Royal Park Health And Rehabilitation

F-F842 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47328

Residents Affected - Few Based on interview and record review the facility failed to ensure resident records were complete, accurate, readily accessible and resident records were safeguarded against loss, destruction, or unauthorized use for 1 of 4 sampled residents (Resident 98), reviewed for accidents. This failure placed residents at risk of having

an incomplete medical record, unauthorized access to confidential health information, and diminished quality of life.

Findings included .

Review of the facility employee handbook related to use of business equipment showed company telephones, computers, tablets, handheld computers, copiers, supplies, and other equipment were to be used for business use. Employees were not allowed to use cell phones or smart phones in resident care areas. Direct care staff were prohibited from using or having their cell phones turned on while on duty and were only to use these items during their meal or break times in non-resident care areas. The handbook further showed all employees were expected to follow applicable state or federal law or regulations regarding

the use of cell phones or smart phones at all times.

According to the [DATE REDACTED] admission assessment, Resident 98 admitted to the facility on [DATE REDACTED] with diagnoses including muscle weakness, reduced mobility, lack of coordination, and chronic pain. Resident 98 required touch assistance to transfer onto the toilet and moderate staff assistance to perform toileting hygiene. Resident 98 had severe cognitive impairment.

Review of the admission agreement, consent for medical treatment, showed the resident group authorizes

the center to take photographs of the resident which are necessary for identification, medical purposes, or both, at any time during the resident's stay and the section on personal health information disclosure showed

the center will not disclose the resident's personal health information, including the resident's medical record, without express written authorization except as permitted by law. The admission agreement further showed it was electronically signed by the severely cognitively impaired Resident 98, not their legal representative, on [DATE REDACTED].

Review of a [DATE REDACTED] facility incident report showed Resident 98 experienced an unanticipated death. Resident 98 was found slumped over on the toilet with a laceration above their left eyebrow.

Review of [DATE REDACTED] nursing progress notes showed Resident 98 required moderate assistance for toileting. On [DATE REDACTED], Resident 98 was found sitting on the toilet unresponsive, staff called emergency medical services and initiated cardiopulmonary resuscitation (CPR) per Resident 98's wishes. Resident 98 expired and the medical examiner (ME) was notified of the laceration to the left upper eyebrow. The progress notes further showed the ME was sent pictures of Resident 98's facial laceration and Resident 98 would need to be picked up for further testing.

Further review of Resident 98's medical record showed no pictures of Resident 98's facial laceration were found.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 0842 The pictures of Resident 98's facial laceration sent to the ME on [DATE REDACTED] were requested from Staff B, Director of Nursing, on [DATE REDACTED] at 2:31 PM, and again on [DATE REDACTED] at 1:41 PM, from Staff A, Administrator. Level of Harm - Minimal harm or potential for actual harm In an interview on [DATE REDACTED] at 2:16 PM, Staff KK, Corporate Licensed Nurse, stated the nurse who took the pictures of Resident 98 deleted the picture from their phone after they were sent to the ME. Staff KK Residents Affected - Few acknowledged the pictures sent to the ME were not in Resident 98's medical record.

In an interview on [DATE REDACTED] at 9:35 AM, the ME stated they requested pictures of Resident 98's head injury to determine the severity of the head injury. The ME acknowledged they received two photographs of Resident 98's head injury via text messaging to the ME's work phone.

In an interview on [DATE REDACTED] at 11:05 AM, Staff GG, Nursing Assistant, stated staff were not allowed to photograph residents, especially by using a staff's personal electronic device. Staff GG explained the health unit coordinators (HUC) would photograph residents for an electronic medical record profile picture.

In an interview on [DATE REDACTED] at 11:21 AM, Staff LL, Licensed Practical Nurse, stated if a resident photograph was taken for medical purposes, then it should be in their medical record. Staff LL acknowledged staff should not use personal phones to take photographs of residents because it would violate HIPAA (Health Insurance Portability and Accountability Act, established standards that protect sensitive health information from disclosure without a patient's consent and protected one's privacy).

In an interview on [DATE REDACTED] at 11:57 AM, Staff Y, Resident Care Manager, stated they were unsure on the facility process for photographing residents.

In an interview on [DATE REDACTED] at 3:10 PM, Staff B, Director of Nursing, stated HUCs used the facility mobile device to obtain resident's profile pictures. Staff B acknowledged staff should not take resident pictures using their own personal cell phones because of HIPAA concerns.

In an interview on [DATE REDACTED] at 12:45 PM, Staff NN, HUC, stated they used the facility mobile tablet to take a resident's picture for their electronic medical record profile. Staff NN explained pictures taken with the facility's mobile tablet were automatically uploaded to the facility computer. Staff NN further sated they had not had to transmit resident photographs and was unsure of the process. Staff NN acknowledged staff were not to use any other devices besides the facility equipment to photograph residents.

In an interview on [DATE REDACTED] at 4:15 PM, Staff A, Administrator, acknowledged Resident 98's picture was taken using a staff's personal cell phone and transmitted to the ME via normal text messaging to a phone number provided by the ME.

Review of additional information provided by the facility on [DATE REDACTED] showed a handwritten statement dated [DATE REDACTED] and signed by Staff MM, Licensed Practical Nurse. The statement acknowledged Staff MM used their personal mobile phone to take a picture of Resident 98, transmitted the photo to the ME as requested, and immediately deleted the picture from my phone.

Reference WAC [DATE REDACTED] (1)(b), (5)(a)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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** 47328 potential for actual harm Based on observation, interview, and record review the facility failed to perform hand hygiene when indicated Residents Affected - Some and follow transmission-based precautions (TBP) when implemented for 1 of 3 sampled residents (Resident 61), reviewed for infection control. This failure placed residents at risk of acquiring communicable diseases and diminished quality of life

Findings included .

TRANSMISSION BASED PRECAUTIONS

Review of the facility policy titled, Transmission-Based Precautions (Isolation) revised March 2024, showed TBP were used whenever measures more stringent than standard precautions were needed to prevent or control the spread of infection. There were three types of TBP (airborne, contact, and droplet). Contact precautions were implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy listed infections, including Shingles (viral infection that caused a painful blistery rash), that would require contact precautions be implemented. The policy instructed persons entering a contact precaution room to wear gloves and a disposable gown upon entering the room, adequately clean and disinfect commonly used items between residents if unable to use or dedicate equipment to a resident on contact precautions.

According to the Center for Disease Control website CDC.gov - with regard to TBP showed, Use contact precautions for patient with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning [applying] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

<Resident 61>

According to the 01/08/2025 annual assessment, Resident 61 had moderate cognitive impairment and was able to clearly verbalize their needs.

Review of the 01/02/2025 care plan showed Resident 61 had shingles and instructed staff to maintain contact precautions, administer antiviral medication per provider orders, and pregnant woman should not provide cares.

Review of provider orders showed a 01/02/2025 order for Resident 61 to be on Contact precautions as recommended for residents known or suspected to be infected with infectious agents transmitted person to person via the direct/indirect contact route for shingles.

Review of 01/09/2025 provider progress note showed Resident 61 had shingles and was on isolation precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 During observation on 01/07/2025 at 8:59 AM, a contact precaution sign was posted on the wall outside of Resident 61's room. The sign instructed staff to perform hand hygiene and wear a gown and gloves prior to Level of Harm - Minimal harm or entering the room. The sign also instructed staff to clean and disinfect shared equipment. Similar potential for actual harm observations were made on 01/07/2025 at 11:12 AM, on 01/08/2025 at 1:34 PM, on 01/09/2025 at 8:04 AM, and on 01/10/2025 at 8:14 AM. Residents Affected - Some

In an interview on 01/08/2025 at 10:38 AM, Resident 61's roommate stated staff did not clean the toilet after Resident 61 used it. Resident 61's roommate further stated the garbage in the room often overflowed with used and soiled gloves and they often emptied it because staff did not.

During observation on 01/08/2025 at 1:34 PM, Staff R, Nursing Assistant, entered Resident 61's room without performing hand hygiene or putting on a gown or gloves. Staff R walked half way into the room, adjusted the privacy curtain, shut the call light off, and exited the room.

During interview on 01/08/2025 at 1:35 PM, Resident 61's roommate stated staff only had to put a gown and gloves on when they worked with Resident 61 but not when they worked with them. Resident 61's roommate explained to Resident 61 staff had to wear the gown and gloves because of the rash on their leg. Resident 61 stated Oh yeah, that rash is driving me nuts, and lifted their blankets to show a blistery rash to their right groin/inner upper thigh.

In an interview on 01/17/2025 at 9:20 AM, Staff EE, Housekeeper, stated housekeeping was responsible for emptying out the garbage, cleaned and disinfected transmission-based precaution rooms but typically waited to until the end of the day to clean TBP rooms. Staff EE explained housekeeping only worked on day shift, but housekeeping would round in the morning and empty out garbage in TBP rooms if it was full. Staff EE acknowledge garbage in TBP rooms got full from evening/night shifts and needed emptied in the morning. Staff EE further stated residents in TBP rooms should not empty out the garbage because it was a potential infection control issue.

In an interview on 01/17/2025 at 9:33 AM, Staff G, Nursing Assistant (NA), was unable to state what contact precautions were.

In an interview on 01/17/2025 at 9:37 AM, Staff FF, NA, explained everyone should put a gown and gloves

on prior to entering a room with a contact precautions sign posted. Staff FF further stated staff should always clean/disinfect the bathroom between roommates. Staff FF stated residents should not empty out garbage in TBP rooms because it was not their job. Staff FF acknowledged TBP should always be followed when implemented to prevent the spread of germs.

In an interview on 01/17/2025 at 9:45 AM, Staff E, Registered Nurse, stated staff were to disinfect the toilet between residents and empty garbage in TBP rooms, not the residents, because of potential infection control issues. Staff E further stated staff should follow TBP when implemented to prevent the spread of infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 01/17/2025 at 10:47 AM, Staff J, acting Infection Preventionist, explained any staff who entered a room to provide care to a resident on contact precautions needed to put a gown and gloves on Level of Harm - Minimal harm or prior to crossing the threshold of the room. This was different than enhanced barrier precautions which potential for actual harm allowed persons to cross the threshold of the room without putting PPE on unless they were going to assist with high contact care activities. Staff J further stated trash in TBP rooms should be emptied by staff, not Residents Affected - Some residents. Staff J expected staff to follow TBP when implemented to prevent the spread of germs and infections.

In an interview on 01/17/2025 at 11:28 AM, Staff B, Director of Nursing, explained a gown and gloves should be placed prior to crossing the threshold of a room on contact precautions. Staff B stated they expected staff to follow the posted TBP signage.

In an interview on 01/17/2025 at 3:54 PM, Staff A, Administrator, stated they expected staff to follow TBP when implemented. Staff A further stated staff should empty the garbage in TBP rooms but they could not stop residents from doing it.

HAND HYGIENE

Review of the facility policy titled, Handwashing/Hand Hygiene updated March 2018, showed hand hygiene was the primary means to prevent the spread of infections. Hand hygiene could be performed by use of alcohol-based hand rub (ABHR) or washing hands with soap and water. The policy showed hand hygiene should be performed before and after direct contact with residents, after contact with a resident's intact skin,

after contact with objects in the immediate vicinity of a resident and after glove removal, before and after entering an isolation precaution setting, and before and after assisting a resident with meals.

According to the website CDC.gov - with regard to hand hygiene showed, hand hygiene protects both healthcare personnel and patients. Hand hygiene means handwashing with water and soap or antiseptic hand rub (alcohol-based foam or gel hand sanitizer). Recommendations for hand hygiene in healthcare settings are immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.

During observation on 01/07/2025 at 12:00 PM, Staff R, NA, did not perform hand hygiene and delivered a lunch tray to room [ROOM NUMBER], set up the tray, and exited the room without performing hand hygiene. Staff R obtained another lunch tray, delivered it to room [ROOM NUMBER], and exited the room without performing hand hygiene. Staff R obtained another lunch tray, delivered it to room [ROOM NUMBER], and exited the room without performing hand hygiene.

During observation on 01/07/2025 at 12:02 PM, Staff DD, NA, did not perform hand hygiene, delivered a lunch tray to room [ROOM NUMBER], and exited the room without performing hand hygiene.

During observation on 01/15/2025 at 11:54 AM, Staff R, NA, did not perform hand hygiene, delivered a lunch tray to room [ROOM NUMBER], and exited room without performing hand hygiene. Staff R obtained another try, delivered it to room [ROOM NUMBER], and exited the room without performing hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 01/15/2025 at 12:15 PM, Staff R, stated hand hygiene was washing their hands but there was no way to do it when passing trays. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/15/2025 at 1:16 PM, Staff D, Resident Care Manager, explained hand hygiene included using ABHR or washing hands with soap and water. Staff D stated hand hygiene was to be performed when Residents Affected - Some entering or exiting a resident room, before serving meals, between residents, before and after cares. Staff D further stated if hand hygiene was not performed when indicated it could spread germs and expected staff to perform hand hygiene when indicated.

In an interview on 01/17/2025 at 10:40 AM, Staff J, acting Infection Preventionist, stated hand hygiene was using ABHR or washing hands with soap and water. Staff J explained if hand hygiene was not performed when indicated it could potentially spread germs. Staff J stated they expected staff to perform hand hygiene when indicated.

In an interview on 01/17/2025 at 11:25 AM, Staff B, DNS, stated hand hygiene was using ABHR or washing hands with soap and water. Staff B stated they expected staff to perform hand hygiene when indicated, including during meal service when passing different resident meal trays.

In an interview on 01/17/2025 at 3:53 PM, Staff A, Administrator, stated they expected staff to perform hand hygiene when indicated.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46033

Residents Affected - Many Based on observation, interview and record review, the facility failed to ensure staff were offered the COVID-19 vaccine (COVID-19, a viral illness that caused fever, difficult breathing, and other viral symptoms that included possible hospitalization or even death), were provided education regarding the risks/benefits and potential side effects of the vaccine, and maintained documentation related to vaccine education, declination,or administration of the vaccine as required for 3 of 3 sampled staff (Staff G, H, and I) reviewed.

This failure placed residents and staff at risk of illness or exposure to the COVID-19 virus and potential unintended health consequences.

Findings included .

The Centers for Disease Control and Prevention (CDC) Recommended Adult Immunization Schedule 2025 for ages [AGE] years or older retrieved from www.cdc.gov/acip-recs/hcp/vaccine-specific/ documented adults age 19-[AGE] years or adults age 65 or older who were unvaccinated for COVID-19 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of COVID-19 vaccine unless contraindicated. Those previously vaccinated before 2024-2025 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of 2024-2025 COVID-19 vaccine unless contraindicated.

On 01/15/2025 at 12:58 PM, room [ROOM NUMBER] on Evergreen Unit was observed to have a new aerosol precaution sign (signage that notified staff of important measures to implement prior to entering a resident room such as donning personal protective equipment, PPE, or performing hand hygiene, for example) on their door and the door was closed. A bin of PPE was positioned at the doorway, and Staff F, Nursing Assistant, NA, was observed putting on a disposable gown, gloves and a respirator-type mask. When interviewed, Staff F stated the resident in room [ROOM NUMBER] had been at the facility for 6 days and had just tested positive for COVID-19 that morning when they developed symptoms of respiratory illness.

During an interview on 01/17/2025 at 9:27 AM, Staff G, NA, stated they had been vaccinated for COVID-19 probably two years prior when the vaccine first came out and was unaware there were additional COVID-19 vaccines available. Staff G stated they had never received any education regarding the vaccine and had not been offered one recently.

During an interview on 01/17/2025 at 10:33 AM, Staff H, NA, stated they did not remember being offered a COVID-19 vaccine recently unless it was offered as part of their initial employment onboarding paperwork.

A review of staff COVID-19 vaccinations documented the following:

-Staff G received two doses of the COVID-19 vaccine on 05/07/2021 and 06/08/2021 and signed a declination for an additional vaccine on 07/26/2023.

-Staff H received two doses of the COVID-19 vaccine on 09/12/2021 and 10/11/2021.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 505379 Department of Health & Human Services Printed: 09/11/2025 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 505379 B. Wing 01/17/2025

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

Royal Park Health & Rehabilitation Center 7411 North Nevada Spokane, WA 99208

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 0887 -A third staff, Staff I, NA, was added to the review and had received two doses of COVID-19 vaccine on 08/25/2021 and 09/16/2021. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/17/2025 at 1:13 PM, Staff J, Licensed Practical Nurse and temporary acting Infection Prevention Nurse, stated the facility did not offer COVID-19 vaccines to staff. They encouraged the Residents Affected - Many staff to see their primary care provider or pharmacies that offered discounted vaccinations and bring in their proof of vaccination. Staff J was uncertain when the facility stopped offering COVID-19 vaccines. They stated if staff did not bring in evidence of their vaccine, the facility had no documentation. Staff J stated they did not keep track of staff education or who had received or declined the COVID-19 vaccine.

Reference: WAC 388-97-1320

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 505379