PRINTED: 12/09/2019 DEPARTMENT OF HEALTH AND

PRINTED: 12/09/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONC03/13/2019B. WING505516NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1301 ORTING-KAPOWSIN HWY EWASHINGTON SOLDIERS HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING 01ORTING, WA 98360SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)K 521 Continued From page 4ensure full closure and lock-in-place if soequipped. The damper shall not be blocked fromclosure in any way. All inspections and testingshall be documented, indicating the location ofthe fire damper, date of inspection, name ofinspector and deficiencies discovered. Thedocumentation shall have a space to indicatewhen and how the deficiencies were corrected.This deficient practice could affect all residents,staff, and visitors.PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EK 521The findings include:The facility failed to provide documentation fortheir 4 year fire/smoke damper testing.The above was discussed and acknowledged bythe facility staff.K 914 Electrical Systems - Maintenance and TestingSS F CFR(s): NFPA 101K 9147/1/19Electrical Systems - Maintenance and TestingHospital-grade receptacles at patient bedlocations and where deep sedation or generalanesthesia is administered, are tested after initialinstallation, replacement or servicing. Additionaltesting is performed at intervals defined bydocumented performance data. Receptacles notlisted as hospital-grade at these locations aretested at intervals not exceeding 12 months. Lineisolation monitors (LIM), if installed, are tested atintervals of less than or equal to 1 month byactuating the LIM test switch per 6.3.2.6.3.6,which activates both visual and audible alarm.For LIM circuits with automated self-testing, thismanual test is performed at intervals less than orequal to 12 months. LIM circuits are tested per6.3.3.3.2 after any repair or renovation to theFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y50F21Facility ID: WA40340This document was prepared by Residential Care Services for the Locator website.If continuation sheet Page 5 of 9

PRINTED: 12/09/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONC03/13/2019B. WING505516NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1301 ORTING-KAPOWSIN HWY EWASHINGTON SOLDIERS HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING 01ORTING, WA 98360SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)K 914 Continued From page 5electric distribution system. Records aremaintained of required tests and associatedrepairs or modifications, containing date, room orarea tested, and results.6.3.4 (NFPA 99)This REQUIREMENT is not met as evidencedby:Based on observation and staff interview on03/13/2019 between approximately 0930 to 1100hours the facility failed to keep records orconduct maintenance on their hospital gradereceptacles, non-hospital grade receptacles, andLine Isolation Monitors. This could cause anincreased risk of fire due to the non-maintenanceof the electrical system.PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EK 914The annual receptacle testing will becompleted 7/1/19Ongoing receptacle testing will bescheduled throughout the year to ensurereceptacles have been tested annually.The results of the receptacle testing willbe reviewed during the monthly QAPImeeting to ensure completion.Administrator to ensure complianceThe findings include:The facility failed to provide documentation oftheir Annual Receptacle testing which includesthe testing of the receptacle's grounding, polarity,integrity, and tension for non-hospital gradereceptacles. The facility failed to provideperformance data for their hospital-gradereceptacles, or annual testing results.The above was discussed and acknowledged bythe facility staff.K 918 Electrical Systems - Essential Electric SysteSS F CFR(s): NFPA 101K 9184/8/19Electrical Systems - Essential Electric SystemMaintenance and TestingThe generator or other alternate power sourceand associated equipment is capable ofsupplying service within 10 seconds. If the10-second criterion is not met during the monthlytest, a process shall be provided to annuallyFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y50F21Facility ID: WA40340This document was prepared by Residential Care Services for the Locator website.If continuation sheet Page 6 of 9

PRINTED: 12/09/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONC03/13/2019B. WING505516NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1301 ORTING-KAPOWSIN HWY EWASHINGTON SOLDIERS HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING 01ORTING, WA 98360SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)K 918 Continued From page 6confirm this capability for the life safety andcritical branches. Maintenance and testing of thegenerator and transfer switches are performed inaccordance with NFPA 110.Generator sets are inspected weekly, exercisedunder load 30 minutes 12 times a year in 20-40day intervals, and exercised once every 36months for 4 continuous hours. Scheduled testunder load conditions include a completesimulated cold start and automatic or manualtransfer of all EES loads, and are conducted bycompetent personnel. Maintenance and testing ofstored energy power sources (Type 3 EES) are inaccordance with NFPA 111. Main and feedercircuit breakers are inspected annually, and aprogram for periodically exercising thecomponents is established according tomanufacturer requirements. Written records ofmaintenance and testing are maintained andreadily available. EES electrical panels andcircuits are marked, readily identifiable, andseparate from normal power circuits. Minimizingthe possibility of damage of the emergencypower source is a design consideration for newinstallations.6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA111, 700.10 (NFPA 70)This REQUIREMENT is not met as evidencedby:Based on observation and staff interview on03/13/2019 between approximately 0930 to 1100hours the facility has failed to maintain and testthe emergency generator in accordance withNFPA 110. This could result in a failure of theemergency power system which would leave thefacility without egress and task lighting in theevent of a power failure which would endangerFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y50F21PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EK 918The annual generator fuel test wascompleted 3/18/19.This testing has been added to theemergency generator testing company scontract to be done regularly inaccordance with other inspections.The results of the inspection will bereviewed during the monthly QAPIFacility ID: WA40340This document was prepared by Residential Care Services for the Locator website.If continuation sheet Page 7 of 9

PRINTED: 12/09/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONC03/13/2019B. WING505516NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1301 ORTING-KAPOWSIN HWY EWASHINGTON SOLDIERS HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING 01ORTING, WA 98360SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)K 918 Continued From page 7the residents, staff, and/or visitors within thefacility.PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EK 918meeting to ensure completion.Administrator to ensure complianceThe findings include:The facility failed to provide documentation oftheir Annual Generator Fuel Testing.The above was discussed and acknowledged bythe facility staff.K 920 Electrical Equipment - Power Cords and ExtensSS E CFR(s): NFPA 101K 9204/8/19Electrical Equipment - Power Cords andExtension CordsPower strips in a patient care vicinity are onlyused for components of movablepatient-care-related electrical equipment(PCREE) assembles that have been assembledby qualified personnel and meet the conditions of10.2.3.6. Power strips in the patient care vicinitymay not be used for non-PCREE (e.g., personalelectronics), except in long-term care residentrooms that do not use PCREE. Power strips forPCREE meet UL 1363A or UL 60601-1. Powerstrips for non-PCREE in the patient care rooms(outside of vicinity) meet UL 1363. In non-patientcare rooms, power strips meet other ULstandards. All power strips are used with generalprecautions. Extension cords are not used as asubstitute for fixed wiring of a structure.Extension cords used temporarily are removedimmediately upon completion of the purpose forwhich it was installed and meets the conditions of10.2.4.10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8(NFPA 70), 590.3(D) (NFPA 70), TIA 12-5FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y50F21Facility ID: WA40340This document was prepared by Residential Care Services for the Locator website.If continuation sheet Page 8 of 9

PRINTED: 12/09/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONC03/13/2019B. WING505516NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1301 ORTING-KAPOWSIN HWY EWASHINGTON SOLDIERS HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING 01ORTING, WA 98360SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)K 920 Continued From page 8This REQUIREMENT is not met as evidencedby:Based on observation and staff interview on03/13/2019 between approximately 1100 to 1200hours the facility failed to restrict the use ofextension cords and non-approved power stripsin their facility. This could endanger people in thefacility due to the increased fire risk.The findings include:The facility has a non over current protected Multiplug adapter in room A12.The facility has a non 1363-A power strip in theirExam room. (Corrected at time of inspection)PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EK 920Power strips in patient care areas havebeen replaced with UL 1363A approvedpower strips.Patient care areas have been audited toensure UL 1363A power strips are inplace.A monthly audit will be completed forthree months to ensure UL 1363A powerstrips in patient care areas are in place.Monthly audits will be tracked andtrended monthly for three months duringour monthly QAPI meeting.Administrator to ensure complianceThe above was discussed and acknowledged bythe facility staff.FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y50F21Facility ID: WA40340This document was prepared by Residential Care Services for the Locator website.If continuation sheet Page 9 of 9

in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be