNS duties. Staff B further stated they worked a 40-hour work week and focused on MDS duties. Staff B stated they were not on-call after hours, staff contacted Staff C in case of emergencies and/or if there were allegations of abuse/neglect made but they were kept in the loop.

In a follow-up interview on 04/23/2025 at 12:01 PM, Staff A, again stated Staff B was the interim DNS since 02/22/2025 and worked 40-ish hours a week. Staff A was asked if they expected Staff B to perform DNS duties 40 hours a week. Staff A stated Staff B was available to work 40 hours a week as a DNS if needed. Staff A further stated Staff B reviewed incident reports and was notified if/when allegations of abuse were made. Payroll data was requested at that time for Staff B from February 2025 until current. No documentation was provided.

Reference WAC 388-97-1080 (2)(b)

Refer to

Manor Care Health Services-spo

Inspection Findings

F-Tag F625

F-Tag F656

F-Tag F657

F-Tag F658

F-Tag F689

F-Tag F806

F-Tag F867

F-Tag F887

F-Tag F919

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