Administrator Avalon Care Center - Federal Way 135 South ... · anti-anxiety consents and new orders for anti-anxiety medications daily by the management staff for two weeks, weekly

February 1, 2019

AdministratorAvalon Care Center - Federal Way135 South 336th StreetFederal Way, WA 98003

Dear Administrator:

The Department of Social and Health Services (DSHS), Residential Care Services, isaccepting your electronic Plan of Correction (ePOC) dated 12/28/2018 and the credibleinformation submitted by you as evidence that violation(s) dated 12/06/18, are in fact,corrected effective 01/29/2019.

The Washington State Patrol, Office of the State Fire Marshal (OSFM) has verified thatthe LSC survey(s) deficiencies have been corrected on 01/23/2019.

Based on this information, DSHS will notify the Centers for Medicare and MedicaidServices (CMS) Region X that your facility is in substantial compliance with participationrequirements effective 01/18/2019, and recommend that your facility's certification forMedicare and/or Medicaid participation continue.

If you have any questions please contact me at 253-234-6044.

Sincerely,

Loretta Maestas, MSN, RNField Manager - Region 2, Unit F Residential Care Services

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as prepared by Residential Care Services for the Locator website.

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 08/16/2019FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

505510 12/06/2018C

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

135 SOUTH 336TH STREETAVALON CARE CENTER - FEDERAL WAY

FEDERAL WAY, WA 98003

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

This report is the result of an unannounced Long Term Care Survey conducted at Avalon Care Center Federal Way on 11/27/18, 11/28/18, 11/29/18, 11/30/18, 12/03/18, 12/04/18, 12/05/18 and 12/06/18. A sample of 33 residents was selected from a census of 103. The sample included 27 current residents, two supplemental residents and the records of four discharged residents.

The survey was conducted by: Tamara Baker-Wagner, RN, MSNChristine Odachowski, RN, BSN Susan Abrisz, MSWMercedes Carrion, RN

The survey team is from:Department of Social and Health ServicesAging and Long Term Care Support AdministrationResidential Care Services, Region 2, Unit F Telephone: 253-234-6000Fax: 253-395-5070

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

12/28/2018Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete MDF111Event ID: Facility ID: WA40790 If continuation sheet Page 1 of 58

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F 000 Continued From page 1 F 000

.F 578SS=D

Request/Refuse/Dscntnue Trmnt;Formlte Adv DirCFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance

F 578 1/18/19


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F 578 Continued From page 2 F 578with State Law.(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the right to consent for treatment was documented for two (#s 70 and 60) of 10 residents reviewed for resident rights including advance directives, and for two of five residents (#4 and 38) reviewed for unnecessary medications. Failure to clarify and document whether or not each resident had completed advance directives, and to ensure informed consent was documented prior to initiating care, did not uphold their right to be fully informed of these rights.

Findings include:

RESIDENT #70:Resident #70 admitted on /18 with care needs related to a knee fracture with impaired mobility as well as several chronic medical conditions. During an initial review of her record, the only documentation found was a form indicating Resident #70's code status and other care decisions if she experienced a serious illness or injury.

A care conference summary, dated 11/27/18, attended by the resident, her husband and staff identified a number of care areas that were addressed during this meeting, but did not

F-578" How the nursing home will correct the deficiency as it relates to the residentResident #70 was offered information relating to the advance directiveResident #60 has an updated POLST, information regarding advance directive was mailed to responsible party.Resident #4 has an updated Anti-anxiety consentResident # 38 has an updated Anti-Anxiety consent" How the nursing home will act to protect residents in similar situationsCurrent residents will be audited for an advance directive and information will be provided to those without one.Current residents will be audited for Anti-Anxiety consentsCurrent residents will have their POLST audited for signatures" Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurSocial Services, Unit Managers, Director of Nursing, Medical records and Admissions department have been re-educated by the Regional Nurse Consultant/Designee on obtaining


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F 578 Continued From page 3 F 578include information about discussion of Advance Directives (ADs), such as a Durable Power of Attorney (DPOA) or Living Will completed by Resident #70 in the past. The care conference summary also did not say if the resident had been offered information about completing ADs, if she wanted. Review of the resident's current care plan, last revised on 11/26/18, did not include information regarding ADs.

On 12/04/18 at 10:00 a.m., during an interview with the Director of Nursing Services (DNS- Staff B) and the Social Services Director (SSD- Staff C), they were asked about the facility's process for obtaining/reviewing ADs. Staff C said this was discussed during care conferences. Staff B said the facility was "reaching out to families" to get any ADs after residents were admitted.

Additionally for Resident #70, when she was prescribed an anti-anxiety medication on 11/12/18, staff asked her to sign a consent form for use of this medication. While the document was signed by the resident, multiple areas of information were left blank, including relevant diagnoses, behaviors or symptoms necessitating use of the medication, non-medication interventions for anxiety to be provided in addition to the medication, and relevant treatment goals.

The absence of this information was reviewed with Staff B and Staff C on 12/04/18 at 10:00 a.m., and was acknowledged.

RESIDENT #60Review of the Annual MDS (Minimum Data Set-an assessment tool) dated 10/30/18 for

Advance Directives, POLST and obtaining consents." How the nursing home plans to monitor its performance to make sure the solutions are sustainedAudits of the medical record of new admissions for advance directives, anti-anxiety consents and new orders for anti-anxiety medications daily by the management staff for two weeks, weekly for two weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further recommendations " Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionAdministrator


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F 578 Continued From page 4 F 578Resident #60 revealed, the resident admitted on

/02, and was rarely or never understood. The MDS stated the resident was moderately impaired in daily decision-making ability. Observation found the resident was unable to be interviewed.

Record review revealed a "Risk vs. Benefits" form dated 05/22/17 which was signed by " (POA)" (Power of Attorney). No POA document, or discussion of a POA advance directive, was found in the resident's record.

Resident #60's record revealed a POLST (Physician Orders for Life-Sustaining Treatment-form that describes a resident's wishes for resuscitation) dated 01/10/13. The form had a checkmark next to "full treatment," and was signed by a healthcare provider. The line marked "Patient or Legal Surrogate Signature" was blank, and the corresponding "Date" section was blank. On 11/30/18 at 7:28 a.m., Staff C acknowledged this finding.

RESIDENT #4The Significant Change MDS dated 09/02/18 for Resident #4 showed the resident admitted on

/17, and the resident took psychoactive medications. Resident #4 was unable to be interviewed.

Review of an undated "Anxiolytic (anti-anxiety) Medication Informed Consent" form showed the staff signature line was blank. Other blank/unfilled areas of the form were "Related Diagnosis/Diagnoses/Clinical Situation Warranting Medication Use", "Potential Contributing Factors Previously Addressed",


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F 578 Continued From page 5 F 578"Target Behavior/Symptoms", and "Non-medication Related Approaches" and treatment goals.

On 12/05/18 at 1:51 p.m., the Unit Manager (RN-Staff F) was asked if it was the process to completely fill out consents for psychoactive medication, and she said it was. Staff F acknowledged the above missing areas of documentation, and the missing date for the above consent.

RESIDENT #38Review of Resident #38's quarterly MDS, dated 10/16/18, found the resident's admission into the facility was /10. The resident was identified as his own decision maker.

Review of the resident's pyschotropic drug consents included a "IC (informed consent) Anxiolytic Medication Informed Consent- V2" form for lorazepam dated 05/21/18. In the last section of the form titled "Informed Consent" there was a box for "Resident/Responsible Party Signature and date:" as well as a box for "If unable to obtain signed consent, was verbal consent received?" Both of these boxes were left blank.

On 12/05/18 at 11:11 a.m., Staff F acknowledged the consent was not signed by the resident.

Reference: WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c).

F 582SS=D

Medicaid/Medicare Coverage/Liability NoticeCFR(s): 483.10(g)(17)(18)(i)-(v)

F 582 1/18/19


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F 582 Continued From page 6 F 582§483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's


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F 582 Continued From page 7 F 582per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to fully inform Resident #37, one of three sample residents reviewed for liability notices, in writing, of the availability of additional care and services, and the possible costs of such care, after the resident was no longer eligible for skilled Medicare (Part A) services. Failure to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to Resident #37, placed the resident at risk for not having adequate information to make informed decisions about options for additional care during a continued facility stay.

Findings include:

Records provided by the facility related to beneficiary notices revealed Resident #37's last covered day of Part A Service was 10/23/18. Records showed the resident remained in the facility but was not provided the required SNF ABN form. Without this notice, he was not informed of choices he could make regarding further skilled care.

F-582" How the nursing home will correct the deficiency as it relates to the residentResident #37 is no longer in the facility" How the nursing home will act to protect residents in similar situationsCurrent residents under a Medicare Part A stay will be given an Advance Beneficiary Notice (ABN) when their skilled services are completed, and they remain in the facility. " Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurThe Social Service staff, Business office and the MDS office have been re-educated by the Regional Case Manager on the policy requirements for when an Advance Beneficiary Notice is required." How the nursing home plans to monitor its performance to make sure the solutions are sustainedThe Resident Assessment Coordinator


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During an interview on 12/04/18 at 12:27 p.m., the Director of Social Services (Staff C) acknowledged Resident #37 had not received a SNF ABN when required.

Reference: (WAC) 388-97-0300(1)(e),(5),(6).

will audit Medicare Residents when they complete their Part A services and remain in the building to determine if the Advance Beneficiary Notice was issued. The audit will be completed weekly for four weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further Recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionAdministrator

F 610SS=D

Investigate/Prevent/Correct Alleged ViolationCFR(s): 483.12(c)(2)-(4)

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.This REQUIREMENT is not met as evidenced by:

F 610 1/18/19

Based on interview and the record review of six F-610


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F 610 Continued From page 9 F 610months of facility Resident Council Minutes (June 2018 through November 2018), the facility failed to investigate allegations of potential abuse for two Residents #30 and #90, during the month of August 2018. Failure to identify residents' comments as allegations of mistreatment/abuse, did not ensure residents were protected from potential abuse.

Findings include:

RESIDENT #30Review of Resident #30's Annual MDS (Minimum Data Set-an assessment tool) dated 10/08/18 revealed the resident admitted /17.

Review of Resident Council Meeting Minutes dated 08/20/18 revealed, Resident #30 stated she had asked for something from a staff member and found the staff member's response "offensive". The minutes also stated Resident #30 said the same staff member told her, "I don't care." There was the corresponding notation, "Grievance Filed" next to the resident's remarks. The minutes revealed the staff member in attendance for the meeting was the Activities Director (Staff D).

Review of the facility's Grievance Log records for August 2018 revealed, an entry of 08/21/2018 that identified the above concerns reported by Resident #30. The corresponding "Disposition of Complaint" section was blank.

A "Grievance Report" dated 08/21/18 showed Staff D filed the related grievance and it was noted, the grievance was discussed in IDT (interdisciplinary team) and a "copy to nursing"

" How the nursing home will correct the deficiency as it relates to the residentResident #30 and 90 have been interviewed regarding concerns stated during Resident Council. Neither residents have concerns and stated issues were resolved." How the nursing home will act to protect residents in similar situationsResident Council minutes were reviewed to determine if all concerns were addressed and investigated when abuse /neglect were alleged. No other incidents were identified." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurResident Council meeting minutes will be reviewed for any allegations of abuse/neglect and a thorough investigation will be completed. All concerns will be reported by log or and /or hotline as required." How the nursing home plans to monitor its performance to make sure the solutions are sustainedResident Council meeting minutes will be audited by the Administrator monthly for three months. Result of audit will be submitted to the QAPI Committee for review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionAdministrator


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F 610 Continued From page 10 F 610was made. The form stated the staff member whose remarks the resident found offensive was educated "...on customer service, tone and perception". The form did not inlcude a thorough investigation to rule out abuse.

Further comment or follow-up regarding this complaint was not found elsewhere in the resident's record or incident log.

RESIDENT #90Review of Resident #90's Annual MDS dated 11/15/18 revealed the resident admitted

/18.

Review of Resident Council Meeting Minutes, dated 08/20/18, revealed Resident #90 stated the same staff member named by Resident #30, "makes her get out of bed early in the mornings to change her wet sheets." A note in the meeting minutes, next to this remark stated,"Grievance Filed". It was noted the staff member in attendance for the meeting was Staff D.

Review of the facility's Grievance Log records for August 2018 revealed an entry of 08/21/18 that stated the above concern was reported by Resident #90. The corresponding "Disposition of Complaint" section was blank. Further comment or follow-up regarding this complaint was not found elsewhere in the resident's record or incident log. The form did not inlcude a thorough investigation to rule out abuse.

INTERVIEWOn 11/30/18 at 8:00 a.m., Staff D was asked to explain the process to address allegations of potential abuse received during Resident Council


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F 610 Continued From page 11 F 610meetings. Staff D said if an allegation of potential abuse was received, he would go directly to the DNS with the information and the allegation would be called in to the State Hotline and followed up on immediately.

Staff D was asked about the allegations made by Residents #30 and #90 during the August 2018 Resident Council meeting. Staff D said he filed grievances for these allegations and took them to Staff B. When asked if the allegations were called into the State Hotline, Staff D said he wasn't sure and commented, "I should have".

On 11/30/18 at 8:14 a.m., the Director of Nursing (DNS-Staff B) was asked about the process when residents voiced potential abuse concerns in Resident Council meetings. Staff B said staff present in the meeting were to notify administration, who would then follow-up. Staff B was asked about the August 2018 remarks by Residents #30 and #90 documented in the Resident Council minutes (described above). Staff B said she would research the issue. On 11/30/18 at 9:15 a.m., Staff B acknowledged the allegations of Resident #30 and #90 above were not investigated in order to establish or rule out if abuse had occurred.

Reference WAC 388-97-0640 (6)(a)(b).

F 641SS=D

Accuracy of AssessmentsCFR(s): 483.20(g)

§483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

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F 641 Continued From page 12 F 641This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to accurately complete the MDS (Minimum Data Set-an assessment tool) for Residents #10, one of two residents reviewed for communication and #81, one of six residents reviewed for activities. This failure placed the residents at risk for unmet care needs.

Findings include:

RESIDENT #10Review of Resident #10's Admission MDS, dated 09/12/18, revealed the resident admitted

/18. In Section A, the language area was marked "No" to the query if the resident wanted or needed an interpreter. The preferred language area was blank. The BIMS (Brief Interview for Mental Status-a cognitive screening tool) showed this was not performed because the resident was "rarely/never understood".

On 11/28/18 at 10:39 a.m., in interview, the resident spoke only . On 11/29/18 at 9:02 a.m., Resident #10 was interviewed with an interpreter. Resident #10 responded appropriately and clearly during the interview, and said she did not understand any English.

On 12/06/18 at 10:24 a.m., a Registered Nurse from the MDS Department (Staff I) was asked about the MDS Section A as noted above. Staff I said the language information was probably obtained from the resident's admission record. Review of the resident's "Admission Record" showed the resident's primary language was "English."

F-641

" How the nursing home will correct the deficiency as it relates to the residentResident #10 has had a BIMS assessment completed. MDS was modified. Resident was interviewed with the use of the translator.Resident #81 MDS was modified, completed section A and submitted by MDS nurse.

" How the nursing home will act to protect residents in similar situationsThe accuracy of the Minimum Data Set(MDS) will be reviewed in section A0800, A1100, B0700, B0800, C0100 and D0100 for current residents of the most current assessment" Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurMDS staff will be reeducated on checking for accuracy of the MDS items by the Regional Case Manager. Residents who do not speak or understand English will be assessed using an interpreter." How the nursing home plans to monitor its performance to make sure the solutions are sustainedThe Resident Assessment Coordinator will randomly check MDS. Section A0800, A1100, B0700, B0800, C0100 and D0100 for accuracy weekly for four weeks, monthly for two months. Audits will be submitted to the QAPI Committee for


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On 12/06/18 at 10:59 a.m., the Social Services Director (Staff C) was asked about the lack of BIMS as noted above. Staff C said she did not have an interpreter available at the time that section was done. Staff C acknowledged the resident was well understood with the use of an interpreter, and that the BIMS should have been performed when an interpreter was available.

RESIDENT #81On 11/28/18 at 9:36 a.m., Resident #81 was observed to be female, and was unable to be interviewed.

Review of Resident #81's Admission MDS, dated 10/20/18, revealed the resident admitted 10/13/18. This MDS identified the resident's gender as "Male".

On 12/04/18 at 12:22 p.m., an MDS nurse (Staff E) was asked about the gender as it appeared in the 10/20/18 MDS. Staff E acknowledged the resident was female and the MDS was in error.

Reference WAC 388-97-1000 (1)(b).

review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionResident Assessment Coordinator (RAC)

F 645SS=D

PASARR Screening for MD & IDCFR(s): 483.20(k)(1)-(3)

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:(i) Mental disorder as defined in paragraph (k)(3)

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F 645 Continued From page 14 F 645(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and(B) If the individual requires such level of services, whether the individual requires specialized services; or(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the


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F 645 Continued From page 15 F 645hospital,(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to complete a Level One PASRR (Preadmission Screening and Resident Review) assessment for Resident #4, one of five sample residents reviewed for PASRR. PASRR is a federal requirement to ensure residents are screened before admission for needed treatment for mental health and/or intellectual disabilities. This failure placed the resident at risk to not receive any needed mental health care.

Findings include:

Review of Resident #4's Significant Change MDS (Minimum Data Set-an assessment tool) dated 09/02/18 revealed the resident admitted

/17.

F-645

" How the nursing home will correct the deficiency as it relates to the residentResident # 4 has had a PASRR completed and submitted. No level 2 services were required." How the nursing home will act to protect residents in similar situationsCurrent resident s medical records will be audited by Medical Records Director for presence of a PASRR form. If no PASRR is present one will be completed by Social Service staff and submitted when required." Measures the nursing home will take or the systems it will alter to ensure that


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Review of Resident #4's record found there was no Level I PASRR assessment completed before, or at the time of, Resident #4's admission.

On 12/05/18 at 9:45 a.m., the absence of an initial PASRR assessment for Resident #4 was discussed with the Social Services Director (SSD-Staff C). On 12/05/18 at 10:41 a.m., Staff C said she could not locate a completed PASRR for the resident. Staff C stated she made a new PASRR form for the resident. This PASRR, dated 12/05/18, showed the resident had depression.

Reference WAC 388-97-1915 (1)(2)(a-c).

the problem does not reoccurThe Admission Coordinator will review admission transfer paperwork for the hospital to determine that a PASRR was completed prior to admission. If a PASRR is not present in the admission transfer paperwork, the admissions coordinator will conduct a follow up call to the Hospital requesting it and if still unsuccessful a new PASRR will be completed and submitted upon admission to the facility.The Admission Coordinator, Admission nurse and Social Service staff will be re-educated on the PASRR process requirements." How the nursing home plans to monitor its performance to make sure the solutions are sustainedMedical records will audit new admission medical records weekly for four weeks and monthly for two months, to determine if a PASRR form is present. Audits will be submitted to the QAPI Committee for review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionSocial Services Director

F 657SS=E

Care Plan Timing and RevisionCFR(s): 483.21(b)(2)(i)-(iii)

§483.21(b) Comprehensive Care Plans§483.21(b)(2) A comprehensive care plan must be-(i) Developed within 7 days after completion of

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F 657 Continued From page 17 F 657the comprehensive assessment.(ii) Prepared by an interdisciplinary team, that includes but is not limited to--(A) The attending physician.(B) A registered nurse with responsibility for the resident.(C) A nurse aide with responsibility for the resident.(D) A member of food and nutrition services staff.(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure care plans (CPs) were revised/accurate for Residents #67, 70, 10, 65, 25, 35, and 299, seven of 27 current residents reviewed for accurate/revised care plans. Failure to create or revise care plans placed the residents at risk for unmet care needs.

Findings include:

RESIDENT #67According to an initial Minimum Data Set (MDS- an assessment tool) dated 09/05/2018, Resident

F-657" How the nursing home will correct the deficiency as it relates to the residentThe care Plans for Residents 67,70,10,65,25,35, and 299 have been updated" How the nursing home will act to protect residents in similar situationsThe Interdisciplinary Team(IDT) will review the 24-hour report during the morning Clinical meeting to determine if there are changes in the care needs. The Resident Care Plan will be updated if


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F 657 Continued From page 18 F 657#67 admitted /18 with care needs related to recovery from surgery. This MDS also stated she required the assistance from one staff member with showers. Her current CP, dated 08/28/18, stated Resident #67 required extensive assistance from one staff person for showers.

Review of recent shower records completed by Certified Nursing Assistants (CNAs) revealed Resident #67 was to be assisted with showers twice a week. However, CNAs documented assisting the resident on only three of the past thirty days as of 12/05/18 (on November 6, 9 and 16, 2018). On November 13, 20, 23 and 30, 2018, CNAs documented Resident #67 was either "not available" or "not applicable" for scheduled showers.

On 12/03/18 at 8:35 a.m., Resident #67 was interviewed about this care. She said she didn't need or want assistance from staff with showers and could wash herself without their assistance.

On 12/06/18 at 9:55 a.m., during an interview with the Unit Manager (Staff G), the resident's reports that she didn't need or want assistance with showers from staff were discussed. Staff G acknowledged this was accurate, according to reports from CNAs. She said the current CP, dated 08/28/18, did not identify the resident's improved abilities in recent weeks and needed to be revised. RESIDENT #70According to an admission MDS dated 11/06/18, Resident #70 admitted /18 with care needs related to a diabetes, impaired memory, and a fractured knee with impaired mobility.

indicated." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurLicensed Nurses(LN)and Social Services staff will be re-educated by the Staff Development Director/designee on the Policy to review and update the care plans when the residents condition warrants. Care Plans will be updated based on observed care and changes in physician orders." How the nursing home plans to monitor its performance to make sure the solutions are sustainedAudits of the Care plan will be completed weekly for four weeks and monthly for two months by the Director of Nursing(DNS)/Designee. Results of the audits will be submitted to the Quality Assurance and Performance Improvement Committee(QAPI) for review and further recommendations." Dates when corrective action will be completeJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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When observed on 11/27/18 at 11:43 a.m., Resident #70 was dressed in a hospital gown. Her hair was very oily and disheveled in appearance. When observed on 12/03/18 at 8:54 a.m., Resident #70 was in bed, dressed in a hospital gown. Her hair was again oily and disheveled. When asked how often she received showers, she said she was given bed baths, not showers.

On 12/06/18 at 10:10 a.m., during an interview with the Unit Manager, Staff H , Resident #70's CP was reviewed, including the lack of documented showers and/or refusals of care. According to Staff H, the resident had requested bed baths and had been adamant with CNAs she didn't want showers or her hair washed. She acknowledged the CP plan needed to be revised to address the resident's preference for bed baths, and past refusals of care.

SKIN RASHReview of Resident #70's November 2018 Treatment Administration Record (TAR) found an 11/01/18 directive to staff to "monitor excoriation in groin area until resolved". Review of nursing skin assessments dated 11/09/18, 11/16/18 and 11/23/18, each identified the presence of a skin rash in the resident's groin.

Review of November 2018 TAR for Resident #70 found directives for weekly head to toe skin checks by a Licensed Nurse every week, as well as daily monitoring of the groin area rash by nursing staff beginning 11/01/18. While an initial CP dated 10/31/18 did identify the resident's skin to be "at risk for impairment" due to multiple


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F 657 Continued From page 20 F 657conditions/ diagnoses, it had not been revised to address the presence of a rash on several areas of the resident's body.

On 12/06/18 at 10:05 a.m., during an interview with Staff H, the November 2018 TAR was reviewed, including documentation of the presence of the excoriated groin area. When the absence of this information from Resident #70's CP was discussed with Staff H, she acknowledged the CP needed to be revised.

RESIDENT #10Review of an Admission MDS, dated 09/12/18, revealed Resident #10 admitted /18 with multiple medical conditions.

On 11/28/18 at 10:39 a.m., it was observed during an interview, Resident #10 spoke only

. On 11/29/18 at 9:02 a.m., during an interview with an interpreter, Resident #10 spoke only , and stated she did not understand any English.

In a progress note dated 09/05/18, it was noted the resident spoke . A progress note of 09/09/18 stated, the resident was able to make her needs known with a translator.

Review of Resident #10's CP, last revised 11/27/18, revealed the section, "Alteration in communication r/t (related to) ESL (English Second Language)- speaking," in which the associated interventions were to anticipate and meet the resident's needs, provide a safe environment and "Speak on an adult level, speaking clearly and slower than normal." No other interventions related to the resident's


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F 657 Continued From page 22 F 657including a .

During observations on 11/30/18 at 9:54 a.m., 12/03/18 at 1:13 p.m., 12/04/18 at 1:10 p.m., and 12/05/18 at 2:23 p.m., Resident #25's heels were observed to be in contact with the mattress surface and her call light was to her left side.

An "Impairment to Skin Integrity" CP, dated 10/12/18, revealed the intervention of, "Heel elevation." In addition, a "Preferences" CP dated 10/12/18, instructed staff, "Call light needs to be on resident right side." In an interview on 12/05/18 at 2:23 p.m., Staff H stated these interventions were no longer applicable to Resident #25 as she was "now able to reach her call light on the left side and move legs often when in bed." A "Self performance deficit" CP, dated 10/12/18, instructed staff, "The resident uses bedpan at this time," but there was no indication how often to offer the bed pan to Resident #25. Staff H acknowledged the CP intervention lacked specific instructions related to frequency of offering toileting assistance to Resident #25.

A "Falls" CP instructed staff that Resident #25, "Should not be left unattended in her room for safety" and "Anticipate and meet the Resident's needs." Staff H stated these interventions were no longer applicable and lacked clarity for care provision respectively.

A Kardex and "Respiratory Status" CP, dated 10/08/18, instructed staff, "OXYGEN SETTINGS: O2 via nasal cannula 2 L (liters)/minute via nasal cannula (NC)." A December 2018 TAR instructed


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F 657 Continued From page 23 F 657staff to administer, "Oxygen 0 - 4 liters per NC..." In an interview on 12/06/18 at 7:46 a.m., Staff H acknowledged the CP should be revised to reflect current oxygen orders as documented on the December 2018 TAR. RESIDENT #35

A Quarterly MDS, dated 10/12/18, indicated Resident #35 was admitted on /17 with medically complex diagnoses, including

. This same MDS identified Resident #35 required extensive assistance of one person for transfers and walking in her room.

A "Potential for Injuries due to falls" CP, dated 04/26/18, included the following interventions for falls prevention: d staff to perform, "Frequent checks, to make sure RSD (resident) is not walking alone." In an interview on 12/04/18 at 9:03 a.m., Staff G acknowledged the intervention lacked clarity as to how often staff should check on Resident #35.

A "Fluid volume deficit" CP dated 08/14/17, instructed staff to, "Ensure that all ... beverages offered at activities comply with diet and fluid restrictions," an intervention Staff G stated did not apply to Resident #35 as she was not on a fluid restriction.

A "Dental Care" CP, dated 08/14/17, instructed staff to, "Use adhesive on upper denture if denture available," and "Daughter will keep dentures." In this interview, Staff G acknowledged the CP did not reflect Resident #35's dental needs, which was the current use of dentures.


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RESIDENT #299An Admission MDS, dated 11/26/18, revealed Resident #299 was admitted on /18 with medically complex diagnoses, including .

A "Preferences" CP, dated 11/24/18, revealed preferences for waking up, going to sleep, how to provide oral care, bathing and when to offer toileting assistance were not included in this CP. In an interview on 12/05/18 at 8:49 a.m., Staff H acknowledged this CP lacked Resident #299's preferences and instructions for toileting and oral hygiene.

A "Falls" CP, dated 11/21/18, instructed staff to, "Anticipate and meet the resident's needs." In this interview, Staff H acknowledged this intervention lacked clarity on how to anticipate specific needs to prevent falls.

An "Elimination" CP, dated 11/24/18, instructed staff to, "Offer frequent toileting and assist with pericare as needed," and "Use incontinent briefs on resident as needed." Staff H acknowledged the CP should indicate when to offer toileting assistance to Resident #299 and the resident always used incontinence briefs and not "as needed."

An "Antidepressant" CP, dated 11/24/18, indicated Resident #299 experienced claustrophobia. Staff H acknowledged this CP did not identify the triggers for claustrophobia or the interventions to prevent those triggers.

Reference: WAC 388-97-1020(2)(c)(d).


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F 658SS=D

Services Provided Meet Professional StandardsCFR(s): 483.21(b)(3)(i)

§483.21(b)(3) Comprehensive Care PlansThe services provided or arranged by the facility, as outlined by the comprehensive care plan, must-(i) Meet professional standards of quality.This REQUIREMENT is not met as evidenced by:

F 658 1/18/19

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice for two (#s 70 and 25) of 27 sampled residents reviewed. Nursing staff failed to follow physician orders for pain management for Resident #70. For Resident #25, the facility failed to notify a physician of elevated blood sugar levels as ordered and accurately document insulin administration. These failures placed residents at risk for unmet care needs.

Findings include:

RESIDENT #70According to an admission MDS (Minimum Data Set-an assessment tool) dated 11/06/18, Resident #70 admitted /18 with care needs related to a fractured knee. Progress notes by nursing staff since the resident's admission revealed reports of pain by the resident. Review of medication ordered for November 2018 revealed for "severe " pain (rated by a resident as a severity of 6 to 10 on a ten-point pain scale) Resident #70 was to receive 5 (mg/milligrams) of Hydrocodone every six hours, as needed. For "moderate" pain (rated as a severity level of 3 to 5 in a ten point scale), Resident #70 was to be

F-658

" How the nursing home will correct the deficiency as it relates to the residentElectronic Medication Record(EMAR) has been corrected for resident #70 and #25.Physician was notified of abnormal blood sugars." How the nursing home will act to protect residents in similar situationsPhysician Orders and EMAR for Pain and Insulin orders will be reviewed for accurate transcription and documentation." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurLN will be re-educated by the Staff Development Director/designee on accurate transcription of physician orders onto the EMAR for pain and insulin orders." How the nursing home plans to monitor its performance to make sure the solutions are sustainedAudits of new physician orders will be completed by The Unit Manager daily for two weeks, weekly for two weeks and monthly for two months. Audits will be submitted to the QAPI Committee for


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F 658 Continued From page 26 F 658administered Tramadol 25 mg every 12 hours as needed.Review of Medication Administration Records (MARs) for November 2018 revealed several instances when staff documented the resident's report of moderate pain (on 11/10/18, 11/11/18, 11/12/18, 11/15/18 and 11/21/18). On these dates, Resident #70 was administered Hydrocodone 5 mg for severe pain, rather than Tramadol 25 mg for moderate pain.

On 12/06/18 at 10:05 a.m., during an interview with the Unit Manager (Staff H) the above records were reviewed and discussed. Staff H acknowledged the orders for pain medication were not consistently followed for Resident #70.

RESIDENT #25An Admission MDS, dated 10/10/2018, revealed Resident #25 was admitted to the facility on

/18 with medically complex diagnoses, including .

An October 2018 MAR instructed nurses to administer 11 units of glargine (a long acting insulin) at bedtime and to, "Notify MD if (blood sugar) greater than 350." Review of this MAR revealed the nurses documented they administered 284 units of glargine on 10/27/18 and 350 units on 10/28/18 at bedtime.

On the same MAR, staff also documented that Resident #25 had blood sugars above 350 on 10/09/18 at 5:00 p.m., 10/20/18 at 5:00 p.m. and 8:00 p.m., and 10/25/18 at 8:00 p.m.. Review of progress notes on these dates did not indicate the physician was notified of elevated blood sugars as was ordered.

review and further Recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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Similarly, the November 2018 MAR revealed the nurses documented they administered 174 units of glargine at bedtime on 11/10/18, instead of the ordered 11 units. In addition, nurses documented they administered at bedtime 323 units on 11/13/18, 338 units on 11/19/18, 322 units on 11/20/18 and 278 units on 11/27/18 instead of the ordered dose of 15 units of glargine.

The same MAR also found the nurses documented they administered 322 units of glargine at bedtime on 11/28/18, instead of the ordered dose of 20 units. Review of this MAR revealed Resident #25 had blood sugars above 350 at 8:00 p.m. on 11/03/18, 11/15/18 and 11/16/18. Review of progress notes on these dates did not indicate the physician was notified of the elevated blood sugars as ordered.

In an interview on 12/05/18 at 2:35 p.m., Staff H stated the above-referenced insulin dosages were actually blood sugar readings, rather than the amount of insulin administered. Staff H also said and that the physician should have been notified of blood sugars above 350 as ordered.

Reference: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i).

F 677SS=D

ADL Care Provided for Dependent ResidentsCFR(s): 483.24(a)(2)

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;This REQUIREMENT is not met as evidenced

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F 677 Continued From page 28 F 677by: Based on interview and record review, the facility failed to provide at least weekly showers for two (#77 and 86) of seven residents reviewed for activities of daily living and one (#40) of five residents reviewed for non-pressure skin conditions. This failure placed residents at risk for a diminished quality of life and unmet care needs.

Findings include:

RESIDENT #77Review of Resident #77's most recent quarterly Minimum Data Set (MDS-an assessment tool), dated 11/08/18, revealed the resident admitted

/12 for multiple care needs. The resident was assessed to be dependent on staff for most care needs, including extensive assistance with showers.

On 11/27/18 at 11:54 a.m., a resident representative stated that the resident went out of the facility twice a week, and it was important that the resident was bathed on the day prior. The resident representative stated there was a time period in November 2018 when showers did not occur as often as they were scheduled.

Review of the resident's bathing documentation showed the resident was to be bathed every Tuesdays and Fridays. Documentation from 11/06/18 through 11/30/18 showed the resident was not bathed between 11/17/18 through 11/27/18.

On 12/05/18 at 10:40 a.m., the Unit Manager (Staff F) stated that there should be

F-677

" How the nursing home will correct the deficiency as it relates to the residentResidents #77, 86 and 40 have received showers per resident preference." How the nursing home will act to protect residents in similar situationsResident showers/bed baths will be audited for documentation and preference. Residents who are declining showers/bed baths will be interviewed for preferences and care plans updated accordingly." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurNursing staff will be in serviced by the Staff Development Director/designee on resident shower schedules, documentation of refusals and the steps to take when a resident refuses shower/bed bath." How the nursing home plans to monitor its performance to make sure the solutions are sustainedShower/bed bath documentation will be audited by the Unit Manager weekly for four weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correction


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F 677 Continued From page 29 F 677documentation of bathing if a resident had a shower, refused it, or if for some reason it did not occur. Staff F acknowledged the absence of bathing documentation during that time.

RESIDENT #86Review of Resident #86's admission MDS, dated 11/09/18, showed the resident admitted /18 for multiple care needs. Resident #86 was assessed to be dependent on staff for most care needs, including extensive assistance for bathing.

According to the resident's bathing documentation, the resident was to be showered every Tuesdays and Fridays. Review of the bathing records from 11/05/18 through 11/30/18 showed the resident did not receive a shower between 11/16/18 through 11/27/18.

On 12/05/18 at 10:40 a.m., Staff F acknowledged the lack of documentation related to bathing or showers for this resident.

RESIDENT #40Review of Resident #40's admission MDS, dated 10/15/18, revealed the resident admitted

/18 for multiple care needs. Resident #40 was assessed to need extensive assistance of staff for most activities of daily living, including bathing.

Review of bathing records showed the resident was to receive showers every Wednesday and Saturday. This documentation showed the resident had not received or been offered a shower between 11/08/18 through 11/28/18.

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F 677 Continued From page 30 F 677On 12/05/18 at 10:40 a.m., Staff F stated she was unable to find documentation to explain why the resident had not received a shower during the above the dates.

Reference: WAC 388-97-1060 (2)(c)

.F 684SS=E

Quality of CareCFR(s): 483.25

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.This REQUIREMENT is not met as evidenced by:

F 684 1/18/19

Based on interview and record review, the facility failed to ensure Residents #89, 70, 40, 77, 10, and 35, six of 27 current residents reviewed for quality of care, received the necessary care and services related to proper transfers (#89), monitoring and treatment of impaired skin integrity (#70 and 40), monitoring a UTI (urinary tract infection) (#77), provision of bowel care (#10 and 35) and follow up on abnormal lab results (#35). These failures placed residents at risk of decline in medical status and quality of life related to unmet care needs.

Findings include:

F-684

" How the nursing home will correct the deficiency as it relates to the residentStaff K was re-educated on the safe steps to take when a resident has a fall with injury. Resident #70 rash has resolved. Resident # 40 bruising is being monitored on the TAR, open area was never present. Resident #77 UTI has resolved. Resident #10 has had a bowel movement and routine bowel medications ordered Res # 35 has had a bowel movement and routine bowel medications ordered." How the nursing home will act to


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F 684 Continued From page 31 F 684RESIDENT #89According to a significant change Minimum Data Set (MDS- an assessment tool) dated 09/10/18, Resident #89 was readmitted /18. Hospital and nursing progress notes revealed Resident #89 had been hospitalized on /18 for a hip fracture due to a fall on that date.

Review of nursing progress notes written by staff who assessed the resident after the fall included the following information: At approximately 6:30 a.m. on 08/27/18, a Certified Nursing Assistant (CNA) heard a call for help and found Resident #89 on the bathroom floor. When assessed by a nurse (Staff K-LPN), Resident #89 stated she had lost her balance while walking to the bathroom, and "landed hard" on her right hip.

According to Staff K's progress note of 08/27/18, the resident also told the nurse she thought her hip was broken, said she had severe pain, and rated the pain as a "20" on a scale of 1 to 10. Staff K's note also stated Resident #89 was unable to completely straighten her affected leg when she was assessed.

After assessing the resident, and hearing the information reported by the resident, Staff K then documented Resident #89 was lifted from the floor by staff and seated in a wheelchair, which would require bending/ movement of the hip and leg. Once in the wheelchair, the resident was moved from the bathroom to her room, and transferred a second time from the wheelchair into her bed.

Both transfers of the resident required significant movement of the hip joint/ limb by staff, even

protect residents in similar situationsBowel Records will be reviewed to determine if Bowel Protocol is being followed. Skin evaluations will be reviewed to ensure treatments are in place and follow up lab orders will be reviewed to determine if necessarily follow up lab was completed. " Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurLN will be in serviced by the Staff Development Director on following bowel protocol, obtain physician orders for all treatments and completing laboratory order follow up. Education will include safe transfers when a resident has a fall with injury." How the nursing home plans to monitor its performance to make sure the solutions are sustainedBowel records, skin evaluations and new physician laboratory lab orders will be audited weekly for four weeks, monthly for two months by the Unit Manager during the morning clinical meeting to determine that timely follow up occurred. " Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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F 684 Continued From page 32 F 684though the resident had told staff it was extremely painful and she believed it was broken. X-rays obtained later that day, as well as hospital records, confirmed Resident #89's right proximal femur (upper leg bone near the hip joint) was fractured.

Moving a fractured limb can place an individual at risk of increased pain and injuries to the area surrounding the fracture.

In spite of these known risks, Staff K and other unknown staff moved the resident twice, first to a seated position into a wheelchair, then a second time in order to move her from a sitting position into her bed.

When interviewed on 12/04/18 at 1:47 p.m., Staff K, who assessed Resident #89 after the fall on 08/27/18, was interviewed about care of residents with a suspected hip fracture. When asked how a person reporting pain and other indicators of a possible hip fracture should be moved, Staff K replied , "I don't believe I would move him, I would call 911 and wait for paramedics."

Staff K was then asked what risks should be considered prior to moving a person with injuries suggestive of a hip fracture. She replied, "I would be concerned that they could be further injured. When asked to elaborate on the possible injuries, she said movement could cause pain, and further injury.

Staff K was then asked, as a nurse, if she thought a resident had sustained a fractured hip, what steps should be taken to address this issue.


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F 684 Continued From page 33 F 684She said staff should keep the resident comfortable, calm and call 911 to transport to the hospital.

When asked about transferring the resident from the floor into a wheelchair, and then transferring the resident into bed, as she documented on 08/27/18, Staff K reviewed her progress note and acknowledged she had written it, and the resident had been moved twice.

Potential medical risks to the resident were again reviewed, and the risk of further trauma in the area of the fracture, were acknowledged by Staff K when reviewed. When asked about the inconsistency between her initial response of not moving a resident and calling 911 so the resident could be evaluated, versus her actions of moving the resident from the floor to a wheelchair and then to bed, Staff K was unable to explain how she had determined it was safe to move Resident #89 after the fall on /18.

During an interview with the Director of Nursing (DNS- Staff B) on the morning of 12/05/18, the details of Resident #89's fall and fracture were discussed along with the investigation of the fall. She acknowledged staff needed to be aware of risks for further injury to residents after a fall.

RESIDENT #70 According to her admission MDS dated 11/06/18, Resident #70 admitted /18 with care needs related to a knee fracture. On admission, Licensed nursing staff identified the resident had rashes on several areas of her body, including her groin.


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F 684 Continued From page 34 F 684Review of Resident #70's November 2018 Treatment Administration Record (TAR) found a 11/01/18 directive to staff to "monitor excoriation in groin area until resolved". Review of nursing skin assessments dated 11/09/18, 11/16/18 and 11/23/18, each identified the presence of the skin rash in this area.

Review of this TAR found directives for weekly head to toe skin checks by a Licensed Nurse, as well as daily monitoring of the groin area rash by nursing staff beginning 11/01/18. A weekly skin assessment dated 11/23/18 stated, "Groin remains red and intact" and "Tx (treatment) ongoing". However, no treatment for the rash was found in previous or current physician orders, except for monitoring.

On 12/06/18 at 10:05 a.m., during an interview with the Unit Manager (Staff H), the November 2018 TAR was reviewed, including documentation of the presence of the excoriated groin area, which had been present for over a month, and documented by staff as still unresolved. When asked if there was other information about treating the rash, Staff H acknowledged there was no current treatment order, despite the earlier note stating treatment of the rash was "ongoing". Staff H also stated if a resident's rash "hasn't resolved in two weeks or so, they (nursing staff) should be looking at some type of treatment. "

RESIDENT #40According to Resident #40's admission MDS, dated 10/15/18, the resident admitted on

/18 with multiple care needs. The resident's skin was intact, but was identified as being at risk


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F 684 Continued From page 35 F 684for pressure ulcers.

Review of the resident's Admission skin assessment, dated 10/08/18, included documentation pertaining to red blanchable areas to the right and left buttock and bruising to the left inner elbow and forearm.

On 12/05/18 at 11:03 a.m. the Unit Manager (Staff F) stated that skin issues that were identified on the weekly skin assessment form should include treatment orders, or be monitored on the TAR.

Review of the resident's weekly skin assessment for 10/15/18, 10/22/18 and 11/12/18 all included documentation of the resident's bruises on the abdomen. Review of the resident's TAR and orders for November 2018 did not include the monitoring of these bruises.

Weekly skin checks identified Resident #40 had an "open area" on the right buttock on 10/29/18. It was still documented as present on the 11/05/18 weekly skin check. Again, review of the November 2018 TAR did not include a treatment order for the open area on the buttock.

On 12/05/18 at 11:03 a.m. Staff F stated any "open area" possibly due to pressure should also have further documentation including an investigation to determine how it occurred and how to prevent others from forming. Staff F acknowledged the lack of monitoring for the abdominal bruises and lack of treatment for the "open area" to the buttock.

RESIDENT #77


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F 684 Continued From page 36 F 684According to Resident #77's quarterly MDS, dated 11/08/18, the resident admitted /12 for multiple care needs. The resident was assessed to be dependent on staff for all of her care needs.

Review of records showed the resident had a UTI in May of 2018 and was treated with antibiotics. Further review of the record showed on the May 2018 MAR a physician's order, dated 05/11/18, for "Augmentin Tablet...give 500 mg (milligrams) by mouth two times a day for Uncomplicated UTI for five days."

Documentation on the same MAR showed the resident received the Augmentin from Friday 05/11/18 through Tuesday 05/15/18. Review of the resident's progress notes showed no documentation from 9:12 a.m. on 05/08/18 until 11:57 p.m. on 05/17/18.

Review of the resident's vital signs documentation also showed no monitoring of the resident's blood pressure from 05/05/18 at 9:59 p.m. until 05/25/18 at 3:18 p.m. The resident also did not have a temperature documented from 05/05/18 at 9:59 p.m. until 05/27/18 at 9:39 p.m.

On 12/05/18 at 10:40 a.m., Staff F stated the resident should have been on alert charting to include monitoring of vital signs, adverse side effects, and response to treatment.

RESIDENT #10The 09/12/18 admission MDS for Resident #10 revealed the resident admitted /18 with multiple medical conditions.


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On 11/29/18 at 9:02 a.m., Resident #10 stated she was constipated.

Resident #10's November 2018 MAR orders showed the resident was to receive "Milk of Magnesia Suspension 400 mg (milligrams/5 ml (milliliters) (Magnesium Hydroxide) Give 30 ml by mouth every 24 hours as needed for bowel care if no BM (bowel movement) in 3 days". The same MAR also showed an order for 10 mg Dulcolax suppository, as needed, if there was no BM for four days, and if constipation was not relieved by Milk of Magnesia.

In the "Task" section of the resident's electronic medical record, it was revealed the resident was documented as having "No Bowel Movement" for six days on 11/08/18, 11/09/18, 11/10/18, 11/11/18, 11/12/18, and 11/13/18. The November 2018 MAR showed the resident did not receive Milk of Magnesia until 11/13/18.

The "Task" section also documented "No Bowel Movement" on 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18 and 11/25/18. The November 2018 MAR showed the resident did not receive any of the ordered as-needed bowel interventions to relieve constipation during this period.

On 12/05/18 at 10:07 a.m., the above findings were shared with Staff F. Staff F said the system to alert staff when a resident required bowel interventions was that on the third full day without a BM, a report was pulled, and Milk of Magnesia was started. Staff F said the findings indicated the resident needed, and staff did not provide,


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F 684 Continued From page 38 F 684ordered bowel interventions.

RESIDENT #35LACK OF BOWEL INTERVENTIONSA quarterly MDS, dated 10/12/17, revealed Resident #35 was admitted on /17 with medically complex diagnoses, including

.

Review of the November 2018 MAR instructed nurses to give as-needed medication ordered by the provider for Milk of Magnesia and Dulcolax.

Review of the November 2018 Bowel Elimination flow sheet revealed Resident #35 did not have a BM on 11/18/18, 11/19/18, 11/20/18, and 11/21/18, or on 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/28/18, 11/29/18 and 11/30/18. Review of the November 2018 MAR and progress notes for the referenced dates revealed there was no documented administration of ordered PRN medications for the treatment of constipation.

On 12/04/18 at 9:03 a.m., the Unit Manager (Staff G) acknowledged no PRN medication was provided for constipation management as ordered.

ABNORMAL LAB VALUESReview of a lab reports revealed Resident #35 had elevated TSH (thyroid stimulating hormone: a thyroid hormone) levels of 7.25 mIU/L (milli-international units per liter) on 08/12/18 and 6.38 mIU/L on 08/15/18.

A physicians progress note, dated 08/31/2018,


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F 684 Continued From page 39 F 684stated, "Elevated TSH: TSH level 7.25, thyroid panel has been ordered." Review of laboratory results between 08/31/18 and 12/03/18 did not reveal a repeat TSH level was obtained.

In this continued interview, Staff G acknowledged a repeat TSH level was not obtained after 08/31/18 as ordered by the physician.

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

F 692SS=D

Nutrition/Hydration Status MaintenanceCFR(s): 483.25(g)(1)-(3)

§483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.This REQUIREMENT is not met as evidenced by:

F 692 1/18/19

Based on observation, interview and record F-692


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F 692 Continued From page 40 F 692review, the facility failed to ensure Residents # 70 and 301, two of two sample residents who required restrictions on the amount of fluid they consumed, received fluids as ordered. Failure to serve residents fluids as ordered by the physician placed them at risk for improper hydration and worsening of known medical conditions.

Findings include:

RESIDENT #70According to Resident #70's admission Minimum Data Set (MDS-an assessmnet tool), dated 11/06/18, the resident admitted /18 with care needs related to a fractured knee, diabetes and other chronic medical conditions. Review of Resident #70's physician orders for November and December 2018 revealed a fluid restriction of 1.5 liters (or 1,500 milliliters- ml) was ordered on 11/14/18, to address a diagnosis of Hyponatremia (low sodium level). By limiting dailyfluid intake, less sodium would be excreted from the body, with a goal of maintaining an adequate sodium level.

Orders pertaining to this fluid restriction stated nursing staff were to administer 750 mls with medications during the day, and the resident was to be served 250 mls (just over 8 ounces) daily with each of her three meals.

When observed on the morning of 11/29/18 and 12/03/18, Resident #70 was served eight ounces each of milk and water with her breakfast. One eight-ounce glass holds 240 ml of fluids, so at both of these meals she received nearly twice her planned amounts of fluid.

" How the nursing home will correct the deficiency as it relates to the residentResidents # 70 is receiving the correct amount of fluids.Resident # 301 is no longer in the facility" How the nursing home will act to protect residents in similar situationsResidents with an order for fluid restriction will be reviewed to determine if correct amount of fluids is being served." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurNursing and dietary staff will be in serviced by Staff Development Director/designee on fluid restriction management." How the nursing home plans to monitor its performance to make sure the solutions are sustainedUnit Manager will audit resident on fluid restriction daily for two weeks, weekly for two weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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F 692 Continued From page 41 F 692Review of fluid intake during meals documented by Certified Nursing Assistants (CNAs) between 11/22/18 and 12/04/18, revealed Resident #70 received fluids in excess of 750 mls on twelve of the thirteen days fluid intake was recorded. On eight of the thirteen days, amounts of fluids consumed by the resident were 1,000 mls or more, according to CNA documentation.

On 12/06/18 at 9:05 a.m., a Unit Manager (Staff H) was interviewed about Resident #70's fluid restriction, and documentation by CNAs that she received fluids with meals well above 750 mls. Staff H said she had also noted this when reviewing the resident's record on 12/04/18, and acknowledged the resident had been receiving fluids in excess of the ordered fluid restriction.

RESIDENT #301According to an Admission MDS, dated 11/23/18, Resident #301 was admitted to the facility on

/18 with medically complex diagnoses, including .

On 11/28/18 at 8:52 a.m., a dietary slip was observed on the breakfast tray which stated, "Fluid restriction 24 ounces." A water pitcher was also observed on the over-the-bed table and Resident #301 stated it was, "Filled with fresh water three times a day, a big thing of ice water."

A "Nutritional problem" care plan, dated 11/26/18, and a November 2018 Treatment Administration Record (TAR) instructed staff to provide fluids as follows: "Dietary 750 cc (cubic centimeters) & Nursing 750 cc. Nursing break up 250 cc= DAY, 250 cc = EVE, 200 cc = NOC (nights)."


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F 692 Continued From page 42 F 692Review of a fluids intake flow sheet and November 2018 TAR revealed Resident #301 received 2,040 cc on 11/26/18, an excess of 540 cc; 1,760 cc on 11/27/18, an excess of 260 cc; 1,790 cc on 11/28/18, an excess of 290 cc and, on 11/29/18, Resident #301 received a total of 1,360 cc on day shift, an excess of 610 cc.

On 12/05/18 at 8:52 a.m., Staff H acknowledged the excess fluid intake and the inaccurate order to administer 200 cc of fluids on night shift, instead of 250 cc.

Reference: WAC 388-97-1060 (3)(i) .

F 695SS=D

Respiratory/Tracheostomy Care and SuctioningCFR(s): 483.25(i)

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.This REQUIREMENT is not met as evidenced by:

F 695 1/18/19

Based on observations, interview and record review, the facility failed to ensure three (#40, 86, 301) of four sample residents reviewed for oxygen and respiratory care were provided ordered care consistent with standards of respiratory care. Failure by the the facility to document how much oxygen was delivered and revise a care plan to indicate a Bilevel Positive Airway Pressure (BiPAP) machine was no longer

F-695

" How the nursing home will correct the deficiency as it relates to the residentResident #40 Oxygen order and Treatment Record was clarified and corrected. The residents care plan was updated. The Care Plan for resident #86 to reflect use of the C-Pap machine. Care


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F 695 Continued From page 43 F 695in use (#40), identify the setting for a continuous positive airway pressure (CPAP) machine (#301), and to correctly identify the piece of respiratory equipment a resident was using on the care plan (#86), placed residents at risk for unmet care needs. Findings include:

RESIDENT #40Review of Resident #40's admission MDS, dated 10/15/18, revealed the resident admitted

/18 for multiple care needs including respiratory failure and used supplemental oxygen.

On 11/28/18 at 1:30 p.m., Resident #40 was observed sitting in a wheelchair in her room not wearing oxygen. An oxygen concentrator was observed next to the bed. The resident stated she was only using oxygen as it was needed.

Review of the resident's November 2018 Treatment Administration Record (TAR) showed an order, started 10/24/18, to "Titrate O2 (oxygen) from 1.5 L (liter) continuous to RA (room air), as tolerated ...Document O2 sats (saturation) and liters per minute every shift ..."

Documentation for the order did not include a place to document the oxygen flow rate.

Review of the resident's Care Plan (CP) for "Potential for alteration in air exchange r/t (related to) ...", revised 10/09/18, included the intervention "BiPAP as ordered." Review of the resident's December 2018 orders did not address the use of the BiPAP.

Plan for resident #301 was updated to include the C-Pap machine." How the nursing home will act to protect residents in similar situationsResidents who have physician orders for Oxygen and/or C-Pap machines will be audited for correct transcription and clarification of order. Treatment records and care plans will be revised to reflect current orders." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurLicensed nurses will be in-serviced by the Staff Development director/designee on accurate transcription, clarification and care plan of physician orders for oxygen and C-Pap pressure settings." How the nursing home plans to monitor its performance to make sure the solutions are sustainedNew Physician orders for oxygen/C-pap machines will be audited by the RCM weekly for four weeks and monthly for two months for accuracy and clarity of orders on Treatment Record and Care Plan." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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On 12/05/18 at 10:40 a.m., the Unit Manager (Staff F) acknowledged the lack of documentation of the oxygen flow rate. Staff F acknowledged that the resident was no longer using her BiPAP and that the care plan needed to be revised.

RESIDENT #86Review of Resident #86's admission MDS, dated 11/09/18, showed the resident admitted /18 for multiple care needs including respiratory therapy and obstructive sleep apnea (a disorder causing long pauses with breathing during sleep).

On 12/06/18 at 06:58 a.m., Resident #86 stated she had a CPAP machine with her in the facility and needed staff assistance to be able to use it.

Review of the resident's orders included, "CPAP to be worn at bedtime", initiated 11/07/18.

Review of the resident's care plan, revised 11/22/18, for "Potential for alteration in air exchange ..." included the intervention of "BiPAP as ordered".

On 12/05/18 at 10:40 a.m., Staff F acknowledged the resident was using a CPAP and not a BiPAP as incorrectly identified in the resident's care plan. RESIDENT #301According to an Admission MDS, dated 11/23/18, Resident #301 was admitted on /18 with medically complex diagnoses, including

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F 695 Continued From page 45 F 695Review of a "Respiratory Status" CP, dated 11/23/18, instructed the staff, "CPAP as ordered." Review of the November 2018 TAR instructed thestaff, "CPAP to be worn at bedtime," but did not specify the pressure setting while the device was in use. On 12/05/18 at 8:52 a.m., the Unit Manager (Staff H) acknowledged the CPAP order did not include a pressure setting and should have. Reference: WAC 388-97-1060 (3)(j)(vi)

F 698SS=D

DialysisCFR(s): 483.25(l)

§483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.This REQUIREMENT is not met as evidenced by:

F 698 1/18/19

Based on observation, interview and record review, the facility failed to ensure dialysis fistula (a surgically created connection between an artery and vein) monitoring was completed for Resident #13, one of one sample residents reviewed for dialysis care and services. This failure placed the resident at risk for complications related to dialysis.

Findings include:

The Significant Change MDS (Minimum Data Set-an assessment tool) dated 09/15/18 revealed Resident #13 re-admitted on /18 with multiple medical conditions, was rarely or never

F-698" How the nursing home will correct the deficiency as it relates to the residentResident #13 Dialysis order was updated. Dialysis run sheet was received" How the nursing home will act to protect residents in similar situationsCurrent residents on dialysis will be audited for post dialysis monitoring. Missing documentation from the dialysis center will be sought and placed in the resident s medical record." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccur


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F 698 Continued From page 46 F 698understood, and received dialysis.

On 12/04/18 at 7:32 a.m., Resident #13 was observed to have a dialysis fistula in his left arm.

Review of the resident's care plan, last revised 11/27/18, revealed interventions related to dialysis due to renal (kidney) disease. The care plan stated staff were to monitor the resident's fistula for bruit (sound generated by flow of arterial blood) and thrill (buzzing feeling that indicates blood is flowing through the fistula).

During an interview on 12/04/18 at 8:05 a.m., a Licensed Practical Nurse (LPN-Staff K) was asked what the procedure was when a resident returned from dialysis. Staff K said staff would assess the resident's fistula and check it for bruit and thrill. Staff K said if the fistula was not functioning, 911 would be called. Staff K also said an after-dialysis assessment form would be completed in the electronic medical record, and two hours after dialysis, the resident's pressure dressing would be removed. Staff K was asked about communication with the dialysis center. Staff K said that if a post-dialysis form was not received from the dialysis center, the facility needed to call the center and document the call.

Review of the resident's November 2018 Medication Administration Record (MAR) revealed the 05/08/18 order, "Ensure that dialysis run sheet returns with resident on dialysis days on Tues (Tuesday), Thurs (Thursday), Sat (Saturday). If not do the following 1. call the dialysis center 2. document phone call in the progress notes and the 24 hour report every evening shift every Tu, Thu, Sat".

Licensed nurses will be re-educated by the Staff Development Director on post dialysis monitoring and contacting the dialysis center for missing documentation." How the nursing home plans to monitor its performance to make sure the solutions are sustainedAudits of post dialysis monitoring will be completed by the Unit Manager weekly for four weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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The above order was marked "n" for "no" for seven of thirteen dialysis appointments on Thursday 11/01/18, Saturday 11/03/18, Tuesday 11/06/18, Thursday 11/08/2018, Saturday 11/17/18, Tuesday 11/20/18, and Thursday 11/29/18. Review of progress notes did not reveal documentation of a call to the dialysis center for these days as specified in the order.

Review of Resident #13's "Monitors" documentation for November 2018 revealed the undated order, "Monitor dialysis fistula L (left) upper arm Q (every) shift for thrill and bruit. Notifynephrologists/MD if absent every day and evening shift". On 11/17/18 both day and evening shifts lacked this documentation as well as day shifts of 11/21/18 and 11/28/18.

Resident #13's "Monitors" sheet for November 2018 also revealed the undated order to, "Monitor dialysis fistula to L upper arm q shift for potential complications and s/sx (symptoms) of infection every day and evening shift". There was no corresponding documentation on day or evening shift for 11/17/18, and none for day shifts of 11/21/18 and 11/28/18.

Resident #13's Treatment Administration Record (TAR) for November 2018 showed the 05/08/18 order, "Remove pressure dressing 2 hours after dialysis from dialysis site one time a day every Tue, Thu, Sat". On Tuesday 11/20/18 there was no documentation this had been done.

On 12/05/18 at 1:55 p.m., a Unit Manager (Staff F) was shown the above findings. Staff F acknowledged the above monitoring


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F 698 Continued From page 48 F 698documentation was incomplete.

Reference WAC 388-97-1900 (1), (6)(a-c).

F 740SS=D

Behavioral Health ServicesCFR(s): 483.40

§483.40 Behavioral health services.Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.This REQUIREMENT is not met as evidenced by:

F 740 1/18/19

Based on observation, interview and record review, the facility failed to ensure one resident (#86) of two residents reviewed for behavioral/emotional status, was referred for further assessment in response to identified concerns regarding possible self-harm during an MDS (Minimum Data Set-an assessment tool). The lack of timely interventions placed the resident at risk for unmet behavioral/emotional needs.

Findings include:

Review of Resident #86's admission MDS, dated 11/09/18, showed the resident admitted /18 for care needs related to a recent stroke. The MDS also included the resident had a diagnosis of and the resident had received an

F-740

" How the nursing home will correct the deficiency as it relates to the residentResident # 86 was interviewed and has no thoughts of hurting herself. Staff J was re-educated on the requirement for a Safety Notification when the MDS item response is triggered." How the nursing home will act to protect residents in similar situationsCurrent residents were reviewed for triggered safety notification. No other residents required Safety notification response. " Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccur


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F 740 Continued From page 49 F 740antidepressant seven of the seven days in the MDS look-back period.

On 11/29/18 at 9:21 a.m., Resident #86 was in bed watching the television. During an interview with the resident at the above time the Resident stated she had no concerns about her mood but was disappointed that she was unable to return to her prior living situation because of her stroke.

Review of the resident's Mood Interview (PHQ-9), dated 11/09/18, part of the above MDS, showed the resident had answered "yes" to a question of "Thoughts that you would be better off dead, or of hurting yourself in some way."

The "Safety Notification" which was triggered by the above included the question, "Was responsible staff or provider informed that there is potential for resident self-harm?" This was answered "yes".

On 12/05/18 at 12:59 p.m., an MDS Nurse (Staff J), stated that she had completed the above section of the MDS, but usually the follow-up for this response would be done by the Social Services Department. Staff J stated that in cases when the MDS triggered a safety notification such as the one above, she would inform the social worker and the unit manager immediately. Staff J said at the time the above MDS assessment was done, there was an interim social worker in the facility.

Review of the resident's progress notes of 11/09/18, the date of the safety notification trigger above, did not address the safety notification trigger or any related safety plan for the resident.

MDS staff, Social Service staff, DNS, and Unit Manager staff will be educated by the Regional Case Manager/designee on PHQ9 Safety Notification requirements." How the nursing home plans to monitor its performance to make sure the solutions are sustainedThe Resident Assessment Coordinator will audit the PHQ9 (section of the MDS for triggered safety notification triggers weekly for 4 weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further recommendations." Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionSocial Service Director


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On 12/06/18 at 12:10 p.m., Staff J acknowledged the lack of safety intervention for Resident #86 after the MDS indicated it was needed.

Reference: No Associated WAC.

F 758SS=D

Free from Unnec Psychotropic Meds/PRN UseCFR(s): 483.45(c)(3)(e)(1)-(5)

§483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:(i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order

F 758 1/18/19


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F 758 Continued From page 51 F 758unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to rule out or manage medically-related treatable causes prior to increasing psychotropic medications for one (#35) of two sample residents reviewed for unnecessary medications with a diagnosis of

. Additionally, for Resident #25, the facility failed to provide non-pharmacological interventions prior to administering "as needed" psychotropic medications for one of one resident reviewed. These failures placed the residents at risk for receiving unnecessary psychotropic medications and any related adverse effects.

Findings include:

RESIDENT #25An Admission MDS (Minimum Data Set - an

F-758

" How the nursing home will correct the deficiency as it relates to the residentResident #25 no longer is taking TemazepamResident #35 had a urinalysis done to rule out an urinary tract infection

" How the nursing home will act to protect residents in similar situationsCurrent resident who receive as needed(PRN) psychotropic medications will be audited to determine if nonpharmacological measures are in place and that medical conditions have been ruled out. EMAR and care plans will be updated accordingly.


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F 758 Continued From page 53 F 758antidepressant) 50 mg daily.

A progress note, dated 04/14/18, said, "Resident was in bathroom without brief or pants on. Resident was in bathroom and aide wanted to put briefs and pants on. Resident refused. Resident daughter was called to talk to resident, resident refused to talk to her daughter. Daughter stated that when she gets like that she might have UTI (urinary tract infection) ... MD was called and ordered UA (urinalysis) ..."

A progress note dated 04/18/18 stated, "Urine specimen collected ..." On 04/20/18, prior to obtaining the results of the urine specimen to determine if the resident had a UTI, staff documented, "Resident is on alert for increased Seroquel to 50 mg at bedtime ... will start tonight ..." A day later on 04/21/18, staff identified a new diagnosis of for Resident #35, a treatable cause which had not been addressed prior to increasing the Seroquel.

On 12/04/18 at 9:23 a.m., the Unit Manager (Staff G), acknowledged the antipsychotic should not had been increased before ruling out a treatable medical cause.

In an interview on 12/04/18 at 9:57 a.m., Staff C, Social Services Director, stated that when behaviors increase, "First we try to get a medical work up and then we have the doctor review and get other interventions first to see if we can alleviate without using other medications like psych meds. If the medical work up proves negative then, while we are trying to use interventions and if they are not working then we look at the least impact of medications, not an


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F 758 Continued From page 54 F 758antipsychotic if not needed."

Reference: WAC 388-97-1060 (3)(k)(i).

F 759SS=D

Free of Medication Error Rts 5 Prcnt or MoreCFR(s): 483.45(f)(1)

§483.45(f) Medication Errors. The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;This REQUIREMENT is not met as evidenced by:

F 759 1/18/19

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent was achieved during observation of medications administered to residents. This failure placed one (#13) of three residents observed for medication administration at risk for complications due to medication-related errors.

Findings include:

On 12/04/18 at 7:50 a.m., observation during medication administration by a Licensed Practical Nurse (Staff K) revealed Resident #13 received Carvedilol 25 milligrams (mg) orally.

Review of Resident #13's Medication Administration Record (MAR) for December 2018 revealed the order dated 09/29/18 for, "Carvedilol Tablet 12.5 mg by mouth two times a day for hypertension."

On 12/04/18 at 8:23 a.m., Staff K acknowledged she had given 25 mgs instead of the 12.5 mg

F-759

" How the nursing home will correct the deficiency as it relates to the residentThere was no outcome related to Resident # 13. Staff K was counseled and re-educated by the DNS on policy and procedure for safe Medication Administration and the steps to take when medications are not available." How the nursing home will act to protect residents in similar situationsLicensed nurses will be re-educated by the Staff Development Director/designee on following Pharmacy Policy and Procedures for safe medication administration and the steps to take when medications are not available." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurLicensed nurses will review an online video on safe medication administration." How the nursing home plans to


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F 759 Continued From page 55 F 759ordered which was a dose related medication order.

During the same 12/04/18 7:50 a.m. medication administration by Staff K, it was observed Resident #13 did not receive two ordered medications as follows: On the December 2018 MAR, an order of 09/12/18 stated the resident was to receive "Rena-Vite Rx Tablet 1 mg (B Complex-C-Folic Acid)" once daily. Additionally, an order dated 04/04/17 stated the resident was to receive an Ocuflox eye drop four times a day. The 7:00 a.m. dose of Oculfox and the daily dose of Rena-Vite were both marked as not administered.

Review of progress notes from 12/04/18 at 10:05 a.m., showed the Rena-Vite was "not available," and on 12/04/18 at 7:00 a.m., the Ocuflox was documented as "on order from pharmacy". On 12/04/18 at 8:14 a.m., Staff K said the two medications were not administered to Resident #13 because they were not available. This constituted two additional medication errors.

Reference: WAC 388-97-1060 (3)(k)(ii).

monitor its performance to make sure the solutions are sustainedRandom audits of medication pass will be completed weekly by the Unit Manager/designee monthly for three months. Audits will be submitted to the QAPI Committee for review and further recommendations" Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing

F 761SS=D

Label/Store Drugs and BiologicalsCFR(s): 483.45(g)(h)(1)(2)

§483.45(g) Labeling of Drugs and BiologicalsDrugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

F 761 1/18/19


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§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure two of five medication carts were locked, and all medications in the medication carts were properly stored and labeled. This failure placed residents at risk for having their medications taken or tampered with.

Findings include:

On 11/30/18 at 4:59 a.m., the medication cart in the 300 hall across from the conference room was observed unlocked. Medications were visible when drawers were opened. At 5:03 a.m., a Registered Nurse (RN-Staff L) was asked to observe the medication cart, in order to confirm it had been left unlocked. Staff L observed the cart was not locked and acknowledged he had forgotten to lock it.

F-761

" How the nursing home will correct the deficiency as it relates to the residentNo specific resident affected." How the nursing home will act to protect residents in similar situationsStaff L and N have received counseling by the DNS on locking the medication cart when not in direct line of sight." Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurLicensed staff have been in serviced on keeping the medication cart locked when not in direct line of sight and in the steps to take when temporarily placing medications back in the cart by the Staff


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On 11/30/18 at 5:28 a.m., a medication cart outside of room 122 was observed to be unlocked. At 5:30 a.m., a Registered Nurse (Staff N) returned to the medication cart and stated it should not have been left unlocked.

On 12/06/18 at 7:28 a.m., a medication cart located on the East hall was observed with an unlabeled plastic cup containing multiple pills in the top drawer. A Registered Nurse (RN-Staff M) said the medications were for a resident who had refused them. Staff M and the Unit Manager (Staff G), also present during this observation, were asked if this manner of storage was consistent with the facility medication policy, and they both stated it was not.

Reference WAC 388-97-1300(2), -2340.

Development Director/designee." How the nursing home plans to monitor its performance to make sure the solutions are sustainedRandom audits of the medication carts daily by the management staff for two weeks, weekly for two weeks and monthly for two months. Audits will be submitted to the QAPI Committee for review and further recommendations" Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionDirector of Nursing (DNS)


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NAME OF PROVIDER OR SUPPLIER

AVALON CARE CENTER - FEDERAL WAY

STREET ADDRESS, CITY, STATE, ZIP CODE

135 SOUTH 336TH STREETFEDERAL WAY, WA 98003



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L 000 WAC - Initial Comments

Note: According to RCW 18.51.060, the Department is authorized to deny, suspend or revoke a license and/or assess monetary fines for deficiencies cited in this report.

.

L 000

This report is the result of an unannounced Long Term Care Survey conducted at Avalon Care Center Federal Way on 11/27/18, 11/28/18, 11/29/18, 11/30/18, 12/03/18, 12/04/18, 12/05/18 and 12/06/18. A sample of 33 residents was selected from a census of 103. The sample included 27 current residents, two supplemental residents and the records of four discharged residents.

The survey was conducted by: Tamara Baker-Wagner, RN, MSNChristine Odachowski, RN, BSN Susan Abrisz, MSWMercedes Carrion, RN

The survey team is from:Department of Social and Health ServicesAging and Long Term Care Support AdministrationResidential Care Services, Region 2, Unit F Telephone: 253-234-6000Fax: 253-395-5070.

State Form 2567LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

12/28/18Electronically Signed

If continuation sheet 1 of 56899STATE FORM MDF111

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L1080Continued From page 1 L1080

L1080 WAC 388-97-1080 Nursing Services

(1) The nursing home must ensure that a sufficient number of qualified nursing personnel are available on a twenty-four hour basis seven days per week to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care.

(2) The nursing home must:

(a) Designate a registered nurse or licensed practical nurse to serve as charge nurse who is accountable for nursing services on each shift; and

(b) Have a full time director of nursing service who is a registered nurse.

(3) Large nonessential community providers must have a registered nurse on duty directly supervising resident care twenty-four hours per day, seven days per week.

(4) The department may permit limited exceptions to subsection (3) of this section if the nursing home can a demonstrate good faith effort to hire a registered nurse for the last eight hours of required coverage per day. The department may not grant exceptions for coverage that are less than sixteen hours per day. When considering an exception, the department may consider the following:

(a) Wages and benefits offered by the nursing home; and

L1080 1/18/19

State Form 2567If continuation sheet 2 of 56899STATE FORM MDF111

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(b) The availability of registered nurses in the nursing home's geographical area.

(5) The department may grant a one-year exception that may be renewable for up to three consecutive years.

(6) If a registered nurse is not on-site and readily available to complete full assessments during a shift, the department may limit the admission of new residents based on the resident's medical conditions or complexity during this period only for the particular shift that a registered nurse is not on-site or readily available.

(7) If the department grants an exception for a nursing home, the department must include this information in its nursing home locator.

(8) Essential community providers and small nonessential community providers must have a registered nurse on duty who directly supervises resident care a minimum of sixteen hours per day, seven days per week, and a registered nurse or a licensed practical nurse on duty who directly supervises resident care the remaining eight hours per day, seven days per week.

(9) The nursing home must ensure that staff respond to resident requests for assistance in a manner that promptly meets the resident's quality of life and quality of care needs.

(10) The director of nursing services is responsible for:

(a) Coordinating the plan of care for each resident;


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(b) Ensuring that registered nurses and licensed practical nurses comply with chapter 18.79 RCW; and

(c) Ensuring that the nursing care provided is based on the nursing process in accordance with nationally recognized and accepted standards of professional nursing practice.

This Washington Administrative Code is not met as evidenced by:Based on record review and interview, the facility failed to meet the requirement for 24 hour Registered Nurse (RN) coverage for six of 15 days for which RN staffing levels was reviewed. Failure to provide RN coverage as required placed residents at risk for not having complex medical needs met.

Findings include:

Review of staffing records for a fifteen day period revealed the facility failed to have 24 hour Registered Nurse (RN) coverage on six days: 11/14/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18 and 11/27/18.

During an interview on 12/06/18 at 11:00 a.m., the Director of Nursing (Staff B) acknowledged the facility did not have 24 hour RN coverage for the above dates.

WAC 388-97-1080

" How the nursing home will correct the deficiency as it relates to the residentNo specific resident identified" How the nursing home will act to protect residents in similar situationsFacility has received the RN Waiver" Measures the nursing home will take or the systems it will alter to ensure that the problem does not reoccurFacility is continuing recruitment efforts, working with nursing programs, offering sign on bonus, competitive wage surveys." How the nursing home plans to monitor its performance to make sure the solutions are sustainedAdministrator/DNS/Staffing Coordinator/Designee will meet to confirm 24-hour RN coverage. Registered Nurses are available by phone 24 hours a day" Dates when corrective action will be completedJanuary 18th 2019" Title of the person responsible to ensure correctionAdministrator


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Administrator Avalon Care Center - Federal Way 135 South ... · anti-anxiety consents and new orders for anti-anxiety medications daily by the management staff for two weeks, weekly

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