PRINTED: 0512012000 vePARTMENT OF HEALTH AND HUMAN SERVICES ORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0838-0391 STATEMENT OF DeFiciencies |i) PROVIDERISUPPLIERIGUA [oy maLTiPLe consTRUCTION [es bare survey JAND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED 4 sunvoins c 05517 ae 03/30/2008 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CTY, STATE. ZIP CODE 4141 BEACH DRIVE )ME-RETSIL, WASHINGTON VETERAN HOF Bere Wh teri 0 “SUMUARY STATENENT OF DEFICIENCIES > | PROVIDER'S PLAN OF CORRECTION 7 Prorm | (GACH DEFICIENCY MUST BE PRECEDED BY FULL Prenx | _leAGHGORRECTVE ACTION SHOULD BE | couttron Tao | REGUATORY OR SC IDENTIFYING INFORMATION Tae (CROSSREFERENCED TO THE APPROPRIATE | "ome | DEFICIENCY) F 000| INITIAL COMMENTS F o00| ‘Surveyor: 26980 This report is the result of an unannounced Abbreviated Survey conducted at Washington Veteran's Home - Retsil on 3/30/2003. A sample of 3 current residents were selected froma census of 196 The following were complaints investigated: RECEIVED +#09-03-06223 MAY 2 12009 +#09-03-08172 7 +#09-03-05603 DSHS-ADSA #09-03-05524 ACS “REGION 5 +#09-03-06501 #09-03-06461 +#09-03-06805 +#09-03-06188 ‘The Abbreviated Survey was conducted by: Christine Kubiak, RN, MSN Phan D. Pham, RN, BSN | The Complaint investigators are from | Department of Social & Health Services ‘Aging and Disability Services Administration Residential Care Services, Region 6, UnitB | 640 Woodland Square Loop SE P.O, Box 45819 Olympia, WA 98504-6819 5 Telephone (360) 725-2502 FAX(380) 725-2640 AMENDED PER IDR 5/20/09 | WA VERTERANS HOME-RETSIL Is in compliance with \ABORATORY ORECTORS OR PROVDERISUPPLIR REGHESENTATIVES SIGNATURE THe ORE Gham) WHA S:al-0F ‘Any dafiiency slalemen! ending with an asterisk) denales a deficiency which the instiution may be excused fiom correcting providing lls determined hat ‘tr ‘equerds provide sufficient protection fo the patents. (See instructions.) Excepl for nursing homas the findings stalad above are discosable 90 days fol the dae of survey whether or nota plan of correction i provided. For nursing homes, the above findings and plans of cortection ave disclosatle 14 dys folowing the date these documents are made available tothe fecly. If deficiencies ae cited, an approvad plan of correction ls requste to continued program paticipation, Fear ons Bare Se aati Fao Waa W coninuatonsheatPape Tal2PRINTED: 05/20/2009 vEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0304 STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIERICLA x2) MULTIPLE CONSTRUCTION ce) oaTE suRVEY [ANID PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘COMBLETED [A BULOING c Ly 505517 Pee creer 03/30/2009 "Néinc: OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE 1141 BEACH DRIVE WASHINGTON VETERAN HOME-RETSIL RETEL WA sear (4) 10 'SUNARY STATEMENT OF DEFICIENGIES, 0. PROVIDER PLAN OF CORRECTION 28) PRErIx | (GACH DEFICIENCY NUST BE PRECEDED BY FULL. PREF (EACH CORRECTIVE ACTION SHOULD BE | cowmLENION Tae REGULATORY OF LSC IDENTIFYING INFORMATION) TAG. (CROSS-REFERENCED TO THE APPROPRIATE are DEFICIENCY) F 000] Continued From page 1 F 000} Fequirements of 42 CFR part 483, subpart B, Tequirements for long term care facilities, ao? hese Del | Sfy ‘OFW CHS-2867(02-09 Previous Verona Obsonte Eventi SAT acl 0: WAAD390 Wcontinuation sheet Page 2 of 2