The Honorable Mary Jo Hesten Chapter 11 UNITED STATES ...The Honorable Mary Jo Hesten Chapter 11...

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The Honorable Mary Jo Hesten Chapter 11

PCO’S FIRST REPORT - 1

FREEMAN LAW OFFICE 1725 NW Market St. #219

Seattle, WA 98108 (206) 491-8843

UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF WASHINGTON

In re:

PNW HEALTHCARE HOLDINGS, LLC, et al.1

Debtors.

Chapter 11 Lead Case No. 19-43754-MJH (Jointly Administered) PATIENT CARE OMBUDSMAN’S FIRST REPORT

Pursuant 11 U.S.C. § 333(b)(2), Patricia Hunter, the Washington State Long-Term Care

Ombudsman, in her capacity as the Patient Care Ombudsman (PCO) for this matter, hereby files

the PCO’s First Report.

1 The debtors and debtors-in-possession in the above-captioned, jointly administered chapter 11 bankruptcy proceedings, along with the last four digits of each Debtor’s federal tax identification number, are: PNW Healthcare Holdings, LLC (9801); North Auburn Health, LLC dba North Auburn Rehabilitation & Health Center (3159); Sequim Health, LLC dba Sequim Health & Rehabilitation (7737); Bremerton Health, LLC dba Bremerton Convalescent & Rehabilitation Center (3188); Crestwood Convalescent-Port Angeles, LLC dba Crestwood Health & Rehabilitation Center (6565); Fir Lane Health-Shelton, LLC dba Fir Lane Health & Rehabilitation Center (7798); Forest Ridge Health-Bremerton, LLC dba Forest Ridge Health & Rehabilitation Center (4019); Meadow Park Health-St Helen, LLC dba Meadow Park Health & Specialty Care Center (9109); Cherrywood Place-Spokane, LLC dba Cherrywood Place (7776); Riverside Nursing-Centralia, LLC dba Riverside Nursing & Rehabilitation Center (3792); PNW Master Tenant I, LLC (9824); Franklin Hills Health-Spokane, LLC dba Franklin Hills Health & Rehabilitation Center (1763); Aldercrest Health-Edmonds, LLC dba Aldercrest Health & Rehabilitation Center (3827); PNW Master Tenant II, LLC (5319); Gardens on University-Spokane Valley, LLC dba The Gardens on University (1917); Puget Sound Healthcare-Olympia, LLC dba Puget Sound Healthcare Center (4419); Care Center East Health-Portland, LLC dba Care Center East Health & Specialty Care Center (8950); LaCrosse Health-Coeur d’Alene, LLC dba LaCrosse Health & Rehabilitation Center (8594); Ivy Court-Coeur d’Alene, LLC dba Ivy Court C (1265); and CRN Pool, LLC (9083) (collectively, “debtors”).

Case 19-43754-MJH Doc 322 Filed 02/11/20 Ent. 02/11/20 23:36:51 Pg. 1 of 35

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Seattle, WA 98108 (206) 491-8843

I. GENERAL INFORMATION REGARDING ALL FACILITIES

A. Primary Goals of First Reporting Period

As PCO, the primary goal during this period was to conduct at least one in-person

monitoring visit in each facility. This goal included observing the physical structures, meeting

leadership and staff, and hearing from residents and residents’ representatives, including family

members and other visitors, and legal decision-makers. Additional monitoring activities

included interviewing major department heads, observing meals, including both lunch and dinner

in all facilities except three, reviewing nursing staffing levels, reviewing resident and family

council meeting minutes, and reviewing state enforcement records.

B. Sources of Information

Information for this report was obtained from a variety of individuals and documents

with an eye toward providing consistent information across facilities wherever possible.

However, it is important to know what the “work day” (or night) looks like in a nursing facility.

Administrative staff who have offices are, understandably, not necessarily in that office all day.

Individuals may or may not be present in the facility on the day of a monitoring visit. Schedules

and availability can easily change based on a variety of factors, including the needs of residents.

Shifts change regularly and staff are on the go. Moreover, as with any complex operation, no

one person “knows everything.”

Interactions with non-employees in facilities also vary depending on the day or time. A

resident may want to speak with you at that moment, or not. A family member may demand

your attention on an unplanned basis. All interactions can lead to greater understanding of the

quality of care for residents, but the information is, by nature, not available all at once and not


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Seattle, WA 98108 (206) 491-8843

available consistently across facilities. This explanation is provided to explain any gaps that may

appear when information appears to be provided about one facility and not another.

C. Confidentiality Measures

Throughout this report, certain terms are used somewhat interchangeably, such as

“issues,” “concerns,” and “grievances.” These terms pertain to information usually shared with

the PCO verbally, whether by residents, resident representatives, staff, administrators, managers,

or local LTC Ombudsmen. The term “complaint” as used in this report2 refers to complaints

received by the relevant LTC Ombudsman Program, which has duties under state and federal

laws to identify, investigate, and resolve “complaints” brought by or on behalf of long-term care

residents with regard to the resident’s health, safety, welfare, or rights.

As with any operation with high stakes, such as health and safety, many individuals fear

retaliation for speaking out. Therefore, the information provided in this report with regard to

issues, concerns, grievances, and complaints are not attributed to any one person. I share

information in this report that I have a good faith belief to be true. In this first reporting period,

there was no need to review confidential documents and none were reviewed.

D. Areas of PCO Concern

The PCO and the state licensing entity are aware of concerns involving vendors, utilities,

and external support factors that may affect resident care during bankruptcy. Based on this first

reporting period, three areas are of particular concern are set forth below.

2 The term complaint is also used occasionally throughout this report to discuss government complaint investigation and enforcement, which is an entirely separate process from the complaint processing done by LTC Ombudsman Programs.


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Seattle, WA 98108 (206) 491-8843

1. Nursing staffing

Monitoring activities have given rise to concerns about nursing staffing levels, and

training and supervision of nursing staff as it relates to resident care.

2. Recommendation re dietary and food services

Monitoring activities have revealed that several of the facilities do not consistently have

appropriate and adequately functioning kitchen equipment and tools, which are particular

important for residents who have missing or false teeth or special diets. This resource issue

negatively impacts the quality and quantity of food available to residents, in turn potentially

impacting the nutrition and dietary needs of residents as well as their overall quality of life and

of care in the facilities.

The PCO recommends the debtor facilities conduct a needs assessment of facility

kitchens and develop a plan to address faulty, broken, or missing equipment and fixtures needed

to meet the needs of all residents, and to provide nutritious, quality meals, beverages, and snacks

including special diets.

3. Adequate resources

The PCO understands that bankruptcy is intended to allow the debtors to reorganize their

business operations and resources. Care must be taken to ensure that resources are adequately

available and used to address building operations, needed repairs, daily operations, and safety

concerns and equipment.

4. New leadership

As I understand, residents and staff at these facilities have gone through two sales and

one bankruptcy already. New leadership is in place in many of the facilities. Many positions

have been newly filled in the last eight months. While turnover is a natural part of any business


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operation, changes in personnel that are too frequent or regularly ongoing can have a particularly

negative impact on the healthy, safety, welfare, and rights of vulnerable adults who live in long-

term care facilities.

5. Closure process and impacts

The PCO is aware of legal disputes among the debtors and creditors regarding the

likelihood of new operators or owners for the facilities. While the PCO is not currently in a

position to opine on this legal dispute, it is important to at least briefly highlight what is needed

when a long-term facility closes. Facility closure requires communication and coordination with

numerous individuals and agencies, including state and federal regulatory bodies, residents and

their representatives, unions, vendors, providers, attorneys, and other advocates. Months of

preparation and planning are needed. Vulnerable residents—along with their personal

belongings, funds kept with the facility, social and medical records, and any specialized medical

equipment— must be appropriately transferred to new locations that are safe and appropriate.

The phenomenon of “transfer trauma” is a real threat for residents who may have serious

difficulty in relocating due to disability or disease and loss of relationships and familiar

surroundings.

Closures can be particularly difficult for Medicaid-funded residents. Locating a

“Medicaid” bed can be challenging because Medicaid contracted providers are not required to

accept potential residents. At current, Washington State is experiencing a number of nursing

homes that are closing for various reasons with one common reason being that Washington State

Medicaid reimbursement rates being historically too low, and not meeting provider costs.

Additionally, workforce labor issues in Washington State make it difficult to find adequate


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Seattle, WA 98108 (206) 491-8843

skilled labor to meet the needs of residents. This is not strictly a regional problem as urban and

rural providers have experienced difficulty in obtaining qualified workers.

II. FACILITY OVERVIEWS

With the exception of Cherrywood Assisted Living, all facilities listed below are skilled

nursing facilities.

A. Explanation of Information in this Section

The bulk of this report is dedicated to providing an individual overview for each facility,

including the dates of the PCO’s monitoring visits and any additional monitoring visit by

certified long-term care ombudsmen who then reported to or shared information with the PCO.

Below is a general explanation of the information provided for each facility listed in this section.

1. Population and Payment

Information is provided for the total number of beds in each facility, the “census” at the

monitoring visit, which means the number of residents living in the facility on the date of the

visit, and the major sources of payment if known. Two government programs pay for the

majority of care in nursing facilities—Medicare and Medicaid. The Medicare program pays at

higher rates than Medicaid, but Medicare is generally available for a shorter amount of time,

such as for rehabilitation after a hospital stay. Medicaid pays at a lower rate but is available for

“long-term” extended stays in nursing facilities. Medicaid is a needs-based program, meaning

that income and resource limits apply to anyone seeking Medicaid-funded nursing facility

services.


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2. Facility and Environment

The information provided in this subsection pertains to observations and information

obtained about the facility’s physical appearance, general environment, and equipment or

supplies.

3. Resident Care

The subsections on resident care provide an overview of grievances and concerns from

residents or their representatives, whether shared with the PCO directly, or reviewed in

documents such as the minutes of resident or family council meetings. The subsections on

staffing draw upon interviews with administrators and other employees, as well as publicly

posted information regarding nursing staffing levels.

Of note, the debtors did recently hire their own pool of Physical Therapists and Rehab

specialists across the state for all facilities. The debtor facilities also contract with Healthcare

Services Group (HCSG) to provide food, laundry, and housekeeping services.

4. Staffing

The subsections on staffing draw upon interviews with administrators and other

employees, as well as documents including department head rosters, and publicly posted

information regarding nursing staffing levels.

5. CMS Ratings, Licensing, and Enforcement—including the CMS “Red Abuse Icon”

CMS offers a website called Nursing Home Compare, which uses a “Five-Star Quality

Rating System” to provide consumers information about nursing facilities around the country.3

3 Individual nursing facilities can be searched at https://www.medicare.gov/nursinghomecompare/search.html. Information on the data used in the rating system can be found on the Nursing Home Compare website at https://www.medicare.gov/NursingHomeCompare/About/howcannhchelp.html. A technical user’s guide is also available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.


https://www.medicare.gov/nursinghomecompare/search.html

https://www.medicare.gov/NursingHomeCompare/About/howcannhchelp.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf


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This report provides the current star ratings for each facility in the main star-rating areas used on

the Nursing Home Compare website: Overall, Staffing, Health Inspection, and Quality

Measures.

Several facilities in this matter have received CMS’s “red alert icon.” As stated in

relevant part on the CMS website:

As you know, nursing home quality can vary. That’s why we added a new feature on Nursing Home Compare to allow you to tell if a nursing home has been cited for issues related to nursing home abuse or neglect.

Now when you use Nursing Home Compare, you’ll see a red alert icon if a facility has been cited for nursing home abuse that led to harm within the last year, or potential harm of a resident within the last two years. Each month, we’ll review nursing home inspection reports and will update the alert icons to make sure you have the most recent information on nursing home abuse.4

It should be noted that over sixty percent of all nursing facilities in Washington have this

relatively new icon from CMS. This icon does not mean that the debtor facilities are worse or

better than other Washington nursing facilities. Nor does it mean that Washington state nursing

homes are worse than other states’ facilities when it comes to abuse. Washington State has a

robust program for nursing facility licensing, surveillance, and enforcement.

The red alert icon, however, is a helpful tool meant to prod consumers into doing their

own research. Unfortunately, this research can be incredibly time-consuming. To truly get to

the bottom of a red alert icon, in order to make an independent assessment, one must make a

deep dive into licensing records. While no type of “abuse” is acceptable, a red abuse icon might

4 Medicare.gov Blog, New Feature Helps You Compare Nursing Home Safety, Oct. 23, 2019, https://www.medicare.gov/blog/nursing-home-abuse (last visited Feb. 11. 2020). For additional information on the red alert icon, see The Center for Medicare Advocacy, Nursing Home Compare’s Abuse Icon is Now Live https://www.medicareadvocacy.org/nursing-home-compares-abuse-icon-is-now-live/ (last visited Feb. 11, 2020) (stating in part that “the absence of an abuse icon . . .does not necessarily indicate the absence of abuse”).


https://www.medicare.gov/blog/nursing-home-abuse

https://www.medicareadvocacy.org/nursing-home-compares-abuse-icon-is-now-live/

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indicate an isolated event of “resident to resident aggression.” For any given investigation by a

licensing authority, multiple documents must be analyzed and compared against one another

with regard to specific dates and individual findings. An event might occur outside the reporting

period but not investigated until much later, or resolved even later still. If specifically ordered by

the Court, the PCO would investigate the underlying basis for the red alert icon at each facility

monitored. Without specific court direction, however, the PCO does not believe it a prudent use

of time to do so.

Where available, information is also provided regarding deficiencies found by regulatory

bodies, including information on severity and scope.5

6. Complaints to PCO/LTC Ombudsman Program

This subsection provides basic information on the number and types of complaints

received by the PCO or the applicable LTC Ombudsman Program, whether in Washington,

Idaho, or Oregon. Because complaint resolution and investigation are the functions of a LTC

Ombudsman and not a Patient Care Ombudsman, the PCO did not attempt to investigate or

resolve complaints that were received in the course of fulfilling PCO duties. Instead, the PCO

referred any such complaints to the relevant LTC Ombudsman Program, whether a Regional

Program in Washington or the State LTC Ombudsman Programs in Idaho and Oregon,

respectively. Still, in receiving any such complaint, the PCO was able to communicate with

residents, their representatives, and others to get a sense of the quality of care in the facilities.

As needed, the PCO seeks and obtains follow-up information from the relevant LTC

5 The severity and scope of deficiencies is explained WAC 388-97-4500. Severity and scope is also explained in A technical user’s guide to the Five-Star Quality Rating System, which is available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.


https://app.leg.wa.gov/wac/default.aspx?cite=388-97-4500


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Ombudsman Program handling the complaint. The PCO did bring some concerns, none

egregious, to the attention of administrators and executive leadership.

B. Aldercrest Health & Rehabilitation Center

Aldercrest Health & Rehabilitation Center (“Aldercrest”) is located at 21400 72nd Ave

W, Edmonds, WA 98026. The PCO monitoring visit took place on January 2, 2020. Additional

monitoring visits were conducted by a Regional LTC Ombuds who reports directly to the PCO.

1. Population and Payment at Aldercrest

Aldercrest has 128 beds. The census on the monitoring visit was 70. The majority

payment source is Medicaid.

2. Facility and Environment of Aldercrest

Aldercrest is situated in an older building. The Aldercrest facility has gone through

several changes in operators over the past five years or so. Aldercrest’s van appears to have been

out of order since the beginning of summer 2019. No additional information is available at this

time as to possible repair or replacement. Once shower was out of order on the date of the

monitoring visit, but has since been fixed.

3. Resident Care at Aldercrest

Aldercrest has limited access to activities outside of the building due to the facility’s van

being out of order since the beginning of summer 2019. Other concerns at Aldercrest include

lack of showering/bathing due to staff being too busy and one shower being out of order;

however, the shower was reported to be fixed as of the date of this report.


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The food choices made by residents at Aldercrest were not always provided on the trays

given to residents. The quantity of snacks available throughout the day and night at Aldercrest

was insufficient.

4. Staffing at Aldercrest

Aldercrest’s management positions are not fully staffed. The director of nursing is an

interim placement. Most mangers at Aldercrest have been in place less than six months.

Staffing seems to be improving slowly, though it is fluctuating. The Aldercrest administrator

presents as being very vested in making the needed improvements to ensure quality of care and

life for all of its residents.

The interim Director of Nursing at Aldercrest was called to work as a Cornerstone “pool

nurse” at another facility from January 6-9, 2020 during that facility’s state survey inspection.

This left Aldercrest with just one Resident Care Manager (RCM), whereas there are usually two

to three RCMs. Aldercrest is also reported to be down one or two staff registered nurses. The

administration, staff, and residents reported a history of nurse staffing problems. However, all

report that staffing levels at Aldercrest are improving and not worsening since the bankruptcy

filing.

5. CMS Ratings, Licensing, and Enforcement at Aldercrest

Aldercrest has a “red alert icon” on the Nursing Home Compare website. In addition,

Aldercrest has the following CMS star ratings: Overall is one star; Health inspection is one star;

Staffing is three star; and Quality measures is two star.

A review of the state’s licensing enforcement records available to the LTC Ombudsman

Program, show two level G citations and one level D citation at Aldercrest during the last year.


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There were no new reports from the regulatory agency in the public file during this first reporting

period known to the PCO or to the LTC Ombudsman Program.

6. Complaints to PCO/LTC Ombudsman Program regarding Aldercrest

Four complaint investigations were received into the local ombudsman program during

the reporting period and remain open at current time. Complaint types are related to telephone

access, nurse staffing levels, quality of care, and safety of residents. Three of these complaints

are also being investigated by the state licensing entity.

7. Recommendations for Aldercrest

The PCO recommends that Aldercrest develop a plan to: address the fluctuations in

nurse staffing levels; obtain a full time Director of Nursing and Resident Care Manager to meet

the needs of residents; allow for use of contracted agency staff when needed; and provide

adequate training for agency and new hires. If Aldercrest’s staffing issues cannot be stabilized, it

is paramount that potential residents are carefully reviewed and approved by skilled clinical staff

and in collaboration with the Aldercrest Administrator.

C. Bremerton Convalescent & Rehabilitation Center

Bremerton Convalescent & Rehabilitation Center (“Bremerton”) is located at 2701 Clare

Ave, Bremerton, WA 98310. The PCO monitoring visit took place on January 21, 2020.

1. Population and Payment at Bremerton

Bremerton has 125 certified beds. The census on the monitoring visit was 94. The

majority payment source is unknown at this time.

2. Facility and Environment of Bremerton:

The Bremerton facility is situated in an older building with uneven terrain and a steep

driveway.


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3. Resident Care at Bremerton

The PCO received several grievances about the quality and quantity of food available to

the residents, and the accuracy of resident choices and preferences. The residents would like to

have more communication with the administrator to hear their concerns and have them

addressed. No hydration stations such as coffee, tea and ice water were seen available for the

residents to access independently. Residents report being hungry at night and not having access

to enough snacks. All of these concerns were brought to the administrator at the end of the

monitoring visit. No concerns were expressed about direct care or nursing care.

4. Staffing at Bremerton

The administrator at the time shared that finding nursing assistants (NAC) is challenging

and that she has several positions open on the day of the visit. The administrator (who was hired

about one year ago has since been replaced and is no longer at Bremerton Convalescent) shared

that she offers pay incentives and recruitment bonuses. The facility also offers nursing assistant

certification classes. On the day of the visit the nursing staffing is: RN-60 hours; LPN/LVN-48;

and NACs-217.5 hours.

5. CMS Ratings, Licensing, and Enforcement at Bremerton

Bremerton has the following CMS star ratings: Overall is one star; Health inspections is

one star; Staffing is two star; and Quality Measures is three star. The state licensing entity public

file shows a full health survey inspection ended on November 25, 2019. Two deficiencies were

found at levels F and K scope and severity.


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6. Complaints to PCO/LTC Ombudsman Program regarding Bremerton

The PCO will make a referral to the Kitsap Long-Term Care Ombudsman Program

regarding food service, quality and quantity and resident choice and preferences. No other

complaints received into the long-term care ombudsman program during the reporting period.

7. Recommendations for Bremerton

The PCO recommends that the new administrator review Quality Assurance and

Performance Improvement (QAPI) goals to include concerns about food and snacks. Also

suggest that administrator assure that grievance procedures are in place.

D. Cherrywood Place

Cherrywood Place (“Cherrywood”) is located at 100 East Dalke Ave, Spokane, WA

99208. The PCO monitoring visit took place on January 29, 2020.

1. Population and Payment at Cherrywood

Cherrywood has 52 beds. The census on the monitoring visit was 44. The majority


2. Facility and Environment of Cherrywood

Cherrywood is licensed as an assisted living facility (ALF) and is the only assisted living

facility in the bankruptcy.

3. Resident Care at Cherrywood

The PCO received concerns and grievances regarding the lack of activities being offered

and lack of outdoor group activities. Additionally, concerns were expressed about damaged and

missing clothes. Multiple concerns were expressed about a lack of attention, respect, dignity and

poor attitudes about residents by facility staff.


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4. Staffing at Cherrywood

At time of the monitoring visit, the administrator has been in her role for about two years.

Total number of employees is fourteen. The facility relies on one part-time RN nurse delegator.

The Administrator does most of the care planning and some of the care assessments. The

activities director is full time but only does activities part time-as has other job responsibilities

related to management and operations.

5. Licensing and Enforcement at Cherrywood

As an assisted living facility there is no federal oversight or certification by CMS.

During this reporting period the state licensing entity identified failed provider practice during a

survey of the facility. No harm to residents was found.

6. Complaints to PCO/LTC Ombudsman Program regarding Cherrywood

There were seven complaints received into the Spokane long-term care ombudsman

Program. Complaint types are Autonomy, Choice and Rights; Financial Property; Care and

Environmental. All but one complaint remains open and still active. The PCO brought

concerns about laundry and activities to the administrator on the day of the visit. The

administrator shared that a faulty dryer was the cause of the damaged clothing and a new dryer

had been ordered.

The PCO has made a referral to the local ombudsman program to investigate concerns

regarding food quality, care services, and unresponsiveness to resident requests.

7. Recommendations for Cherrywood

The PCO recommends additional staffing be hired and more nurse delegation hours to

meet the needs of residents.


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E. Crestwood Health & Rehabilitation Center

Crestwood Health & Rehabilitation Center (“Crestwood”) is located at 1116 E Lauridsen

Blvd, Port Angeles, WA 98362. The PCO monitoring visit took place on January 3, 2020.

1. Population and Payment at Crestwood

Crestwood has 101 beds. The census on the monitoring visit was 82. The majority


2. Facility and Environment of Crestwood

Crestwood is set in a spacious older building from the 1960s or 70s with lots of light. It

appeared well organized and clean during the monitoring visit.

3. Resident Care at Crestwood

The PCO observed some residents appearing disheveled. The residents were in clothing

that was ill-fitting and not clean. One resident using a wheelchair went most of the day without

socks or shoes. Concerns pertained to staffing levels.

The PCO observed that lunch was served approximately 30 minutes late. Residents

waiting in the dining room received proper attention, including the offer of beverages while they

waited. Late meal service is not unusual but improving on service times, per staff and residents.

It was reported that the administration and the director of nursing are working to resolve late

meal delivery, which is due to a lack of staff.

4. Staffing at Crestwood

At time of the monitoring visit, the interim director of nursing was transitioning out of the

facility. The new director of nursing was in training and waiting for state licensure. Otherwise,

all management positions were fully staffed. The administrator was hired one week before the

bankruptcy was announced in 2019. As of the day of filing this report, the PCO was informed


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that the Administrator is no longer with Crestwood and possibly has transferred to another debtor

facility. The new administrator at Crestwood was previously an assistant administrator at Sequim

Health and Rehabilitation Center.

5. CMS Ratings, Licensing, and Enforcement at Crestwood

Crestwood has a red alert icon on the CMS website. In addition, Crestwood has the

following CMS star ratings: Overall is one star; Health inspections is one star; Staffing is three

star; and Quality measures is two star. A review of the state’s licensing enforcement records

available to the LTC Ombudsman Program, show that investigation was conducted during the

reporting period, and a level D deficiency was identified. Crestwood also had a full

unannounced health survey by state licensing during the reporting period. The results are not yet

known to the PCO.

6. Complaints to PCO/LTC Ombudsman Program regarding Crestwood

No complaints were received during the monitoring visit and there are no open

complaints with the local long-term care ombudsman program.

7. Recommendations for Crestwood

The PCO makes no recommendations at this time.

F. Fir Lane Health & Rehabilitation Center

Fir Lane Health & Rehabilitation Center (“Fir Lane”) is located at 2430 North 13th St,

Shelton, WA 98584. The PCO monitoring visit took place on January 10, 2020.

1. Population and Payment at Fir Lane

Fir Lane has 135 beds. The census on the monitoring visit was 92. The majority

payment source is unknown at this time.


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2. Facility and Environment of Fir Lane

During this visit the state licensing entity was conducting a full health survey inspection.

Surveyors discovered what appeared to be mold in the facility on two walls in the main dining

room. The main dining room was closed off and remains closed as of the time of this report.

Testing of the mold and air quality were ordered. A level I-J deficiency was made by state

licensing.

Flooring was also noted to have warping in parts of two hallways, a long standing issue

possibly caused by past flooding in the area per employees and the facility administrator. The

warped areas are not necessarily visible to the eye. One entire wing is “semi” closed in the

facility for renovations of the flooring but it has not yet happened.

Additionally, a storage room roof caved in. Repair of the storage room was also stopped

due to a lack of permits.

3. Resident Care at Fir Lane

The PCO was unable to interview staff and residents during this visit because the visit

was ended due to concerns about alleged mold in the building.

4. Staffing at Fir Lane

At the time of the monitoring visit, the administrator reported that all department head

positions are filled. The administrator has been in his role for less than a year. He reported to

the PCO that recruitment of staff is challenging.

5. CMS Ratings, Licensing, and Enforcement at Fir Lane

Fir Lane has the following CMS star ratings: Overall is one star; Health inspections is

one star; Staffing is two star; and Quality measures is three star.


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6. Complaints to PCO/LTC Ombudsman Program regarding Fir Lane

The PCO referred to the local Long-Term Care Ombudsman Program for complaint

resolution regarding condition of building and safety of residents. A conversation was had with

Cornerstone leadership and state licensing. Testing has since been done and there is mold in the

dining room which has since been removed and treated. The dining room remains closed for

permitting for repairs. Additionally, air testing was also done and the air is reported to be safe.

7. Recommendations for Fir Lane

The PCO recommends that the building be repaired and renovated so that all residents are

living in a safe, secure, homelike environment.

G. Forest Ridge Health & Rehabilitation Center

Forest Ridge Health & Rehabilitation Center (“Forest Ridge”) is located at 140 Marion

Ave South, Bremerton, WA 98312. The PCO monitoring visit took place on January 22, 2020

1. Population and Payment at Forest Ridge

Forest Ridge has 98 beds. The census on the monitoring visit was 83. The majority

payment source is unknown.

2. Facility and Environment of Forest Ridge

The Forest Ridge facility is an older facility.

3. Resident Care at Forest Ridge

No comments regarding resident care at this time.

4. Staffing at Forest Ridge

At the time of the monitoring visit, the Administrator reports that the Director of Nursing

position is vacant but he has recruited a new employee who will begin February 3, 2020. A


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Residential care manager position is open in the “C” Wing of the building. There are four nurse

manager positions in total. The facility offers training for certified nursing assistants. The

administrator is authorized to utilize agency staff if needed.

5. CMS Ratings, Licensing, and Enforcement at Forest Ridge

Forest Ridge has the following CMS star ratings: Overall two star; health inspection is

two star; Staffing is two star; and Quality measures is two star.

6. Complaints to PCO/LTC Ombudsman Program regarding Forest Ridge

There are no open complaints with the Regional LTC Ombudsman Program at current.

Three complaints were open since November 1, 2019 with one complaint being received in

December of 2019. Complaint types are Admission, Transfer, Discharge and Eviction

(discharge) and Autonomy, Choice and Rights (Other rights and preferences).

7. Recommendations for Forest Ridge

The PCO has no recommendations at this time.

H. Franklin Hills Health & Rehabilitation Center

Franklin Hills Health & Rehabilitation Center (“Franklin Hills”) is located at 6021 North

Lidgerwood St., Spokane, WA 99208. The PCO monitoring visit took place on January 27,

2020.

1. Population and Payment at Franklin Hills

Franklin Hills has 100 beds. The census on the monitoring visit was 71 . The majority


2. Facility and Environment of Franklin Hills

The Franklin Hills facility is an older, larger building.


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3. Resident Care at Franklin Hills

The PCO attended the resident council meeting and sat in on the food committee meeting

during this visit. Staffing was historically poor but has been improving over the recent months

with some issues from time to time. The majority of concerns received were about food quality,

choice, accuracy of diets and preferences, late tray service, and cold food. Concerns expressed

about the new kitchen services vendor not setting up trays correctly according to resident’s needs

and requests.

4. Staffing at Franklin Hills

At the time of the monitoring visit, the administrator had been in her position less than

three months but she was previously an assistant executive director there. All department head

positions are fully staffed. The facility has two resident care managers. Nurse staffing on the

day of visit was as follows: RNs- 44 hours; LPNs/LVNs-8 hours; and NACs- 152 hours.

5. CMS Ratings, Licensing, and Enforcement at Franklin Hills

Franklin Hills has the following CMS star ratings: Overall is two star; Health inspection

is one star; Staffing is four star; and Quality measures is three star.

6. Complaints to PCO/LTC Ombudsman Program regarding Franklin Hills

No open cases with Spokane LTC Ombudsman Program are in existence during this

reporting time.

7. Recommendations for Franklin Hills



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I. Ivy Court

Ivy Court (“Ivy Court”) is located at 2200 Ironwood Pl, Coeur d’Alene, ID 83814. The

PCO monitoring visit took place on January 31, 2020. An additional monitoring visit was

conducted by a local LTC Ombudsman in Idaho who provided information to the PCO.

1. Population and Payment at Ivy Court.

Ivy Court has 80 certified beds. The census on the monitoring visit was 72. The majority


2. Facility and Environment of Ivy Court

The facility is an older building that has gone through several changes in operators over

the last five years. The building is undergoing renovation of the hallway flooring and nursing

stations.

3. Resident Care at Ivy Court

The most consistent concerns are the need to: change bed linens after resident bathes,

maintain shower schedules, and provide drinking water by the residents’ beds. Additional

concerns pertained to slow response to call lights. All of these issues are being audited internally

by the administrator and management.

4. Staffing at Ivy Court

Management positions at Ivy Court are fully staffed. During this visit nursing staffing total is

RNs-16 hours; LPN/LVNs-72 hours; and NACs 157.5 hours. The facility utilizes existing staff

first to fill call-ins or short staffing in order to give staff an opportunity to earn extra pay. The

facility also utilizes the Cornerstone pool of workers and just recently contracted with a staffing

agency.

5. CMS Ratings, Licensing, and Enforcement at Ivy Court


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On the CMS website, Ivy Court is marked with a “red alert icon.” In addition, Ivy Court

has the following CMS star ratings: Overall is two star; Health inspections is one star; Staffing

is four star; and Quality measures is three star. There are no licensing reports from the

regulatory agency in the public file during this first reporting period known to the PCO or to the

LTC Ombudsman Program.

6. Complaints to PCO/LTC Ombudsman Program regarding Ivy Court

The local long-term care ombudsman reports no complaints received or open during the

reporting period.

7. Recommendations for Ivy Court


J. LaCrosse Health & Rehabilitation Center

LaCrosse Health & Rehabilitation Center (“LaCrosse”) is located at 210 West LaCrosse

Ave, Coeur d’Alene, ID 83814. The PCO monitoring visit took place on January 30, 2020.

1. Population and Payment at LaCrosse

LaCrosse has 100 beds. The census on the monitoring visit was 94. The majority

payment source is unknown at this time. An additional monitoring visit was conducted by a

local LTC Ombudsman in Idaho who provided information to the PCO.

2. Facility and Environment of LaCrosse


the last five years. LaCrosse offers special services to residents with significant respiratory

needs including ventilator care. The wing has capacity for 24 residents and on this visit 10

residents were utilizing ventilators. The remaining residents on the wing are described as having


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high respiratory needs such as tracheostomy care, per the Director of Nursing. LaCrosse is one

of only two nursing homes in the state that care for residents who use ventilators.

3. Resident Care at LaCrosse

The most consistent concern reported is staffing levels as the census number increases.

LaCrosse utilizes Cornerstone’s pool of workers. The director of nursing and department

managers seem committed to improving care outcomes for the residents. The director of nursing

explained the facility quality assurance and performance improvement management system. She

also noted the facility’s “Stop and Watch, Early Warning Tool” which is a form posted for

anyone to report changes while caring for or observing a resident. Initial impressions are that

this facility appears to function well and progress is being made.

4. Staffing at LaCrosse

Management positions are fully staffed. During the monitoring visit, the nursing staffing

totals were: RNs–20 hours; LPN/LVNs–92 hours; and NACs– 225 hours.

5. CMS Ratings, Licensing, and Enforcement at LaCrosse

LaCrosse has the following CMS star ratings: Overall is one star; Health inspections is

one star; Staffing is three star; and Quality measures is two star.

There are no licensing reports from the regulatory agency in the public file during this

first reporting period known to the PCO or to the LTC Ombudsman Program.

The last full survey inspection occurred in June 2019 of which there were six citations

with highest level being an “F”. Complaint investigations since the last full survey have all been

determined “unsubstantiated” according to Idaho’s nursing home licensing public file.


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6. Complaints to PCO/LTC Ombudsman Program regarding LaCrosse

No complaints were received and there are no open complaints with the local long-term care

ombudsman program.

7. Recommendations for LaCrosse

The PCO recommends that LaCrosse have detailed transition plans in place if there is any

chance of a change in ownership or operators. Any new operator must have the proven ability

and resources to meet the needs of all residents, but especially the residents on the respiratory

wing. If this facility were to close, the options to transfer residents to another facility in Idaho

may very limited, given that there are only two nursing facilities in Idaho that specialize in

respiratory services.

K. Meadow Park Health & Specialty Care Center

Meadow Park Health & Specialty Care Center (“Meadow Park”) is located at 75 Shore

Dr, St Helens, OR 97051. The PCO monitoring visit took place on February 4, 2020.

1. Population and Payment at Meadow Park

Meadow Park has 92 certified beds. The census on the monitoring visit was 36. The

majority payment source is unknown.

2. Facility and Environment of Meadow Park

The Meadow Park facility is an older facility that needs repair and upkeep of the grounds

and building. Staff report that the water in the kitchen is slow to heat and maintenance replied

that the water reaches higher temperatures but that it takes time due to age of the building.

Facility appears clean and odor free during visit.


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3. Resident Care at Meadow Park

No concerns received about care during visit. Residents would, however, like resident

care meetings to not be held in public areas with doctors and state workers.

4. Staffing at Meadow Park

Director of Nursing shared that they have been overstaffing at times. Today, they are

using one Cornerstone pool nursing assistant.

5. CMS Ratings, Licensing, and Enforcement at Meadow Park

Meadow Park has the following CMS star ratings: Overall rating is two star; Health

inspections is one star; Staffing is four star; and Quality measures is five star.

6. Complaints to PCO/LTC Ombudsman Program regarding Meadow Park

The PCO received complaints about the quality of food and missing clothing from the

laundry service. Information about complaints in the Oregon State LTC Ombudsman Program is

not yet available.

7. Recommendations for Meadow Park


L. North Auburn Rehabilitation & Health Center

North Auburn Rehabilitation & Health Center (“North Auburn”) is located at 2830 I

Street NE, Auburn, WA 98002. The PCO monitoring visit took place on January 20, 2020.

1. Population and Payment at North Auburn

North Auburn has 125 beds. The census on the monitoring visit was 79. The majority



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2. Facility and Environment of North Auburn

North Auburn is located in an older spacious building. There was a strong smell of bleach

in hallways and in the dining room area.

3. Resident Care at North Auburn

On the day of the monitoring visit, the Administrator and very few department heads

were in the building. Multiple concerns reported regarding food services, poor staffing and new

nurses. Allegations were made that nurses sometimes use harsh tones with residents; loudness in

hallways while people are sleeping; staff cannot be found when needed at night; staff sleeping;

call lights don’t get answered or slow to answer at night; dirty meal trays left in rooms until next

meal; snacks passed out too late; nurses arguing with residents about medications; and nurses not

listening to residents’ needs. Other concerns were expressed about security, including a large

group of homeless people in the parking lot at night and a visitor with a dog.

Multiple grievances and concerns were reported regarding food services and quality of

food including “horrible” on weekends, late delivery, wrong food on trays, and dirty trays left

too long in rooms.

4. Staffing at North Auburn

The current management positions are vacant: Dietary Manager, Housekeeping

Manager, and Life Enrichment Director. A new Social Services Director was expected to start

the day of the monitoring visit. The Administrator was not available for an interview on the day

of the monitoring visit.

5. CMS Ratings, Licensing, and Enforcement at North Auburn

North Auburn has a red alert icon on the CMS website. In addition, North Auburn has

the following CMS star ratings: Overall is two star; Health inspection is two star; Staffing is


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three star; and Quality measures is four star. A full standard health survey and complaint

investigation during the monitoring period identified the most serious deficiency at level G. The

facility had a full unannounced survey during the reporting period. Complete results are not yet

known to the PCO.

6. Complaints to PCO/LTC Ombudsman Program for North Auburn

During the reporting period, sixteen complaints were received and are still open. The

complaints involve: Access to Information (language and communication barriers); Admission,

Transfer, Discharge, Eviction (discharge or eviction); Autonomy, Choice, Rights (dignity and

respect, retaliation, response to complaints, live in less restrictive setting, privacy, dignity and

respect); Personal Property; Care (assistive devices or equipment, medications, care planning);

Activities, Community Integration and Social Services (conflict resolution); Environment

(housekeeping, laundry and pest abatement); and Facility Policies, Procedures and Practices

(staffing).

7. Recommendations for North Auburn

The PCO recommends management observe food service delivery on weekends, make

unannounced visits at different shifts and provide retraining for all staff on resident rights, abuse

and neglect, and job performance expectations when working with vulnerable adults. Facility

management should also address security concerns.

M. Puget Sound Healthcare Center

Puget Sound Healthcare Center (“Puget Sound”) is located at 4001 Capitol Mall Dr SW,

Olympia, WA 98502. The PCO monitoring visit took place on January 13, 2020. Additional

monitoring visits were conducted by a Regional LTC Ombuds who reports directly to the PCO.


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1. Population and Payment at Puget Sound

Puget Sound has 108 beds. The census on the monitoring visit was 97. The majority


2. Facility and Environment of Puget Sound

Puget Sound is an older building that has gone through several changes in operators over

the last five years. It appears clean and orderly.

3. Resident Care at Puget Sound

Puget Sound’s food was reported to be cold at times. Puget Sound holds a resident “food

committee” in partnership with the kitchen manager and residents to resolve issues.

4. Staffing at Puget Sound

Management positions at Puget Sound are fully staffed. The Administrator has been in

place for over three years.

5. CMS Ratings, Licensing, and Enforcement at Puget Sound

Puget Sounds has the following CMS star ratings: Overall is four star; Health inspection is four

star; Staffing is four star; and Quality Measures is four star.

6. Complaints to PCO/LTC Ombudsman Program regarding Puget Sound

PCO will be referring a complaint to the local long-term care ombudsman about

temperature and texture of food (too tough, dry).

7. Recommendations for Puget Sound



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N. Riverside Nursing & Rehabilitation Center

Riverside Nursing & Rehabilitation Center (“Riverside”) is located at 1305 Alexander St,

Centralia, WA 98531. The PCO monitoring visit took place on January 17, 2020.

1. Population and Payment at Riverside

Riverside has 91 beds. The census on the monitoring visit was 66. The majority


2. Facility and Environment of Riverside


the last five years.

3. Resident Care at Riverside

Concerns included lack of showering/bathing due to staffing being too busy and one

shower room being down, quality of food viewed as poor, and not enough snacks available.

Linens not being changed after resident showers. Issues identified during the visit have been

resolved or are currently being remedied by administration.

4. Staffing at Riverside

Management positions at Riverside are fully staffed, with the exception of the

Maintenance Director position. The Administrator has been in place less than four months. The

administration, staff and residents report history of nurse staffing problems and all report that

staffing levels are improving and not worsening since the bankruptcy filing as of January 31,

2020.

5. CMS Ratings, Licensing, and Enforcement at Riverside

Riverside has the following CMS star ratings: Overall is two star; Health inspection is

three star; Nurse Staffing is three star; and Quality measures is one star.


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There was one new report from the regulatory agency in the public file during this first

reporting period, known to the PCO or to the LTC Ombudsman Program. A review of the state’s

licensing enforcement records available to the LTC Ombudsman Program, show one level L and

one level D citations. The level L was corrected the following day, per the state licensing entity.

There are no public records of the inspection available yet.

6. Complaints to PCO/LTC Ombudsman Program regarding Riverside

The PCO is referring a complaint regarding response to requests for assistance and

quality and availability of food choices to the local long-term care ombudsman program for

resolution.

7. Recommendations for Riverside

The PCO recommends a review of the facility’s QAPI system with leadership to

guarantee adequate resources and support are being provided to improve care outcomes and the

quality of life for all residents. The facility’s QAPI system should address staffing levels,

training of nurse leadership (registered nurses, resident care managers), certified nursing

assistants, residents’ rights, and food.

O. Sequim Health

Sequim Health & Rehabilitation (“Sequim Health”) is located at 650 West Hemlock St,

Sequim, WA 98382. The PCO monitoring visit took place on February 5, 2020.

1. Population and Payment at Sequim Health

Sequim Health has 100 beds. The census on the monitoring visit was 91. The majority



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2. Facility and Environment of Sequim Health

Sequim Health appears to be resourced adequately according to interviews with facility

department managers. It has a van and a bus for transporting residents for social and medical

needs.

3. Resident Care at Sequim Health

Concerns were reported regarding noise in the hallways at night and throughout the day,

showers being missed on scheduled days, phones/access issues, training of newer certified

nursing assistants, housekeeping, nursing staff training, meal times, and being kept informed of

new hires. The Sequim Health administrator responds to and address grievances and concerns

expressed during council meetings. Staff and residents report satisfaction with equipment,

medical supplies, nursing services, activities, social work, rehab services and food/snacks. This

facility also has a new family council that meets monthly

Residents express food quality is improving now that new menus have been instituted.

The PCO observed two meal services in the dining room that were 30-45 minutes later than

posted mealtimes. Very few individuals eat in the dining rooms, which may be by resident

preference. Trays were also late to the floors. The reason given for the delay was that the

facility has a new cook in training.


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4. Staffing at Sequim Health

Sequim Health’s management positions are fully staffed. The administrator has been in

place since 2008 when the facility opened. Nursing staffing total: RNs-42.5 hours; LPN/LVNs-

59.5 hours; and NACs 96 hours. Residents expressed that staffing levels are improving.

5. CMS Ratings, Licensing, and Enforcement at Sequim Health

Sequim Health has received a “red alert icon” on the CMS website which means it has

been recently cited for resident harm or potential harm for abuse or neglect (the icon is the red

circle with a hand in it.). In addition, Sequim Health has the following CMS star ratings: Overall

is two star; Health inspections is two star; Nurse staffing is three star; and Quality measures is

three star.

There are no licensing reports from the regulatory agency in the public file during this

first reporting period known to the PCO or to the LTC Ombudsman Program.

6. Complaints to PCO/LTC Ombudsman Program regarding Sequim Health

The Olympic Long-Term Care Ombudsman Program has received six complaints since

November 6, 2019. Two of the cases were resolved and one remains open. Complaint types are

financial property (Personal property and billing and charges by the facility) and Care (response

to requests for assistance, symptoms not attended to and access to health related services.

7. Recommendations for Sequim Health


P. The Gardens on University

The Gardens on University (“The Gardens”) is located at 414 S University Rd., Spokane

Valley, WA 99206. The PCO monitoring visit took place on January 28, 2020.


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1. Population and Payment at The Gardens

North Auburn has 124 beds. The census on the monitoring visit was 111, which included

17 residents in the transitional care unit (“TCU”). The majority payment source is Medicaid.

The payment sources for the TUC are 9 on Managed Care/Managed Medicaid; 6 on Medicare

Part A; 2 on combination of Medicaid, private pay, and HMO.

2. Facility and Environment of The Gardens

The Gardens is set in an older, large building. The TCU is in its own wing and focuses

on shorter term rehabilitation. The TCU’s interiors were updated in the last ten to fifteen years.

3. Resident Care at The Gardens

Per staff interviews, bankruptcy has had little to no impact on residents. Two residents

asked about the facility closing down due to the bankruptcy. PCO responded to the effect that

shutting down is not the goal of the bankruptcy; the goal is to keep facilities operating, but the

Court, the debtors, and the creditors need to work out how to manage the debt.

4. Staffing at The Gardens

Management positions at the Gardens are fully staffed. The Administrator has been in

place less than six months. Nursing levels the time of the visit were RN 88 hrs; LPN 40 hrs;

CNA 224 hrs. Staff appear to be attentive and concerned about the residents’ quality of life and

care. Staffing seems to be improving in the short-term (last several weeks/months).

The PCO expressed concern to the kitchen night manager about the quantity of the food

served and choices offered to the residents. The PCO also brought this issue to the head of

Healthcare Services Group which contracts with debtors to provide all food, laundry and

housekeeping services. Grievances reported were mostly about food (temperature, taste, quality,

and quantity).


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Seattle, WA 98108 (206) 491-8843

5. CMS Ratings, Licensing, and Enforcement at The Gardens

The Gardens has the following CMS star ratings: Overall is two star; Health inspections

is one star; Staffing is four star; and Quality measures is four star. The facility has a red “abuse”

icon on the CMS website. In the past year, the facility received citations ranging from Level D

to G, as a result of complaint investigations. There were no serious citations in the past year,

although the facility does have a history of serious violations resulting in fines. For the reporting

period, there were no reports from the regulatory agency in the public file available to the PCO

or LTC Ombudsman Program.

6. Complaints to PCO/LTC Ombudsman Program regarding The Gardens

Complaints regarding food service and quality were referred to the Spokane Long-term

Care Ombudsman Program for investigation and resolution.

7. Recommendations for The Gardens


Dated this 11th day of February, 2020.

/s/ Amy Freeman Amy Freeman, WSBA No. 38801 Attorney for Patient Care Ombudsman


The Honorable Mary Jo Hesten Chapter 11 UNITED STATES ...The Honorable Mary Jo Hesten Chapter 11...

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