Alaska Gardens Health And Rehabilitation

F-F580 Notification of Changes and another abbreviated CI initiated 02/03/2025 resulted in failed practice identified in the care areas of: Abuse, Care Planning, Substandard Quality of Care

in Nutrition/Hydration Status Maintenance, other Quality of Care areas, and Pharmacy Services on 03/19/2025 (including repeated citations in

F-F684 on 01/22/2025 and remains out of compliance. This is a repeated citation.

REFERENCE WAC 388-97-1060 (1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46472 Residents Affected - Few Based on observation, interview, and record review the facility failed to develop and implement a resident-centered fall prevention care plan (CP) to reduce their specific risk factors for falls, consistently provide adequate supervision, and ensure residents were consistently monitored for post-fall injuries for 3 of 6 Residents (Residents 1, 8, & 11) reviewed for falls. Resident 1 experienced harm when they fell out of their wheelchair at the nurse's station and sustained a hip fracture. These failures placed all residents at risk for avoidable future falls, adverse events, physical injuries, pain, functional decline, and diminished quality of care/quality of life.

Findings included .

<POLICY>

Review of the facility's Managing Falls and Fall Risk policy, revised [DATE REDACTED], showed the facility would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The facility, physician, and consultant pharmacist would identify and adjust medications known to increase the risk of falls or indicate rationale why the medications could not be adjusted, even for a trial period.

Review of the facility's Assessing Falls and Their Causes policy, revised [DATE REDACTED], showed the facility would timely notify the physician and family when a fall occurred. They would monitor for delayed complications and document their findings in the clinical record. The facility would initiate an incident report with details defining the fall including the preceding chain of events to identify potential causes for the fall. The physician would examine the resident after a fall. A Post-Fall Evaluation would be conducted. After the fall, the facility would document in the clinical record: the condition in which they were found, assessment data, medical interventions implemented, notifications of physician and family, completion of a fall risk assessment, appropriate interventions taken to prevent future falls, and their response to the interventions.

Review of a The Fall Prevention Program (undated, one page document) showed the facility would place blue tags on the doors that said FALL PROGRAM, blue arm bands on the residents that say Resident on the fall program, non-skid socks were available for residents on the fall program, a blue information sheet above

the patient's bed that would list their specific fall intervention codes (D=Dysum, T=Tipper bars, L=low bed, FW=Footwear, FM=Floor mat, and assistive device they needed), and a fall binder would be kept each nurse's station. The nurses would also enter orders for the specific fall interventions and add the tasks into

the POC (Point-of-Care -electronic documentation system for the Certified Nursing Assistants, CNAs).

Review of the facility's Alert Charting/Skilled Charting Guidelines, updated [DATE REDACTED], showed when a resident fell , nurses were required to monitor and document their status by placing them on Alert Charting with vital signs every shift for 72 hours to monitor for: pain, injury, change in level of consciousness or mentation, problems with balance or functional abilities, and implement nursing interventions to prevent falls. If there was an injury with the fall, they would also do routine neurological checks (for head injury or unwitnessed fall) and skin evaluations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 1>

Level of Harm - Actual harm Review of the [DATE REDACTED] Admission Minimum Data Set (MDS-an assessment tool) showed Resident 1 admitted to the facility on [DATE REDACTED] and was assessed to have moderate cognition problems, hallucinations, and Residents Affected - Few behaviors. Resident 1 diagnoses included atrial fibrillation (a cardiac-rhythm problem known to increase fall risk), a fracture of the spine, Parkinson's disease (a progressive neurological disorder that can cause hallucinations and increase fall risk), and hallucinations. Resident 1 required staff assistance for all activities of daily living (ADLs) and had occasional incontinence. Resident 1 had frequent pain that effected their sleep and day-to-day routine, their highest level of pain was ,d+[DATE REDACTED] (per pain scale 0=no pain and 10=extreme pain), and no routine scheduled pain medication. Resident 1 had falls that resulted in fractures prior to admission, one non-injury fall since admission, and medications associated with high fall risk included antipsychotics and antidepressants.

Review of Resident 1's Fall CP dated [DATE REDACTED] showed non-personalized interventions dated [DATE REDACTED] to: announce themselves when approaching resident, ensure nonskid footwear were on, ensure the call light was within reach and answered promptly, encourage call light use, explain all procedures and purpose prior to starting tasks, and monitor for side effects of any medications that could cause gait disturbances, sudden drop in blood pressure and pulse, weakness, dizziness, sedation, fatigue, seizures, fainting, or vertigo.

Review of Resident 1's Kardex (quick reference CP interventions and alerts for CNAs) dated [DATE REDACTED] showed none of the [DATE REDACTED] Fall CP interventions were present on the Kardex for the CNAs to implement.

FALL #1:

Review of a nurse progress note dated [DATE REDACTED] at 5:04 PM showed Resident 1 had a fall at the nurse's station after trying to stand up from their wheelchair without assistance. The documentation showed they would encourage Resident 1 to remain in highly supervised area when in their wheelchair.

Review of the progress notes did not provide documentation to show Resident 1 was consistently monitored

on alert charting every shift for 72 hours after the fall on [DATE REDACTED].

Review of the facility's Fall (Witnessed) Risk Management Report dated [DATE REDACTED] at 3:30 PM showed their investigation was not thorough or complete. The investigation did not include the preceding chain of events/circumstances regarding the fall and no root cause analysis to identify the unmet care need or reason Resident 1 tried to stand without assistance. The investigation did not provide documentation to show a fall risk assessment was conducted, the CP was updated to prevent future falls, or they monitored Resident 1's response to the interventions.

Review of the Kardex dated [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] did not show any fall interventions for CNAs to implement.

FALL #2:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 facility 's Fall (Witnessed) Risk Management Report dated [DATE REDACTED] at 4:12 PM showed Resident 1 was attempting to stand without assistance in their room, the CNA saw Resident 1 attempt to Level of Harm - Actual harm stand and tried to assist but Resident 1 scratched them and they were not able to stop them from falling. Their plan was to have Resident 1 seen by mental health services, place them on the Fall Prevention Residents Affected - Few Program to increase supervision, alert charting for behaviors, monitoring for a change in condition or latent injuries, and update the CP.

Review of the progress notes did not provide documentation to show a fall event occurred on [DATE REDACTED] at 4:12 PM, notification to the physician and responsible party of a fall, new interventions implemented, or consistent post-fall alert charting every shift for 72 hours after the fall.

Review of the physician progress note on [DATE REDACTED] showed Resident 1 was confused, agitated, and made multiple attempts to walk independently despite redirection to sit back in the wheelchair. Resident 1 was seated in the wheelchair at the nurse's station during the encounter and was uncomfortable due to back pain. The documentation did not show they evaluated Resident 1 for a fall and there were no changes made to their plan.

Review of a Physical Medicine Rehabilitation Physiatry (a medical specialty that focuses on the diagnosis, prevention, and treatment of disabilities related to the brain, nerves, bones, muscles, and joints to restore function, reduce pain, and improve quality of life) Initial evaluation dated [DATE REDACTED] at 3:38 PM showed Resident 1 reported pain ,d+[DATE REDACTED] and described their back pain as bothersome, their right knee as sore, and had pain when they urinated. Resident 1 reported they fell (date not specified) but were not injured. The provider planned to schedule acetaminophen (pain medication) routinely throughout the day and would order

a pain medication cream to apply to the skin. A UA (urinalysis- a test used to diagnose urinary tract infection) was ordered on [DATE REDACTED].

Review of the Fall CP showed an update on [DATE REDACTED] to keep resident in a highly visualized area when in the wheelchair (four days after the Fall #1 and two days after Fall #2); mental health referral and Fall Prevention Program (two days after Fall #2). The CP showed the updates were not timely.

Review of the Kardex dated [DATE REDACTED] showed the updates: on the Fall Prevention Program (from the intervention for the fall on [DATE REDACTED]) and to keep them in highly visible areas when up in the wheelchair (the intervention from the fall on [DATE REDACTED])

Review of a physician progress note dated [DATE REDACTED] showed Resident 1 was very confused, a very high fall risk, and continued to try to self-ambulate.

Review of a therapy progress note dated [DATE REDACTED] at 5:17 PM showed Resident 1 ambulated 35-feet with minimal assistance for balance and safety. Resident 1 ambulated a total of 60 feet.

FALL #3:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 facility's Fall (Witnessed) Risk management report, dated [DATE REDACTED] at 2:15 PM showed Resident 1 was at the nurse's station in their wheelchair, stood up, fell , and landed on their buttocks. The Level of Harm - Actual harm documentation showed one staff member (coming on shift) reported they saw the resident stand and fall but could not get to them in time. A typed interview statement with Staff R, CNA, showed they tried to change Residents Affected - Few Resident 1 before the end of their shift but Resident 1 refused so they left them in the wheelchair at the nurse station for safety. The interventions and conclusion, dated [DATE REDACTED], showed they would place auto-lock brakes on the wheelchair, place Resident 1 on alert charting, and update the CP.

Review of the clinical record did not show physician orders were obtained for their specific Fall Prevention Program interventions or auto-lock brakes for the wheelchair.

Review of the nurse progress notes for [DATE REDACTED] did not provide documentation to show a fall occurred, that

the physician and responsible party were notified, that new interventions were implemented, or that consistent post-fall alert charting was done every shift for 72 hours after the fall.

Review of the physical therapy progress note dated [DATE REDACTED] at 4:27 PM showed therapy attempted to work with Resident 1 but they were unable to get Resident 1 to stand (using maximum assist of two staff), they resisted standing and kept sitting back down. The documentation did not show the therapy staff notified nursing or the physician of their new onset of inability or unwillingness to stand.

Review of the physician note dated [DATE REDACTED] showed Resident 1 had worsening confusion and agitation. The nursing staff reported to the provider they needed one-to-one care; they were still a fall risk and tried to leave

the wheelchair on multiple occasions. The provider documented Resident 1 is staying by the nurse station most of the time.

Review of a nurse progress note dated [DATE REDACTED] at 2:22 PM showed Resident 1's Collateral Contact (CC) arrived to visit, called [DATE REDACTED], and Resident 1 was transferred to the hospital.

In an interview on [DATE REDACTED] at 10:27 AM, Resident 1's Responsible Party (Resident R1-RP) stated after resident 1 fell ,

the facility did nothing about it. They only received one notification of a fall, on [DATE REDACTED] but were not notified of

the falls on [DATE REDACTED] and [DATE REDACTED]. Resident 1 was left to sit up in the wheelchair all day, in the halls or at the nurse station, and was not allowed to lay down for naps. Resident R1-RP stated they visited every day and sometimes twice a day and there were many occasions they arrived to find Resident 1 in the wheelchair either at the nurse's station or down the hall towards their room and there were no staff around. On one visit a staff member put a blue wrist band on Resident 1's wrist and when we asked why, they said 'so the staff knew

they were a high fall risk'. The next day when we were in to visit the blue band was gone and we never saw it again. They were at the facility [DATE REDACTED] just before dinner time and noticed Resident 1 was not doing well;

they were so groggy they could barely talk and looked out-of-it. Resident R1-RP stated they were out of town on [DATE REDACTED] so their Collateral Contact (CC) went to check on Resident 1. Resident R1-RP stated CC found Resident 1 in

the wheelchair at the nurse's station, slumped over to the side, and thought Resident 1 had died . CC had to go find help because there were no staff at the nurse's station. After CC found staff who said they would lay Resident 1 down, CC went outside and called Resident R1-RP to report what occurred. Resident R1-RP directed CC to call 911 and then call Resident R1-RP back. Resident R1-RP was on speaker phone and could hear the paramedics repeatedly calling out Resident 1's name to get them awake. Resident R1-Rp stated at the hospital they found Resident 1 was too sedated from their psychotropic medications and had a hip fracture.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 Inpatient Hospitalist History & Physical Note dated [DATE REDACTED] showed Resident 1 was admitted to

the hospital for mental status changes due to psychotropic medications, a fever, an elevated white blood cell Level of Harm - Actual harm count, and an abnormal UA. They held their antipsychotic, antidepressant, and Parkinsons medications on admission to the hospital. On [DATE REDACTED], after Resident 1 was more alert, the hospital physical therapist Residents Affected - Few attempted to transfer Resident 1 and they were not able to stand, sat back down, had facial grimacing, and guarded their right hip. An x-ray showed Resident 1 had an acute hip fracture which required surgical intervention.

In an interview on [DATE REDACTED] at 2:30 PM, Staff C, Registered Nurse-Resident Care Manager (RCM), stated Resident 1 had three falls while a resident at the facility according to the electronic risk management system:

a fall on [DATE REDACTED] at 3:30 PM, a fall on [DATE REDACTED] at 4:12 PM, and a fall on [DATE REDACTED] at 2:15 PM. Staff C was unable to locate documentation to show the fall events on [DATE REDACTED] and [DATE REDACTED] were recorded in the medical

record and alert charting was completed. Staff C stated the CP updated after the fall were not done timely and there could have been more relevant CP interventions after the first fall since Resident 1 was already at

the nurse's station when they fell . Staff C stated nurses were expected to document the event in the nurse progress notes, place the resident on Alert charting (for a minimum of 72 hours), and ensure a relevant intervention was updated in the CP before the end of their shift. Staff C stated the nurses knew how to update the CP and Kardex and it was not done timely. Staff C stated the RCMs, or Staff B, Director of Nursing, DNS, reviewed the documentation to ensure the post fall steps were completed. Staff C was unable to locate the lab result report for the UA ordered [DATE REDACTED]. Staff C stated they would investigate. No further information was provided.

In an interview on [DATE REDACTED] at 1:00 PM, Staff D, Physician, stated they were unaware of Resident 1's falls but would need to review their documentation. Staff D stated if they were notified of a fall, they would have addressed it in their visit note. Staff D stated it was their expectation the facility notified them of each fall in a timely manner and that the licensed nurses or Resident Care Managers reviewed their provider notes after each visit and followed their recommended plans they documented at the end of their progress notes.

In an interview on [DATE REDACTED] at 8:40 AM, Staff R, CNA, stated they did not know what the facility's Fall Prevention Program was or why some name tags on the name plates were blue and some were white. Staff R stated they knew who a fall risk was by looking at their Kardex every day and notifications during shift change. They stated for every resident that was a high fall risk, they made sure their beds were in the lowest position (most of the time), and they had fall mats on the floor. They also did 15-minute checks, ensured the doors stayed open, and residents could not be alone in their room in their wheelchairs, they needed to be at

the nurse's station to be monitored. They had never seen residents wear blue wrist bands.

<RESIDENT 8>

Review of the [DATE REDACTED] Admission MDS showed Resident 8 had moderate cognition problems, required assistance for ADLs, had frequent bowel incontinence, and diagnoses included stroke, diabetes, obstructive sleep apnea, and a newly placed feeding tube. Resident 8 had falls prior to admission but no falls since they admitted .

Review of the [DATE REDACTED] Death in facility MDS showed Resident 8 passed away.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 Fall CP dated [DATE REDACTED] showed they were at risk of falls and had non-personalized fall interventions that included: appropriate footwear always, call light within reach and answered promptly, Level of Harm - Actual harm monitor for medication side effects, refer to therapy, and report falls to the provider.

Residents Affected - Few In an interview on [DATE REDACTED] at 4:41 PM, Resident 8's responsible party, Resident R8-RP, stated after Resident 8's roommate discharged ; Resident 8 started falling because there was no one in the room to call for help for Resident 8. Resident R8-RP stated Resident 8 told them their call light was often out of their reach. They also experienced long call wait times and by the time staff arrived they were already incontinent. Resident R8-RP stated Resident 8 fell on [DATE REDACTED]. Resident R8-RP stated they were contacted by someone at the facility and told Resident 8 fell and asked if they could put side rails on the bed, but nothing was done. Resident R8-RP stated Resident 8 fell again after the first fall and hit their head. The nurse did not know Resident 8 fell until they did their rounds.

Review of the facility's mandatory reporting log for [DATE REDACTED] showed Resident 8 had two falls on [DATE REDACTED], the first fall was at 8:21 PM and the second fall was at 10:30 PM.

Fall#1:

Review of the facility's fall investigation dated [DATE REDACTED] at 8:21 PM showed Resident 8 was found lying on the floor beside their bed. Resident 8 reported they were getting ready for bed and slid off the bed. They were evaluated for injuries and assisted back into bed. The new intervention was to get them a wider bed.

Fall#2:

Review of the facility's fall investigation dated [DATE REDACTED] at 10:30 PM (two hours after the first fall) showed Resident 8 was found lying on the floor beside their bed, again. Resident 8 stated they were trying to go to

the bathroom and fell . They placed a fall mat on the side of the bed. Review of the typed-in resident statement showed Resident 8 stated they were trying to go the bathroom and fell to their right side. The one staff typed-in statement showed 'they found them on the floor, they said they rolled out of bed'. The investigation did not show written, signed/dated witness statements were obtained, details of the scene including whether the call light was on or not, analysis of the prior chain of events, identification of Resident 8's unmet care need, or a plan on how to better provide more prompt toileting assistance. The investigation did not include completed neurological checks or post-fall monitoring. The new intervention was to get them

a wider bed, the same intervention from the first fall, add them to The Fall Prevention Program, and placed a fall mat on the floor next to the bed.

Review of a SBAR notification to the provider, dated [DATE REDACTED], showed Resident 8 fell . There was no description or time of the fall indicated on the notification. They requested to put side rails on the bed and floor mats on the floor on the side of the bed. The physician signed the response on [DATE REDACTED].

Review of a Fall CP update, dated [DATE REDACTED], showed Resident 8 was on the Fall Prevention Program. The CP did not show updates that included: fall mats, side rails, low bed, or a wider mattress.

Review of the Kardex, dated [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] showed no fall care plan interventions for CNAs to implement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 Resident 8's physician orders showed an order, dated [DATE REDACTED] for a larger mattress to allow more room for bed mobility and care to help reduce the risk of falls. The physician orders did not show orders for Level of Harm - Actual harm side rails, low bed, or fall mats were transcribed and implemented.

Residents Affected - Few Review of a Fall CP update, dated [DATE REDACTED], showed Resident 8 was provided a wider mattress (four days

after the falls).

Review of the Resident 8's progress notes did not provide documentation to show fall events occurred on [DATE REDACTED] or: notification to the physician and responsible party of the falls, new interventions implemented, or consistent post-fall alert charting every shift for 72 hours after the falls.

<RESIDENT 11>

Review of the [DATE REDACTED] Quarterly MDS showed Resident 11 had cognition problems, required assistance with ADLs, and diagnoses included diabetes, depression, chronic lung disorders, and muscle weakness. Resident 11 had two or more non injury falls since their prior assessment.

Review of the Fall CP dated [DATE REDACTED] showed Resident 11 was at risk for falls or injury due to impaired balance and mobility. The CP showed they fell on [DATE REDACTED]. The Fall CP interventions included: an intervention dated [DATE REDACTED] to keep call light within reach; an intervention dated [DATE REDACTED] to keep the right side of the bed against the wall; [DATE REDACTED] to ensure the bed was in the lowest position before leaving the room; an intervention on [DATE REDACTED] for the Fall Prevention Program; [DATE REDACTED] to place a perimeter mattress to define bed edges; and a fall intervention dated [DATE REDACTED] for a bariatric alternating pressure mattress.

Review of a nurse progress note dated [DATE REDACTED] at 12:57 AM, showed Resident 11 fell from their bed. Resident 11 reported they were trying to adjust themselves in their bed but leaned too far over to the left, fell , and landed on their left side. After they were assessed for injury, they were assisted back to bed, educated

on call light use, lowered the bed to the lowest position, and ensured the bed brakes were in the locked position. The documentation did not show the physician and responsible party were notified. The documentation showed there was not consistent post fall alert charting documented every shift for 72 hours

after the fall.

Review of Resident 11's Kardex dated [DATE REDACTED] directed staff to encourage use of the call light for assistance and to ensure they left the bed in the lowest position prior to leaving the room. There were no other interventions for fall prevention on the Kardex.

During an interview and observation on [DATE REDACTED] at 8:10 AM, Resident 11 was in bed. There were no other staff in the room. Their bed was not in the lowest position and not with the right side of the bed against the wall. Between the bed and the wall on the right side was an IV pole and their oxygen concentrator. The mattress was not a perimeter mattress. There was a blue piece of paper with nothing on it-covering another blue piece of paper on the wall at the head of the bed. Resident 11 stated they had not fallen in a while and was doing good at staying off the floor. They did not know they had a blue sign at the head of their bed, so

they did not know what it said. The sign was not reachable due to the bed and medical equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 [DATE REDACTED] at 8:40 AM, Staff R, CNA, Staff R stated the blue sign on the wall in Resident 11's room was information about their transfers and bed mobility. Staff R was not aware Resident 1's right side of Level of Harm - Actual harm the bed was supposed to be against the wall.

Residents Affected - Few <THE FALL PREVENTION PROGRAM>

In an interview on [DATE REDACTED] at 1:15 PM, Staff C, Registered Nurse-RN, stated when residents had a second fall, they were placed on the Fall Prevention Program. Staff C stated they were unsure if there were documented protocol. After a resident had a second fall, they would be placed on the Fall Prevention Program: they would have a blue sign in their room with their fall interventions on them, they would have blue name tags on the outside of their doors. Staff C stated they obtained physician orders for fall interventions that required an order (like side rails, low beds, or beds against the wall). Staff C stated they have never seen a fall binder at the nurse station or blue wrist bands used, and the facility did not have a structured clinical systems meeting for falls (like they did for Nutrition/Skin weekly meetings) or other ongoing monitoring process for residents with repeated falls, but did discuss falls that occurred the prior day (or weekend) during their morning clinical meeting.

In an interview on [DATE REDACTED] at 9:30 AM, Staff JJ, CNA, stated they were unsure why some name plate name tags were blue, and some were white. They did not know the specifics of the Fall Prevention Program but knew that they would look at the Kardex to tell them if the resident had interventions for fall prevention.

In an interview on [DATE REDACTED] at 6:40 AM, Staff KK, LPN, stated they were unsure what the significance was of

the blue name tags versus the white name tags on the name plates, but they would find out. No further information was provided.

In an interview on [DATE REDACTED] at 2:45 PM, Staff A stated some of the components on the Fall Prevention Program were not done at the facility including the nurses' putting orders in for fall interventions and tasks into the CNAs POC documentation program, they did not keep a fall binder at the nurse stations, and did not place blue wrist bands on residents.

In an interview on [DATE REDACTED] at 11:50 AM, Staff I, RN, stated they knew which residents were fall risks by looking in their room to see if they had fall mats by their bed. Staff I stated after a resident fell , they were required to document the event, initiate an investigation, report the fall to the physician and responsible party, and implement an intervention to help prevent further falls. Staff I stated they knew how to update the CP but did not know how the interventions transferred over to the Kardex for CNAs to implement. Staff I stated their system to educate the oncoming staff of the CP updates with new interventions was verbally

during shift report.

Refer to

F-F689 Free of Accident Hazards/supervision/devices:

Level of Harm - Minimal harm or During an interview on 03/04/2025 at 2:11 PM, Staff A stated, the facility tracked missed alert charting notes potential for actual harm and skilled notes. Staff A stated Medical Records staff conducted the audits. Staff A stated they reviewed the clinical alert list in PCC (the computer charting program), and the 24-hour log to see who was on alert Residents Affected - Many monitoring documentation.

The facility did not self-identify their failure to consistently implement fall care plans, initiate incident reports, or consistently document monitoring following resident falls.

4. Refer to CFR: S483.95

F-F692 Nutrition/Hydration Status Maintenance:

During an interview on 03/04/2025 at 2:11 PM, Staff A stated in the December 2024 and January 2025 QAPI meetings the residents who triggered for significant weight changes were consistent, monitored, and the variance reports showed improvement. When asked if the committee had identified any tube feeding dependent resident's that experienced weight loss or other hydration/electrolyte problems, Staff A stated No.

The facility did not self-identify their failure to ensure residents received the nutrition they required and consistently monitored the residents response to interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 0867 3. Refer to CFR: S483.25(d)

F-F758

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46472 potential for actual harm Based on observation, interview, and record review the facility failed to ensure 12 of 12 sampled residents Residents Affected - Some (Residents 26, 2, 22, 13, 10, 38, 14, 8, 17, 34, 23, & 15) were free from significant medication errors. The failure to: conduct a thorough medication reconciliation on admission, verify allergies prior to administration, clarify duplicate or questionable orders, correctly transcribe orders into the electronic Medication Administration Record (MAR), administer medications timely in accordance with professional standards of practice, and report/investigate all identified medication errors placed residents at risk for adverse events, rehospitalization , poorly managed health conditions, and diminished quality of care/quality of life.

Findings included .

Review of the facility's Adverse Consequences and Medication Errors policy, revised April 2014, showed the Interdisciplinary Team (IDT) would evaluate medication usage to prevent and detect adverse consequences and medication-related problems like adverse drug reactions and side effects. Adverse outcomes would be reported to the appropriate entities. The facility would follow clinical guidelines, manufacturer's instructions, ensure appropriate indications for use, and determine whether the resident has a known allergy to the medication. The IDT would review the resident's medication regimen for efficacy and actual/potential medication-related problems on an ongoing basis. The facility would notify the physician of medication errors promptly and monitor the resident closely for 24-72 hours or as directed, documented in the clinical record, and complete an incident report. The Quality Assurance Performance Improvement (QAPI) committee would conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps, and compare results over time to determine that system improvements were effective at reducing errors.

Review of the facility's Admission Assessment and Follow-Up: Role of the Nurse policy revised September 2012 showed the policy had not been reviewed/revised or updated since 2012. The policy showed the facility would reconcile the list of medications from their medication history, admitting orders, and the discharge summary. They would contact the physician to communicate and review findings of their initial assessment and obtain admission orders based on their assessment and finding. They would contact outside services as necessary and follow professional standards of practice.

<RESIDENT 26>

Review of Resident 26's hospital Discharge Summary dated 12/16/2024 showed they had a history of a stroke, heart attack, and long-term use of blood thinners. The discharge summary medication list included orders dabigatran 150mg twice daily, an oral blood thinner.

Review of Resident 26's 12/22/2024 Admission Minimum Data Set (MDS-assessment tool) showed they admitted [DATE REDACTED] and were not on blood thinners during the observation period.

Review of Resident 26's facility Admission orders dated 12/16/2024 showed the order for dabigatran was not transcribed to the admission orders and implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Review of the clinical record showed Resident 26 was transferred to the hospital for neurologic changes on 01/30/2025. Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's hospital Discharge Summary 02/21/2024 showed the hospital identified [they] were not given the blood thinner after admission to the facility (between 12/16/2024 and 01/30/2025). Residents Affected - Some

Review of the clinical record did not show a medication reconciliation was conducted on the admission or the readmission.

<RESIDENT 2>

Insulin Allergy:

Review of Resident 2's Interfacility Discharge Orders dated 12/02/2024 showed they were allergic to glargine (Lantus) insulin. They were ordered Degludec (a long-acting insulin) 21 units every day with dinner for diabetes.

Review of the December 2024 MARs showed two long-acting insulin orders: 1) a physician's order dated 12/02/2024 for Lantus 21 units at bedtime (the medication listed on the allergy list). The documentation showed the Lantus was administered on 12/02/2024 and 2) a 12/02/2024 physician order for Deglu[DATE REDACTED] units one time a day at 5:00 PM that showed it was not administered on 12/02/2024.

Review of the clinical record did not provide documentation to show a medication reconciliation was conducted or admission insulin orders were clarified.

Pain Medications:

Review of Resident 2's hospital Interfacility Discharge Orders and Medication Administration Record (MARs) dated 12/02/2024 showed orders for oxycodone (an opioid narcotic) 5mg tablets, take 0.5-1 tablet (2. 5mg-5mg) every six hours as needed for severe pain, lidocaine 4% patch applied topically cut in half and placed on the skin on both sides of the chest surgical incision at bedtime and removed after 12 hours of use, and acetaminophen 1,000mg every six hours for pain.

Review of Resident 2's facility Admission physician orders dated 12/02/2024 showed an order for oxycodone 2.5mg every six hours as needed for pain 1-5/10 (mild-moderate pain), an order for oxycodone 5mg every six hours as needed for pain 6-10/10 (moderate-severe), and lidocaine 4 % patch (apply to painful area, apply at bedtime and remove in the morning). The oxycodone and lidocaine patch orders were not accurately transcribed and/or clarified.

Review of the December 2024 MAR for 12/03/2024 at 12:00 AM showed scheduled acetaminophen was due but was not administered until 3:39 AM (three and a half hours late).

Review of the December 2024 MAR for 12/06/2024 at 12:00 AM showed scheduled acetaminophen was due but was not administered until 3:15 AM (over three hours late).

Review of the December 2024 MAR for 12/06/2024 at 6:00 PM showed their scheduled acetaminophen was due but was not administered until 7:26 PM (over an hour late).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Review of Resident 2's Medication Administration Report, MARs, and progress notes for December 2024 showed Resident 2 received their scheduled acetaminophen one hour late (or more) 14 doses of 44 total Level of Harm - Minimal harm or administered. potential for actual harm <RESIDENT 22> Residents Affected - Some

Review of Resident 22's Post Acute & Transition of Care Orders dated 02/17/2025 showed (in RED print) Please control BG (blood glucose-sugar). Use medium dose SSI (sliding scale insulin). The SSI was ordered for every six hours due to their tube feeding/NPO (nothing by mouth) status.

Review of the February 2025 MAR showed:

-An order dated 02/17/2025 for long-acting insulin 20 units twice daily- was not administered on the 02/17/2025 evening or 02/18/2025 morning doses.

-The blood sugar checks every six hours and SSI were not transcribed or initiated on readmission.

Review of the clinical record did not show the facility conducted a medication reconciliation at readmission.

In an interview on 02/25/2025 at 3:30 PM, Staff H, Licensed Practical Nurse-LPN, Resident Care Manager-RCM, stated insulins should have been transcribed and administered as ordered but were not.

<RESIDENT 13>

Review of Resident 13's Provider Orders-Nursing Home Transfer dated 02/18/2025 showed they admitted to

the facility with a serious heart infection, pneumonia, sepsis, diabetes, and neuropathy (nerve pain). Resident 13's discharge orders included three different intravenous (IV) antibiotics daily, scheduled and sliding scale insulins for diabetes, and several scheduled pain medications.

Review of the February 2025 MAR showed Resident 13 was not administered any of their ordered medications on 02/18/2025 or 02/19/2025.

Review of Medication Administration Notes dated 02/19/2025 at 3:17 AM and 02/19/2025 at 10:16 AM showed Meds on order as the reason medications were not administered.

In an interview on 02/20/2025 at 9:18 AM, Staff FF, LPN, stated Resident 13's narcotic pain medication was not available to administer and they just sent a signed prescription to the pharmacy so it could be delivered. Resident 13 had not received their scheduled pain narcotic pain medication for their morning dose on 02/20/2025. Staff FF stated when medications were not available, the nurses were supposed to call the physician to notify them and obtain further orders to either hold the medication or administer an alternative medication if one was available. Staff FF stated they did not know why Resident 13's medications were not received from the pharmacy.

Review of the clinical record did not show the physician was notified their medications were unavailable or that a medication reconciliation on admission was conducted.

<RESIDENT 10>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Review of Resident 10's Hospital Post Acute Transfer Orders dated 12/06/2024 showed orders for a lidocaine patch (for pain) to be applied to their shoulder every day and a diuretic (water pill) 2.5mg every Level of Harm - Minimal harm or other day for heart failure. potential for actual harm

Review of Resident 10's December 2024 and January 2025 MAR diuretic documentation showed 10 of 30 Residents Affected - Some scheduled doses were not administered and the lidocaine patch on 01/27/2025 was not administered.

Review of the Medication Administration note dated 01/27/2025 at 10:51 AM showed the pain patch was not available to administer.

Review of the Medication Administration note dated 01/27/2025 at 10:54 AM showed the diuretic medication was not available. The documentation did not show they notified the physician.

Review of the clinical record did not show a medication reconciliation was conducted on readmission.

In an interview on 02/13/2025 at 1:10 PM, Staff D, Physician, stated they were not aware the medications were not available and or that they missed 10 doses of their diuretic medication.

In an interview on 02/13/2025 at 1:44 PM, Staff C, Registered Nurse-RN, Resident Care Manger-RCM, stated the nurse should have contacted the physician to notify them the medication was not available. Staff C was not able to locate documentation to show the physician was notified.

<RESIDENT 38>

Review of the 01/29/2025 Admission MDS showed Resident 38 admitted to the facility on [DATE REDACTED]. They had severe cognition problems, required maximum assistant with ADLs, and was incontinent. Resident 38 had no behaviors and diagnoses included surgical repair of a hip fracture, dementia, difficulty swallowing, and knee pain. Resident 38 received antipsychotic and antidepressant medications.

Review of Resident 38's hospital After Visit Summary (AVS) physician orders dated 01/23/2025 showed instructions to STOP giving five different medications: Seroquel (the antipsychotic medication), bethanechol, loratadine, Miralax, and senna-doss.

Review of Resident 38's January 2025 MAR showed orders dated 01/23/2025 for the five medications they were ordered to STOP taking according to the AVS. The documentation showed the medications were administered.

Review of the clinical record did not show a medication reconciliation was completed on admission or orders were clarified.

In an interview on 03/19/2025 at 12:40 PM Staff C, stated the nurse entering the admission orders should have clarified the Seroquel with the physician. Staff C was unable to locate a medication reconciliation completed on admission.

<RESIDENT 14>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Review of Resident 14's Admission MDS dated [DATE REDACTED] showed they admitted [DATE REDACTED] and had diabetes with long-term use of insulin. Level of Harm - Minimal harm or potential for actual harm Review of Resident 14's hospital physician Discharge Summary dated 12/30/2024 showed they started a long-acting insulin 5 units every day at bedtime for diabetes on 12/25/2024 and they required insulin while on Residents Affected - Some steroids.

Review of Resident 14's Hospital MAR showed they received the long-acting insulin, and a sliding scale insulin as needed before meals and at bedtime.

Review of Resident 14's Skilled Nursing Facility Transfer Orders dated 12/30/2024 showed orders for:

-An oral diabetic medication 500mg tablet-two tablets (1000 mg) twice daily for diabetes.

-Blood sugar checks before each meal and at bedtime (AC & HS).

-A steroid medication daily.

-No insulins orders were on the discharge medication list.

Review of the Resident 14's December 2024 MAR showed the oral diabetic medication was transcribed incorrectly on admission as 500 mg-one table twice daily and administered on 12/30/2024 at 4:00 PM and 12/31/2024 at 8:00 AM (a transcription error). The MAR also showed the blood sugar checks were transcribed for every six hours, not AC & HS as ordered.

Review of Resident 14's clinical record did not show a medication reconciliation was completed on admission including clarification of Resident 14's insulin orders.

Review of Resident 14's January 2025 MAR showed a physician's order dated 01/02/2025 to administer sliding scale insulin four times a day and was scheduled for every six hours (12:00 AM, 6:00 AM, 12:00 PM, 6:00 PM), not AC&HS. On 01/09/2025 the order times were changed AC&HS (7:30AM, 11:30AM, 4:30 PM and 9:00 PM).

Review of Resident 14's Medication Administration Audit Report and blood sugar record documentation showed:

-On 01/09/2025 at 9:00 PM their blood sugar was 281 and four units of insulin were administered on 1/10/2025 at 4:36 AM, over seven hours after the blood sugar.

-On 01/10/2025 at 4:30 PM their blood sugar was 288 and four units of insulin were administered at 6:15 PM (almost two hours after the blood sugar was taken and after dinner was served).

-On 01/10/2025 at 9:00 PM their blood sugar was 290 and four units of insulin were administered on 01/11/2025 at 12:08 AM, three hours after bedtime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 In an interview on 02/13/2025 at 9:35 AM, Resident 14's Responsible Party, Resident R14-RP, stated Resident 14 blood sugars were poorly controlled and they were supposed to be on insulin but were not when they Level of Harm - Minimal harm or admitted . Resident R14-RP stated they notified the facility of their concerns regarding diabetic management and potential for actual harm medications but did not believe they were heard. Resident R14-RP stated family was always present for mealtimes.

They observed nurses administer Resident 14 insulin without checking their blood sugar before the insulin Residents Affected - Some administration, especially at breakfast. When they questioned the staff, the staff reported the blood sugar was already checked. Some nurses brought their insulin way after the meal, sometimes over an hour.

<RESIDENT 8>

Review of Resident 8's Hospital Continuum of Care Orders, dated 12/25/2024, showed orders for tube feeding administration that started at 4:00 PM and stopped at 8:00 AM, orders for a long-acting insulin 10 units daily and to hold if fasting (not eating), and blood sugar checks every six hours with sliding scale insulin coverage. Resident 8 also had orders for continuous oxygen.

Review of the Resident 8's December 2025 MAR/TAR documentation showed:

-A 12/25/2024 physician order for long-acting insulin 10 units one time a day and hold if blood sugar was less than 100. The long-acting insulin was scheduled for 7:30 AM, 30 minutes before the tube feeding was stopped for eight hours.

-A 12/25/2024 physician order for blood sugar checks and sliding scale insulin scheduled for AC& HS, not every six hours as ordered. The MAR documentation showed Resident 8 received insulin at

-No orders for continuous oxygen.

Review of the clinical record did not provide documentation to show the facility conducted an admission medication reconciliation or clarification of orders.

In an interview on 02/13/2025 at 1:35 PM, Staff D stated it was their expectation the nurses conducted a thorough medication reconciliation on admission, called the physician when clarification was needed, when medications were not available, and for medication errors.

<RESIDENT 17>

Review of a Medication Administration Note dated 01/31/2025 at 9:03 AM showed their Advair inhalant medication (for the treatment of chronic respiratory disease) was not available. The documentation showed

they reordered it from the pharmacy and were told it was already filled the week prior on 01/23/2025. The nurse requested the pharmacy to fill another prescription and bill the facility. The documentation did not show

the provider was notified.

LATE MEDICATION ADMINISTRATION & DOCUMENTATION:

<RESIDENT 23>

In an interview on 02/13/2025 at 4:00 PM, Resident 23 stated they did not receive their medications on time, and sometimes did not get them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Review of Resident 23's February 2025 MAR showed they had end-stage kidney disease and went to dialysis three times a week. Review of the physician order dated 02/09/2025 showed orders for a phosphate Level of Harm - Minimal harm or binder (a medication taken with meals for residents who have end-stage kidney disease) scheduled every potential for actual harm day at mealtimes (at 8:00 AM, 12:00 PM, and 5:00 PM). The documentation showed the 12:00 PM doses on 02/10/2025 and 02/12/2025 were not administered-they were out at dialysis. Residents Affected - Some

Review of Resident 23's Late Medication Administration Report showed they received the scheduled phosphate binder (due at 5:00 PM) more than two hours after the meal on 02/04/2025, 02/05/2025, 02/13/2025, 02/14/2025, 2/15/2025, 02/16/2025, 02/17/2025, 02/19/2025, 02/21/2025, 02/24/2025, 02/26/2025, 02/27/2025, 02/28/2025.

<RESIDENT 34>

Review of Resident 34's clinical census showed they admitted to the facility on [DATE REDACTED] and transferred to the hospital 02/13/2025.

Review of Resident 34's January and February 2025 MARs showed orders for sliding scale insulin before meals and bedtime, a routine combination insulin 70/30 (fast acting and medium acting) 10 units in the morning and at bedtime, a diuretic in the morning and early evening hours, and routine acetaminophen (pain reliever) in the morning and early evening hours.

Review of Resident 34's Late Medication Administration Report (of greater than one hour) between 01/01/2025 and 02/13/2025 showed Staff RR, LPN, consistently documented [they] administered all Resident 34's medications at the same time on each of two Day shifts and 12 Night shifts they worked in January 2025 and five Night shifts in February 2025.

In an interview on 02/20/2025, Staff KK, LPN, stated the professional standards of medication administration included the Right time and Right documentation (along with Right medication, dose/frequency, and route) and nurses were expected to follow a consistent safe process for medication administration to prevent medication errors.

Similar findings for .

<RESIDENT 10>

Review of Resident 10's MAR showed: early evening orders for a diuretic, a muscle relaxer for pain management, an anti-anxiety medication (scheduled three times a day), a routine pain reliever gel; and bedtime scheduled orders for a muscle relaxer, anti-anxiety medication, potassium and magnesium supplements, and a routine pain reliever gel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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

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

F 0760 Review of Resident 10's Late Medication Administration Report for February 2025 showed Staff RR documented Resident 10's early evening ordered medications as administered at the same time as their late Level of Harm - Minimal harm or evening medications or was over an hour late with medication administration on: 02/01/2025, 02/05/2025, potential for actual harm 02/06/2025, 02/07/2025, 2/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/16/2025, 02/17/2025, 02/18/2025, 02/19/2025, 02/22/2025, 02/24/2025, 02/25/2025, and 02/28/2025. The report also showed Staff Residents Affected - Some SS, LPN, administered Resident 10's early evening ordered medications as administered at the same time as their late evening medications, or was late with medication administration over two hours on: 02/03/2025, 02/08/2025, 02/09/2025, 2/14/2025, 02/20/2025, 02/21/2025, 02/26/2025, 02/27/2025.

<RESIDENT 15>

Review of Resident 15's February MAR showed orders for early evening administration of two different seizure medications and bedtime medications that included blood pressure medications.

Review of Resident 15's Late Medication Administration Report for February 2025 showed Staff RR documented Resident 15's early evening ordered medications as administered at the same time as their late evening medications or was over an hour late with medication administration on: 02/01/2025, 02/05/2025, 02/06/2025, 02/07/2025, 2/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/16/2025, 02/17/2025, 02/18/2025, 02/19/2025, 02/22/2025, 02/24/2025, 02/25/2025, and 02/28/2025.

The facility was cited

F-F760 Residents are Free of Significant Med Errors:

During an interview on 03/04/2025 at 2:11 PM, when asked if the facility had any active Performance Improvement Projects (PIPs) Staff A, Administrator stated they had PIPs for their three citations they received in January 2025 including but not limited to: Significant Medication Errors for not having medications available. Staff A was asked if the QAPI committee had identified any concerns regarding their new resident admission process, Staff A stated they developed a new admission check list.

Review of the facility history showed the facility failed to ensure administration of a prescribed respiratory medication (a medication used to treat breathing problems) and received a citation 01/22/2025. The facility alleged compliance on 01/27/2025.

The facility did not identify their failure to ensure newly admitted resident's medications were readily available

in a timely manner upon admission and the orders were accurate, complete, and reconciled.

2. Refer to CFR: S483.25(g)(1)

F-F940 Training Requirements:

In an interview on 03/04/2025 at 1:21 PM, Staff P, Staff Development Coordinator, shared the tracking tools used by the facility. The hours were not tracked annually and Staff P had to add up the hours for each staff reviewed.

During an interview on 03/04/2025 at 2:11 PM, Staff A stated the trainings were logged and they kept track of

the hours. Staff A stated they expected the facility to meet the required annual in-service hours for CNAs.

The facility did not self-identify they were not in compliance with the training requirements.

REFERENCE: WAC 388-97-1760(1)(2).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or 46472 potential for actual harm Based on interview and record review, the facility failed to ensure staff were educated on all required topics Residents Affected - Some specified on their Facility Assessment for 4 of 4 sampled staff (Staff Q, R, S & T) reviewed for annual education and training. Failure to ensure staff received required trainings placed residents at risk for unmet care needs, inadequate quality of care, and diminished quality of life.

Findings included .

Review of the facility assessment, dated 02/27/2025, showed the following trainings were provided to staff annually:

-Resident Rights and Facility Responsibilities - ensured staff members were educated on the rights of the resident and the facility's responsibility to provide proper quality care.

-Change of Condition - ensured staff were educated on how to identify a resident's change of condition including: including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.

-Person-Centered Care Competencies - the delivery of personalized care that aligned with the residents' goals and professional standards.

-Activities of Daily Living Competencies

Review of employee files showed Staff Q, Nursing Assistant Certified (NAC) was hired 01/24/2024.

In an interview and record review on 03/04/2025 at 1:21 PM, Staff P, Staff Development Coordinator, reviewed the facility's training records and stated Staff Q did not have Resident Rights training. Staff P was unable to find documentation to support Staff Q had been educated on Identification of resident changes in condition, I don't see that. Staff P was unable to find a completed competency for Person-centered care and added, I don't know what that is. Staff P was unable to find documentation that Staff Q completed a competency for Activities of Daily Living.

During an interview on 03/04/2025 at 2:11 PM, when asked regarding the trainings listed on the Facility Assessment, Staff A, Administrator stated the training was provided based on a calendar of annual of required trainings.

During an interview on 03/04/2025 at 3:30 PM, Staff Z, Regional [NAME] President of Clinicals, stated they created the in-service calendar to ensure mandatory trainings were conducted as planned. The calendar was requested and not provided.

In addition, training records were requested for Staff R, NAC, (hired 03/29/2022), Staff S, NAC, (hired 09/21/2023), and Staff T, NAC, (hired 12/01/2023) to show they received the required annual training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 0940 During an interview on 03/04/2025 at 4:34 PM, Staff Z, stated that Staff P was not able to find competencies for the requested staff. Level of Harm - Minimal harm or potential for actual harm REFERENCE: WAC 388-97-1680.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 46472

Residents Affected - Some Based on interview and record review, the facility failed to ensure 4 of 4 Certified Nursing Assistants (CNAs) (Staff Q, R, S, & T) were provided mandatory Quality Assurance and Performance Improvement (QAPI) training. Failure to ensure staff received the required QAPI training, which included how to communicate concerns, problems, or opportunities for improvement placed residents at risk for unmet care needs, unsafe environment, and diminished quality of care/quality of life.

Findings included .

In an interview on 03/04/2025 at 12:15 PM, Staff R, CNA, stated they did not know what the QAPI committee was or what QAPI meant. Staff R stated if they had concerns they told their nurse.

In an interview and record review on 03/04/2025 at 1:21 PM, Staff P, Staff Development Coordinator reviewed the facility's training records and stated Staff Q did not have QAPI training.

During the interview Staff P was not able to provide a carriculum for QAPI training, but did say the facility trained staff on Stop and Watch, directing staff that if they see something to report it and put a note in the computer.

The facility was unable to provide documentation to show Staff R, NAC, (hired 03/29/2022), Staff S, NAC, (hired 09/21/2023), and Staff T, NAC, (hired 12/01/2023) recieved the required annual training.

Reference WAC 388-97-1680 (2) (a)(b)(ii).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 64 505483

F-F944 QAPI Training.

REFERENCE: WAC 388-97-1620.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 64 505483 Department of Health & Human Services Printed: 09/04/2025 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 505483 B. Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 46472

Residents Affected - Many Based on interview and record review, the facility failed to have an effective Quality Assurance/Performance Improvement (QAPI) Committee that self-identified deficient practices, and/or implemented corrective action for identified deficiencies. The failure to utilize the facility's QAPI procedures to sustain compliance with regulations for the facility, placed residents at risk for adverse events, unsafe conditions, delay in necessary care and services, and a diminished quality of care/quality of life.

Findings included .

Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, revised March 2020, showed that quality of care deficiencies was identified through feedback and data, and would undergo appropriate corrective action. Corrective actions were monitored against established goals and benchmarks by the QAPI committee.

1. Refer to Code of Federal Regulations (CFR): S483.45(f)(2)