PRINTED: 03/14/2018 DEPARTMENT OF HEALTH AND …...Apr 18, 2001 · a. building _____ (x1) provider/supplier/clia identification number: statement of deficiencies and plan of correction

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 03/14/2018FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

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

505092 01/04/2018C

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

2726 ALDERWOOD AVENUEALDERWOOD PARK HEALTH AND REHABILITATION

BELLINGHAM, WA 98225

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG

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 Abbreviated with Partial Extended Survey conducted at Alderwood Park Health and Rehab on 12/28/17, 01/03/18 and 01/04/18. A sample of 18 residents was selected from a census of 93. The sample included 18 current residents.

On 01/04/18 an immediate jeopardy was identified related to F 755 for Pharmacy Services and F 835 for Administration. The facility removed the jeopardy on 01/05/18 by reassessing the resident, educating the staff, to assure that accurate acquiring, dispensing, and administrations of all medications.

The following complaints were investigated as part of this survey:# 3466113 # 3469375# 3475658# 3478419# 3478654 # 3479277

The survey was conducted by: Joy Kerns RN, BSNMichelle Scollard RN, BSNSarah Benjamin RN, BSNLeslie Watts RN

The survey team is from:Department of Social and Health ServicesAging & Long-Term Support AdministrationResidential Care Services3906 172nd St. NE Suite 100Arlington, WA 98223

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

01/29/2018Electronically 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 F6LO11Event ID: Facility ID: WA12900 If continuation sheet Page 1 of 76

A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 000 Continued From page 1 F 000

Telephone: 360-651-6850Fax: 360-651-6940

.F 561SS=D

Self-DeterminationCFR(s): 483.10(f)(1)-(3)(8)

§483.10(f) Self-determination.The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

F 561 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 561 Continued From page 2 F 561This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to honor residents' right to make choices for frequency of bathing for 2 of 3 residents (10 and 11) reviewed for choices. Failure to honor resident choices placed residents at risk for impaired hygiene and a diminished quality of life.

Findings included:

RESIDENT 11Review of Resident 11's nursing admission assessment, dated 09/27/17, indicated the resident preferred to have two tub baths a week.

In an interview on 01/04/18 at 10:35 AM, Resident 11 stated he was not bathed as frequently as he wished. The resident stated he wanted two baths a week.

Review of the September 27 through January 1, 2018 "Shower/Bath Sheet," showed the resident received no baths in September, two in October (on the 13th and 16th), five in November (on the 8th, 10th, 15th, 24th and 26th) and four in December (on the 1st, 8th, 22nd and 29th). The resident did refuse one bath in November.

Review of the care plan and care directive did not reflect how many times a week the resident preferred to bathe.

RESIDENT 10Review of Resident 10's nursing admission assessment, dated 09/13/17, the resident wanted two showers a week. In an interview on 01/04/18 at 11:55 AM, Resident

1) Resident 11’s bathing preference has been updated and is on the care plan and care directive. Resident 10’s bathing preference has been updated and is on the care plan and care directive2) Residents residing in the center reviewed for bathing preference and placed on the care plan and care directive. Shower book is updated to reflect resident preferences.3) Shower book will be reviewed weekly to validate showers are being received according to preference. Staff educated on care plan and care directive process.4) Shower schedule will be audited for 2 weeks and monthly x2 and results will be brought to QAPI meeting.5) 2/13/186) Administrator and/or designee to validate compliance


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 561 Continued From page 3 F 56110 stated he was not getting showers as frequently as he wanted. The resident stated he would like showers "as much as possible."

Review of the September 27 through January 1, 2018 "Shower/Bath Sheet," showed the resident received two showers in September (on the 13th and 14th), three showers in October (on the 1st, 19th and 26th), three in November (on the 5th, 20th and 26th) and five in December (on the 10th, 17th, 24th, 25th and 31st).

Review of the care plan and care directive did not reflect how many times a week the resident preferred to shower.

In an interview on 01/04/18 at 2:44 PM, the Administrator and Director of Nursing Services were informed residents' were not receiving their showers per the preference.

At 3:49 PM, Staff C, Registered Nurse, stated staff attempted to make up showers when staff called in. Staff C stated the residents were asked their shower preferences and frequency upon admission. This information was carried over to the care plan. Staff C stated there was no shower room on the East wing and the Administrator was working on getting this fixed.

Reference: WAC 388-97-0090(1)(2)


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 561 Continued From page 4 F 561.

F 583SS=D

Personal Privacy/Confidentiality of RecordsCFR(s): 483.10(h)(1)-(3)(i)(ii)

§483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.This REQUIREMENT is not met as evidenced

F 583 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 583 Continued From page 6 F 583a private place to meet with residents on a consistent basis. An ideal situation would be to meet in private so the residents could hear me without all the background noise. Also, "it would be a more therapeutic session if we had privacy." The doctor went on to say that sometimes a room is empty, or the dining room is empty, or a resident's roomate is willing to leave so we can speak. I have learned to be flexible since I don't have a permenent area to meet residents. She reported social services was "working with me to get the key to the beauty salon." When asked if this offers privacy required for a therapeutic behavioral health session, she reported "it has windows so people can see into the room, so privacy continues to be an issue."

The facility failed to provide a private place for residents to meet when engaging in a behavioral health session, which requires privacy in order to be therapeutic to the residents.

Reference: WAC 388-97-0360

.F 656SS=E

Develop/Implement Comprehensive Care PlanCFR(s): 483.21(b)(1)

§483.21(b) Comprehensive Care Plans§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's

F 656 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 656 Continued From page 8 F 656comprehensive care planning. The failure to ensure the comprehensive care plan was person-centered to maintain or attain the residents highest practicable well-being placed the residents' at risk of not receiving services that would meet their desires or wants and a decreased quality of life.

Findings included:

The facility's care directive policy states a licensed nurse established a care directive with the care plan at time of admission. The care directive plan was reviewed and updated with change in condition of care, during the Resident Assessment Instrument (RAI) process or when there was a revision in care cervices. The care directive was part of the care planning process.

RESIDENT 11A review of the Minimum Data Set (MDS) assessment, dated 12/10/17, showed Resident 11 had a significant change in condition.

Review of the Care Area Assessment (a tool used to develop the comprehensive care plan), identified and behavior as triggered concerns. Staff F, Social Service, indicated these concerns would be care planned.

There was no or behavioral care plan in place.

Review of the depression care plan was generic and lacked person-centered goals and interventions.

Review of the Care Area Assessment, identified Resident 11 had a decline in his Activity of Daily

care plan. Resident 11’s care plan for ADL’s, falls, and have been updated to be individualized, include measurable goals, interventions, and resident-centered. The care directive is updated to show assistance required for ADLs and the assistive device resident uses. A new MDS completed to reflect current status of condition.

Resident 6 has discharged from the center

Resident 5’s care directive has been updated to reflect wandering. Care plan has been updated to reflect wandering with interventions, measurable goals, measurable time frames, and is resident-centered. A new MDS completed to reflect current status of condition.Resident 4’s care plan and care directive has been updated to include and is resident-centered.2) Residents residing in the center had care plan and care directives audited and updated to reflect individualization and approaches to be resident-centered.3) Staff reeducated on individualizing care planning process, implementation, and updating resident care directives. Care plans and care directives will be reviewed weekly.4) Random audits of resident care plan and care directive by Administrator/Designee will be conducted for 2 weeks and monthly x2. Identified concerns will be addressed at time of discovery and findings will be brought to QAPI meeting.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 657 Continued From page 13 F 657F 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 the 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:

F 657 2/13/18

Based on observation, interview and record review the facility failed to review and revise care plans for 4 of 5 residents (10, 6, 5 and 9) reviewed for care plan revisions. The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for unmet care needs

1) Resident 10’s fall risk evaluation updated and fall care plan individualized to reflect the use of a walker as the assistive device and resident-centered interventions. Care directive has been updated with interventions, walker, and 1 person limited assist to change position


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 657 Continued From page 14 F 657and a diminished quality of life.

Findings included:

RESIDENT 10Review of the medical record showed Resident 10 had a quarterly Minimum Data Set (MDS) assessment, dated 12/20/17.

Review of the care plan, dated 12/22/17, showed it was generic, lacked measurable goals, individualized interventions and was not person-centered. For example, the resident was a fall risk related to a history of a problem standing/walking and used assisted devices. The goal was to not experience any injuries as a resultof a fall. The interventions were not individualized. There was no evidence the resident was involved in the care planning process.

Review of the medical record showed no documentation reflecting how the staff obtained the information, what staff were interviewed, resident involvement or any other interdisciplinary input when revising the resident's plan of care.

In an interview on 01/04/18 at 12:06 PM, Staff B, Licensed Practical Nurse/MDS Coordinator, stated quarterly care plans were revised by the Resident Care Manager (RCM). Staff B stated she obtained information to complete the MDS by reviewing therapy notes, nursing assistant notes, the chart and physician progress notes. Staff B stated she did interview or ask staff across all shifts who work with the resident. Staff B stated she documented quarterly reviews "at times" in the medical record. Staff B was aware this was not done for Resident 10.

slowly. Care conference with resident to involve in care plan process.


Resident 5’s care plan has been individualized to reflect diagnosis, wandering, with resident centered interventions and goals.


2) Residents residing in the center care plans and care directives audited to reflect individualized approaches and are resident-centered. Residents will have care conferences on admission, quarterly, and with change in condition, to review care plan and involve in the care plan process. 3) Staff educated on care plan and care directive process4) Random care plan audits to validate accuracy for 2 weeks and monthly x2 and results will be brought to QAPI meeting.5) 2/13/186) Administrator and/or designee to validate compliance


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 657 Continued From page 16 F 657environment. Interventions included re-direction,

device, music, and exercise groups. Goal date is 02-13-18. unfortunately, the care plan has not been revised with interventions and measurable goals for the resident. The resident's wandering is intrusive to other residents.

The care plan addressed wandering as an issue and the goals were for the resident to not have injuries, meet daily needs and reduced wandering. The one intervention was to establish and maintain a consistent routine/environment-based on the residents likes. To be re-evaluated in 90 days. RESIDENT 9Review of the care plan included altered thought process r/t with the potential for injury related to inappropriate judgement and inappropriate affection. The care plan goals were listed as resident will not have any injury, needs will be met daily and resident will not solicit affection inappropriately. The care plan approaches listed establish and maintain consistent routine, provide calm, quiet environment, one to one supervision when OOB (out of bed) with a discontinuation date of 12/04/17.

There were no new interventions added to the care plan when the one to one supervision was discontinued.

The care plan was not revised to include the 01/03/18 incident of Resident 9 kissing Resident 5. Additionally, the one on one supervision initiated at that time was not present on the care plan. The care plan did not include specific interventions or measureable goals.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




Review of the medical record showed no documentation reflecting how the staff obtained the information, what staff were interviewed, resident involvement or any other interdisciplinary input when revising the resident's plan of care

Reference: WAC 388-97-1020 (5)(b)F 658SS=E

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 2/13/18

Based on interview, observation and record review the facility failed to ensure services met professional standards of practice for 13 of 18 residents reviewed. Nursing staff failed to ensure medication administration practices were consistently provided to avoid medication errors (1,2,7,8,13,14,16,17), a lack of comprehensive care plans (4,5,6,11), and failed to supervise residents with behaviors (5,9). These failure resulted in harm of medication errors, plans of care which were not comprehensive, and residents with behaviors having repeat incidents.

Findings Include:

Lippincott Manual of Nursing Practice 10th edition, decribes accountability as;1. Intergral to the practice of any profession is the

1) Resident 1’s Vitamin D3 order is now correct

Resident 2 has a head to toe assessment completed and MAR review for accuracy.



Resident 13 has a head to toe assessment completed and MAR review for accuracy. Social Services assessment completed for harm. A med error report was created and investigated.

Resident 14 has a head to toe


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 658 Continued From page 22 F 658comprehensive care plan nor a care plan to assist staff in providing care and services.

The care plan for Resident 5 did not address the resident's intrusive wandering, interventions, nor measurable goals for the issue of wandering. The care plan had one review date for the entire care plan; it does not list goals with measurable time frames. A review of the progress notes revealed multiple notes regarding the resident's wandering and difficulty to re-direct. Complaints from resident 6 reported intrusive wandering continues and disrupts her quality of life.

RESIDENT 6The care plan review date was 11/09/17. There was no care plan for the resident's diagnosis of

There was a care plan for social distress for the resident feeling unappreciated. There were no updates on her care plan to acknowledge the privacy concerns she had with resident 6 related to wandering.

RESIDENT 11A review of the Minimum Data Set (MDS) assessment, dated 12/10/17, showed Resident 11 had a significant change in condition.

Review of the Care Area Assessment (a tool used to develop the comprehensive care plan), identified and behavior as triggered concerns. There was no

or behavioral care plan in place.

A review of the depression care plan was generic and lacked person-centered goals and interventions.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




BEHAVIORSRESIDENT 5Resident 5 was placed on a 1:1, per progress notes for one day. No mention of 1:1 was on the care plan. The resident continued to wander in the facility. After Administration was made aware on 12/28/17 of resident 5's continued concerns for privacy only then was the resident was placed on 1:1 as observed on 01/03 and 01/04/18.

RESIDENT 9Resident 9 had an incident in November when she kissed a resident. She was placed on a 1:1 observation and it was noted on the care plan. She was placed on alert for soliciting affection.

The care plan noted a discontinue for the 1:1 on 12/04/17.

On 01/03/18 the resident again was seen kissing a resident.

The facility failed to apply professional standards of nursing practice which resulted in the harm of medication errors, lack of care planning, and continued behaviors of residents causing harm to other resident's quality of life.

Refer to F656 CFR 483.21(b)(1) Develop/Implement Comprehensive Care PlansRefer to F744 CFR 483.40(b)(2) Treatment and Service for DementiaRefer to F755 CFR 483.45(a)(b)(1)-(3) Pharmacy ServicesRefer to F760 CFR483.45(f)(2) Residents are Free from Significant Med Errors


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i)F 725SS=E

Sufficient Nursing StaffCFR(s): 483.35(a)(1)(2)

§483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and 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 and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:(i) Except when waived under paragraph (e) of this section, licensed nurses; and(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.This REQUIREMENT is not met as evidenced by:

F 725 2/13/18

Based on observation, interview and record review the facility failed to ensure sufficient number of licensed staff and competent nursing services to provide care and services to 15 of 18

1) Resident 1’s order is now correct

Resident 2 has a head to toe assessment


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 725 Continued From page 25 F 725residents in safe environment. This failure resulted in nursing staff being unable to provide medications in a timely manner, an increase in medication errors (1,2,7,8,13,14,16,17), a lack of supervision for wandering residents(5,9), lack of individualized care plans (4,5,6,9,10,11), and an inability to meet residents needs to maintain their highest practicable level of health.

Findings Include:

A six month review of scheduling noted the Director of Nursing Services (DNS) had worked on the floor 21 times, in addition to performing her DNS duties.

In an interview on 01/03/18 at 11:00 A.M., with Staff C, Staff Development Coordinator (SDC), she reported it is difficult to get medication pass completed on time. She stated she gets pulled to work on the floor and having 34 residents to one nurse is extremely difficult. She reported she has had several medication errors she feels is because of the amount of people you are responsible for on a shift. I am having difficulty getting my work done as SDC because I am pulled away from it to work on the floor. When I work on the floor I cannot focus on medications, if there is a fall or care needs I am it. I have made the Administrator and the DNS aware of my concerns. Unfortunately, we continue to see an increase in medication errors.

In an interview on 01/03/18 with Staff D, LN, she reported she also had concerns with staffing related to being able to complete medication pass on time. She reported she can rarely complete it

completed and MAR review for accuracy.



Resident 16 has a head to toe assessment completed and MAR review for accuracy. A med error report was created and investigated. Disciplinary action and education with staff member H completed.

Resident 13 has a head to toe assessment completed and MAR review for accuracy. Social Services assessment completed for harm. A med error report was created and investigated.

Resident 14 has a head to toe assessment completed and MAR review for accuracy. A med error report was created and investigated.

Resident 17 has a head to toe assessment completed and MAR review for accuracy


Resident 5 has a wandering and care plan in place with

interventionsResident 10’s bathing preference has been updated and is on the care plan and care directiveResident 11’s bathing preference has been updated and is on the care plan and


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 725 Continued From page 28 F 72517 days. On 09/01/18 the nurse practitioner (NP) signed she agreed with the recommendation. Staff did not address the order nor, clarify the order. On 11/29/17 the order was discontinued and no order was in the chart. The order was addressed on 01/04/18 by the NP.

Additionally, review of the November and December MARs showed the LN did not accurately administer on 12/02/17 and 12/03/17 7:30 AM shift; on 12/19/17 Noon; and on 12/21/17 4:00 PM. In an interview on 01/04/18 at 4:16 PM, Staff A, RCM, confirmed the resident did not receive the correct the dose of .

Review of the state reporting log showed the medication errors were not identified or investigated.

RESIDENT 17 In a 12/26/17 report Resident 17 did not receive a 1:30 PM, dose of In an interview on 01/03/18 at 11:00 A.M., with Staff C, SDC remembered there was a call out; she had just gotten busy with many other residents, and did not even realize the mistake until a medication review was done. Staff C, SDC denied there had been any house wide in-services for the licensed nurses despite the increase in medication errors.

RESIDENT 6 PRIVACYIn an interview on 12/28/17 at 12:40 P.M., Resident 6 voiced concerns over a wandering resident. Resident 6 who is in a wheelchair and requires staff assistance for care has concerns


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 725 Continued From page 30 F 725 care plan with few interventions to stop

the wandering or to figure out why he wanders. No updates since the incidents with Resident 6. Residents 10 and 11 care plans did not reflect their bathing preferences

Additionally, residents 4,9,10,11, had care plan development and/or revision concerns.

The facility failed to provide the necessary staff to meet the care and services needs of the residents as demonstrated by the resident and staff interviews, lack of comprehensive care plans, and multiple medication errors.

Refer to F656 CFR 483.21(b)(1) Refer to F657 CFR 483.21(b)(2)(i)-(iii) Refer to F658 CFR 483.21(b)(3)(i) Refer to F755 CFR 483.(a)(b)(1)-(3) Refer to F838 CFR 483.70(e)(1)-(3)

Reference WAC 388-97-1080 (1), 1090 (1)

.F 744SS=G

Treatment/Service for DementiaCFR(s): 483.40(b)(3)

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.This REQUIREMENT is not met as evidenced by:

F 744 2/13/18

Based on observation, interview, and record 1) Resident 5’s care directive has been


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 744 Continued From page 32 F 744A review of the progress notes revealed multiple notes regarding the resident's wandering into a number of rooms and staff experiencing difficulty re-directing him. A note dated 12/04/17 stated the resident was on 1:1 and was encouraged to read,distract with activity. A note on 12/05/17 stated the resident was having frequent checks, no mention of 1:1 supervision.

In an interview on 12/28/17 at 4:30 P.M., the Administrator was made of aware of Resident 6 concerns of Resident 5 wandering into her room. The Administrator reported she had addressed this issue several weeks ago and was not aware the problem persisted.

In observations on 01/03 and 01/04/18 the resident had been placed on 1:1 supervision.

A review of Resident 5's care directive, which the nursing assistants use, does not address the resident's wandering into other resident's rooms. It assessed the resident as alert, oriented and forgetful.

The care plan, with a goal date of 02/13/18, revealed a care plan for wandering which noted the resident's diagnosis of and the goal was the resident would remain safe in the environment. Interventions included re-direction,

device, music, and exercise groups.

The care plan addressed wandering as


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 744 Continued From page 34 F 744was redirected and kept under supervision through the night. One to one tomorrow for safety until discharge. Care plan placed. Placed on alert for soliciting affection inappropriately."

In a progress note dated 12/01/17 at 2200, "No inappropriate behavior. Reiterated the meaning of consent and that many of our residents are incapable of consenting. Res. (resident) expressed understanding."

In a progress note dated 12/04/17 at 10:00 "remove 1:1 as resident states understanding of consent and inappropriate bxs (behaviors).

Review of a progress note dated 01/03/18 day (day shift-no exact time) revealed "This nurse witnessed resident holding hand with another resident. When asked to head back towards her room, they both stood up and she kissed him on the cheek."

On 01/04/18 at 9:05 AM, Resident 9 was observed resting in her bed. A female staff member was seated in a chair outside her door. She confirmed she was doing one on ones for Resident 9.

In an interview on 01/04/18 at 9:15 AM. Staff E, Licensed Practical Nurse, was asked why Resident 9 was receiving one on one supervision. Staff E stated he was familiar with Resident 9 then stated " I am not sure I haven't read the chart but it is something about a resident on East


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 744 Continued From page 35 F 744and I believe sexual in nature."

On 01/04/18 at 3:45 PM, The Director of Nursing Services confirmed Resident 9 did not have a detailed care plan in place or interventions to assist the resident who had difficulty with personal interaction and socialization.

The facility failed to ensure care plans addressed interventions and were re-evaluated as to their effectiveness. Placing both residents on short term 1:1 supervision allowed behaviors to re-occur. These failures resulted in harm of resident 6 having to seclude herself in her room so resident 5 would no longer enter uninvited.

Refer to F656 CFR 483.21(b)(1) Develop/Implement Comprehensive Care PlansRefer to F657 CFR 483.21(b)(2)(i)-(iii) Care Plan Timimg and RevisionRefer to F658 CFR 483.21(b)(3)(i) Services Provided Meet Professional StandardsRefer to F725 CFR 483.(a)(1)(2) Sufficient Nurse StaffingRefer to F838 CFR 483.70(e)(1)-(3) Facility Assessment

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


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 744 Continued From page 36 F 744.

F 755SS=K

Pharmacy Srvcs/Procedures/Pharmacist/RecordsCFR(s): 483.45(a)(b)(1)-(3)

§483.45 Pharmacy ServicesThe facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.This REQUIREMENT is not met as evidenced by:

F 755 2/13/18

Based on observation, interview and record 1) Resident 1’s order is now


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 755 Continued From page 39 F 755the resident's bedside and the potential for other residents to potentially take the unsecured medication.

RESIDENT 14During a record review on 01/03/17 at 1:30 PM, showed a pharmacy recommendation, dated 08/15/17, to address an order.

On 09/01/17, the Nurse Practitioner (NP) agreed with the pharmacy recommendation. The order was marked as processed on 09/01/17. The MAR did not reflect the new order.

Review of the MAR showed the was discontinued on 11/29/17, unfortunately, there was no order found in the chart to discontinue this medication.

In an interview on 01/03/17 at 1:45 PM, Staff A, Resident Care Manager (RCM), looked through Resident 14's medical record and reported that papers were put in different sections of the chart by different people. Staff A was unable to explain why the medication was discontinued without an order, nor why the original order was not on the MAR.

In an interview on 01/04/18 at 1:00 PM, Staff C reported she had asked the NP to address the medication error by writing a new order for

The pharmacy request was dated 08/15/17, the order was not addressed until 09/01/17 and as of 01/03/17 the order was still not correct, nor addressed by the RCM of the unit.

6) Administrator and/or designee to validate compliance.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




Review of the state reporting log revealed the above medications errors were not investigated.

At 2:44 PM the Director of Nursing Services was not aware the LN woke the resident up even though she did not need to check the resident's

why the LN did not notify physician orders regarding notification of abnormal

or and why the LN did not notify mange the resident's per the physician orders. The DNS confirmed no medication error report was done regarding the multiple errors as outlined above.

MEDICATION PASS OBSERVATIONRESIDENT 16In a medication pass observation on 01/04/17 at 9:10 AM, Staff H, Registered Nurse (RN), was asked to unlock the medication cart which revealed a clear medication cup in the top right single locked drawer containing 4 small white tablets inside labeled with a black marker with the name Resident 16.

In continued observation at 10:30 AM, the clear medication cup remained in the top right single locked drawer. Staff H stated the medications were for Resident 16. "They are her pain medications ... I know her, and she usually wants them early, but today when I brought them in she told me she wanted to take them later ... that is why you are seeing them there."

Record review of the tracking book revealed Staff H had signed out 10 mg of

for Resident 16 at 8:00 AM. The medication's pharmacy label identified it was a


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




The facility failed to ensure a consistent and competent medication administration system throughout the facility resulting in a Immediate Jeopardy situation.

CONTROLLED MEDICATIONSOn 01/04/18 at 9:07 AM, a medication pass was observed with Staff D, LPN on the Central hall. Staff D stated scheduled II and III controlled medications were reconciled at change of shift. If there was a discrepancy, the Licensed Nurse would start an investigation and notify the Director of Nursing Services.

At 12:53 PM, Staff D was asked if the facility ensured all scheduled II -V medications were reconciled. Staff D stated only scheduled II and III controlled medications were reconciled. Staff D opened up the Central medication cart and pulled out a card of a scheduled IV medication, and stated they were not reconciled or in a secured area. Staff D pointed to the other cart on the hall (Swing cart) and stated none of the scheduled IV or V medications were reconciled.

In an observation of the West and East hall medication carts showed the scheduled IV and V medications were located with the routine medications. The medications were not doubled locked.

In an interview with the DNS at 1:35 PM, she stated "We keep the scheduled IV's and V's with the residents other medications." She confirmed the scheduled medications were not secured with the other narcotics or counted each shift.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 755 Continued From page 51 F 755The MAR had a variety of times for medications. Some were scheduled from 0600-1000, or 18- 22 (6:00 PM to 10:00 PM), or were scheduled at an hour (6 am), other orders for the same medication if given more than once a day could be seen on multiple sheets.

In an interview with the DNS on 01/04/17 at 4:00 P.M., she reported the MAR was being made in the click point care system, although the facility was not using the computer system for administration of medications, they were printing the monthly MAR's from the system. The DNS stated the computer system was not written by people who give medication so it was not printing "as we would normally see our medications scheduled. This is the first month we are trying this and I am trying to delete the extra orders to make it easier."

At 5:10 PM, Staff B, LPN, stated the new computer system did not print out on the MAR with correct times. For example, the physician order stated to administer the medication between 6 AM and 10 AM, which allowed the LN flexibility. Staff B stated on some of the MAR's it was printed as "AM(6," which looked like it was to be administered at 6 AM. Staff B stated this was not correct. Staff B was not able to state what time the medications were actually administered when it appeared on the MAR this way. Staff B was asked if a medication was scheduled more than once daily and the medication needed to be at a therapeutic level, how as this reflected on the MAR when the time frames to administer the medication was so vague. Staff B was not able to offer any additional information.

Refer F760 CFR 483.45 (f)(2) Residents Are


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 755 Continued From page 52 F 755Free of Significant Medication Errors

Reference WAC 388-97-1300 (1)(B)(ii) (c)(i-iv) (2) & -2340

F 756SS=D

Drug Regimen Review, Report Irregular, Act OnCFR(s): 483.45(c)(1)(2)(4)(5)

§483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and

F 756 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 756 Continued From page 53 F 756maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure pharmacy recommendations were followed up on 2 of 3 residents (10 and 14). These failures placed residents at risk for receiving an inaccurate dosing of medication, adverse side effects, and the risk of receiving a medication longer than medically necessary.

Findings included:

RESIDENT 10Review of a pharmacy recommendation, dated 09/14/17, showed the pharmacist recommended to change an inhaler from as needed to routine.

On 10/03/17, approximately three weeks later, the physician agreed with the recommendation to change the inhaler from as needed to twice daily.

In an interview on 01/04/18 at 3:39 PM, Staff C, Registered Nurse, stated the pharmacy evaluations were handled by the Resident Care Manager. Staff C was not able to state why the pharmacy evaluation took over three weeks to be addressed.RESIDENT 14 A pharmacy recommendation, dated 08/15/17, showed the pharmacist recommended decreasing to 20 milligrams (mg) twice daily for two weeks, then further decrease

to 20 mg daily.

1) Resident 10 has a head to toe assessment completed and MAR review for accuracy. A med error report was created and investigated.


2) Pharmacy recommendations for previous month were reviewed and addressed.3) Reeducate nursing management on the timeliness of pharmacy recommendations4) Random audits of pharmacy recommendations to validate accurate and timely execution will be completed 2 times a week and monthly x2 and results will be brought to QAPI.5) 2/13/186) Administrator and/or designee to validate compliance


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




On 09/01/17, 17 days later, the Nurse Practitioner agreed with the recommendation.

In an interview 01/03/17 at 1:45 PM, Staff A, Residential Care Manager (RCM), stated she was not here when the pharmacy recommendation was done but confirmed it was late.

Reference: WAC 388-97-1300 (4)(c)F 760SS=G

Residents are Free of Significant Med ErrorsCFR(s): 483.45(f)(2)

The facility must ensure that its-§483.45(f)(2) Residents are free of any significant medication errors.This REQUIREMENT is not met as evidenced by:

F 760 2/13/18

Based on observation, interview and record review the facility failed to ensure 8 of 14 residents (1, 2, 8, 7, 16, 13, 14, & 17) were free from significant medication errors. The lack of a functioning medication system caused harm to residents because licensed staff did not use professional standards nor follow facility policy when administering medications to vulnerable adults. These failures placed residents at higher risk for complications and declines in health status.

Findings Include:

Review of the facility's "Medication Administration Policy," directed the Licensed Nurse (LN) to:1. The nurse reviews each resident's MAR or TAR for ordered medications.2. At no time is the nurse allowed to pre-pour or

1) Resident 1’s order is now correct




Resident 16 has a head to toe assessment completed and MAR review for accuracy. A med error report was created and investigated. Disciplinary action and education with staff member H completed.

Resident 13 has a head to toe


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 760 Continued From page 55 F 760pre-chart the ordered medications.3. The nurse does not borrow medications.4. Medications are not left at the bedside for the resident to take later. 5. The nurse follows the 5 Rights of Medication Administration.

Review of the facility's "Flexible Medication Pass" policy revealed the following medication administration times, unless the physician specified a certain time for the medication to be administered, was:~AM med's to be administered between 0700-0930 (2 hour window open to pass=0600-10:30)~Midday med's 12:00-1300 (2 hour window open to pass med's=11:00-14:00)~PM med's 15:30-17:00 (2 hours window open to pass=14:30-18:00)~HS med's 19:30-21:30 (2 hour window to pass=18:30-22:30)(if a physician indicates a specific administration time, in these cases a time will be scheduled)

Review of the facility's "Controlled Medications" policy stated when a dose of a controlled medication was removed from the container for administration but refused by the resident or not given for any reason, it was not placed back in the container. The controlled medication must be destroyed according to facility policy for Controlled Medication Disposal.

According to Lippincott Nursing Procedures 7th Ed, defined a medication error as a mistake that occurs during a medication administration process. If a mistake occurs, it doesn't matter whether the patient was harmed or whether there was only a potential for injury; it's still considered

assessment completed and MAR review for accuracy. Social Services assessment completed for harm. A med error report was created and investigated.



2) Med pass competencies completed on licensed staff. Facility wide audit for medication at bedside.3) Reeducate licensed nurses on med pass administration, med pass check-offs, medication storage. Medication errors will addressed immediately and be tracked and trended for patterns and results will be brought to QAPI.4) Random audit rooms for medication at bedside for 2 weeks and monthly x2 and results will be brought to QAPI5) 2/13/186) Administrator and/or designee to validate compliance.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 760 Continued From page 58 F 760At 4:30 PM, the Director of Nursing Services stated Staff H would be disciplined regarding the incident.

RESIDENT 13In an interview on 01/04/18 at 12:10 P.M., the resident was visibly upset about not receiving her medications in a timely manner. She reported she received her medication) injection anytime between 9 AM, and as late as after 12 PM. Staff H walked into the resident's room and told her she would administer the

injection when she changed her dressing. The dressing change was to occur around 1:00 P.M. The resident was then tearful and told Staff H she wanted it now as it was already late. The resident was visibly upset about the lack of a standard time in which she received her medications. The resident reported fears of complications from not receiving her ordered medications on time.

Review of the MAR showed the was adminstered at 11:00 AM and 11:00 PM. The

was adminstered outside of the scheduled timeframe.

At 4:30 PM, the DNS was made aware of the above medication error.

RESIDENT 14During a record review on 01/03/17 at 1:30 PM, revealed a pharmacy recommendation, dated 08/15/17, to address an order. It was addressed by the Nurse Practitioner (NP) on 09/01/17 who marked Agree with the pharmacists recommendation. The order was marked as processed on 09/01/17. The MAR did not reflect the new order.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




On 11/29/17 the order was discontinued and there was no order found in the chart.

In an interview 01/03/17 at 1:45 PM, Staff A, Residential Care Manager (RCM), was unable to explain why the was discontinued without an order or why the original order was not on the MAR.

In an interview on 01/04/18 at 1:00 P.M. with Staff C, SCD, reported she had asked the NP to address the medication error by writing a new order for

The pharmacy request was dated 08/15/17, the order was not addressed until 09/01/17 and as of 01/03/17 the order was still not correct, nor addressed by the RCM of the unit.

Additionally, review of the November and December MARs showed the LN did not accurately administer on 12/02/17 and 12/03/17 7:30 AM shift; on 12/19/17 Noon; and on 12/21/17 4:00 PM.

Review of the state reporting log showed the medication error were not identified or investigated.

In an interview on 01/04/18 at 4:16 PM, Staff A, RCM, confirmed the resident did not receive the correct the dose of .

RESIDENT 17Review of a facility investigation, dated 12/26/17, reported Resident 17 did not receive a 1:30 PM, dose of


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 760 Continued From page 60 F 760In an interview on 01/03/18 at 11:00 A.M., with Staff C, SDC remembered there was a call out, she had just gotten busy with many other residents, and did not even realize the mistake until a medication review was done. Staff C, SDC denied there had been any house wide in-services for the licensed nurses despite the increase in medication errors.

Refer to F725 CFR 483.35(a)(1)(2) Sufficient Nurse StaffRefer to F755 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures

Reference WAC 388-97-1060 (3)(k)(iii)

.

.F 761SS=E

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.

§483.45(h) Storage of Drugs and Biologicals

F 761 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 761 Continued From page 61 F 761§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, interview and record review the facility failed to ensure controlled medications were maintained in a separately locked permanently affixed compartment for 4 of 4 medication carts. The failure to ensure controlled medications were separately locked placed the facility at risk for potential abuse of controlled medications.

Findings included:

According to the State Operations Manual, Appendix PP, transmittal 173, dated 11/22/17 a controlled medication was substances that have an accepted medical use (scheduled II -V medications) have a potential for abuse, ranging from low to high, and may also lead to physical or

dependence.

In an observation on 01/04/18 at 12:53 PM, the Central and Swing medication cart was observed to have scheduled IV and V medications mixed in

1) No residents were identified2) Schedule 4 and 5 medications are now counted and double locked.3) Reeducate on proper storage of schedule 4 and 5 medications4) Random audits to validate schedule 4 and 5 medications are counted and double locked for 2 weeks and monthly x2and results will be brought to QAPI5) 2/13/186) Administrator and/or designee to validate compliance


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 761 Continued From page 62 F 761with the other non-scheduled medications. Staff D, Licensed Practical Nurse, stated only the scheduled II and III medications were locked in a separate compartment and reconciled every shift. Staff D stated it was not the facility practice to ensure the scheduled IV and V medications were also in a separately locked container.

In an additional observation on 1/4/18 at 1030 AM of the East and West medication carts showed the scheduled IV and V medications were stored with the other routine medications and not periodically reconciled.

On 01/04/18 at 2:44 PM, the Director of Nursing Service stated the facility did not lock up or count the scheduled IV and V controlled medications.

Reference: WAC 388-97-1300 (2) & -2340F 773SS=D

Lab Srvcs Physician Order/Notify of ResultsCFR(s): 483.50(a)(2)(i)(ii)

§483.50(a)(2) The facility must-(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.This REQUIREMENT is not met as evidenced by:

F 773 2/13/18

Based on interview and record review the facility 1) Resident 11 head to toe assessment


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 773 Continued From page 64 F 773physician orders showed there was no diagnosis the resident had the or if the resident was placed on contact precautions.

Reference: WAC 388-97-1620 (6)(b)(i)F 835SS=K

AdministrationCFR(s): 483.70

§483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.This REQUIREMENT is not met as evidenced by:

F 835 2/13/18

Based on observation, interview and record review, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements. The Administrator failed to ensure compliance related to the pharmacy services including medication errors, misappropriation of medications, delay in the delivery of medication, usage of expired medications and unattended medications being left at the bedside. By not ensuring the facility had a functioning medication system, this resulted in an Immediate Jeopardy situation.

Findings include:

Failed practice found during the abbreviated survey ending on 01/04/18 was as follows:

F 561- 483.10(f)(1)-(3)(8), Self DeterminationThe administration failed to ensure resident's choices were honored regarding bathing and

The facility is managed by a licensed nursing home administrator. Compliance with federal regulations is a key component of this individuals responsibility in cooperation with the Director of Nursing and other key team members. A plan of correction has been established for F-561, F-583, F-656, F-657, F-658, F-725, F-744, F-755, F-756, F-760, F-761, F-773, F-838, F842, and WAC 388-97-1620(I)

A review of other federal regulations and WAC's has been completed by the licensed nursing home administrator and Facility Leadership team to assure no other regulations are out of compliance.

An in-service for the licensed nursing home administrator and facility leadership team was conducted by the Divisional


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 835 Continued From page 65 F 835showers.

F 583 - 483.10(h), Privacy and ConfidentialityThe administration failed to ensure privacy was maintained for meetings between a Provider and resident.

F 656 - 483.21(b)(1), Develop/Implement Comprehensive Care PlanThe administration failed to ensure care plans were developed and revised as necessary to meet the needs of residents.

F 657 - 483.21(b), Comprehensive Care PlansThe administration failed to ensure facility staff developed individualized care plans.

F 658 - 483.21(b)(3)(ii)(iii), Services Provided Meet Professional StandardsThe administration failed to ensure facility staff provided care and services according to professional standards of practice.

F 725 - 483.35(a)(1)(2), Sufficient Nursing Staff The administration failed to ensure the facility had adequate staff to provide basic care and services. This caused harm related to the lack of a functioning medication administration system.

F 744 - 483.40(b)(3), Treatment/Service for DementiaThe administration failed to ensure appropriate treatment and services were provided to residents with dementia.

F 755 - 483.45, Pharmacy Services The administration failed to have a working accurate medication system in place to ensure accurate dispensing, administering, and storage.

Director of Clinical Services on state and federal regulations.

The progress on plans of correction for cited regulations will be reviewed weekly by the licensed nursing home administrator and the facility leadership team. This progress will be reported to the Divisional Director of Clinical operations. Trends identified will be reported to the QAPI committee monthly and as needed until a lesser frequency is deemed appropriate. Compliance with Federal and State Regulations will be audited monthly through the QAPI committee.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 835 Continued From page 66 F 835An immediate jeopardy was identified.

F 756 - 483, Drug Regimen ReviewThe administration failed to ensure that all pharmacy recommendations were followed up on.

F 760 - 483.45(f)(2), Residents are free from Medication ErrorsThe administration did not ensure drugs were stored in accordance with currently accepted principles.

F 761 - 483.45(g)(h)(1)(2), Label/Store Drugs & BiologicalsThe administration did not ensure drugs were stored in accordance with currently accepted principles.

F 773 - 483.50(a)(2)(i), Provide or obtain Laboratory services The administration failed to ensure the facility obtained physician order laboratory tests for a resident.

F838 - 483.70(e), Facility AssessmentThe administration failed to develop a facility wide assessment to determine resources necessary for care and services on a daily basis.

F842- 483.70(i)(1)-(5), Resident Records-Identifiable InformationThe administration failed to ensure resident records were legible and contained the required health information for Licensed Staff be able to provide care and services.

Reference (WAC) 388-97-1620(1)


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




.F 838SS=F

Facility AssessmentCFR(s): 483.70(e)(1)-(3)

§483.70(e) Facility assessment.The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and

F 838 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 838 Continued From page 68 F 838food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.This REQUIREMENT is not met as evidenced by: Based on observation interview and record review the facility failed to develop a thorough facility wide assessment to determine what resources were needed to care for the residents. Failure to include all of the essential components resulted in an assessment which was lacking facility and community-based risk, a plan based on risk, nor did it identify resources necessary for care and services on a daily basis.

Findings Include:

1) No residents identified2) The facility assessment is updated to include a community based all hazards risk assessment addressing how the facility provides services for each resident and population. The assessment now addresses behavior care services, staffing plan, day to day operations, competency review, preferences of care, staff resources, and planning for enhancements.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG




On 01/03/18 at 3:00 P.M., in an interview with the Director of Nursing Services and the Administrator, the Facility Assessment was jointly reviewed. Both were made aware the form provided lacked detail and some pages were blank. Information that was present was not complete, nor thorough. The Administrator was made aware the facility assessment was incomplete.

A review of the facility assessment found it lacked a facility and community based all hazards risk assessment. The assessment contained quarterly trending analysis for medical conditions in the facility but did not disclose how facility staff were going to provide services for each resident population within the analysis.

Per the assessment, the topic of behavioral care services warranted one person/staff to meet the basic staffing needs. This was identified by the Administrator on 01/04/17 at 1:30 P.M., as the

who comes to the facility to provide care to referred residents. Currently in the facility, four residents are requiring one to one monitoring. Three residents for intrusive wandering/exit seeking behaviors and another for kissing another resident. One staff was not adequate to meet the needs of these residents, nor did it explain care of the other behaviorally challenged residents.

The staffing plan is generic and nonspecific to the population identified in the trending analysis. There were no specific examples of populations and the services they were to receive.

There was nothing addressed about running day

3) Administrator educated on facility assessment requirements4) Audit of facility assessment completed monthly for 3 months and then quarterly by the governing body and medical director and results will be brought to QAPI5) 2/13/186) Governing body, administrator, and or designee to validate compliance.


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 838 Continued From page 70 F 838to day operations versus emergency operations.

There was no information provided in the competency review.

No specific information was provided for the ethnic, cultural or religious preferences of care.

No competency information was provided in the specific care or practice section of the assessment.

Staff resources sheet which listed specialized staff or outside facility resources, was blank. Contracts listed Premera Blue Cross Insurance. No other information was available regarding outside contracts.

The Planning for Enhancements section noted that no policy and procedure was needed for IV therapy or respiratory services. Training was required but materials would be provided through in-services, and there were no training dates listed. Projected date of materials is 01/31/18.

At a minimum, the facility assessment was to determine resources needed to have the facility function on a daily basis. It is individualized to the residents who live in the facility and their individual needs and preferences. This facility assessment was incomplete and lacked the thoroughness required by this assessment. This assessment did not demonstrate what resources are need to provide care for residents competently daily and during an emergency.

In addition, see the below citations for further information of how the incomplete facility assessment with lack of analysis resulted in


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 838 Continued From page 71 F 838failures of lack of staffing, lack of staff competencies and environmental challenges resulting in lack of privacy.

F 561- 483.10(f)(1)-(3)(8), Self DeterminationF 583 - 483.10(h), Privacy and ConfidentialityF 656 - 483.21(b)(1), Develop/Implement Comprehensive Care PlanF 657 - 483.21(b), Comprehensive Care PlansF 658 - 483.21(b)(3)(ii)(iii), Services Provided Meet Professional StandardsF 725 - 483.35(a)(1)(2), Sufficient Nursing Staff F 744 - 483.40(b)(3), Treatment/Service for DementiaF 755 - 483.45, Pharmacy Services F 756 - 483, Drug Regimen ReviewF 760 - 483.45(f)(2), Residents are free from Medication ErrorsF 761 - 483.45(g)(h)(1)(2), Label/Store Drugs & BiologicalsF 773 - 483.50(a)(2)(i), Provide or obtain Laboratory services

Reference: WAC 388-97-1000(1)(a)(b)(c)(d)F 842SS=E

Resident Records - Identifiable InformationCFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

§483.20(f)(5) Resident-identifiable information.(i) A facility may not release information that is resident-identifiable to the public.(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.

F 842 2/13/18


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 842 Continued From page 72 F 842§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete;(ii) Accurately documented;(iii) Readily accessible; and(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches


A. BUILDING ______________________






B. WING _____________________________


505092 01/04/2018C






(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 842 Continued From page 75 F 842Review of the December Medication Administration Record (MAR) showed the LN did not monitor the resident's on 18th or 21st.

Review of the medical record showed no further evidence the were completed.

The LN did not notify the physician of the missed .

In an interview on 01/04/18 at 4:16 PM, Staff A, LPN, confirmed the were not done and as directed by the physician. RESIDENT 9Review of progress notes since November admission revealed the nurses did not consistently record the time of the progress note on 21 of 31 entries. The entries listed the shift (day, eve, or noc) rather than the time the entry was made, leaving it largely unclear what time the entry was made.

Reference: WAC 388-97-1720 (1)(a)(i-iv)(b)


Documents

PRINTED: 03/14/2018 DEPARTMENT OF HEALTH AND …...Apr 18, 2001 · a. building _____ (x1) provider/supplier/clia identification number: statement of deficiencies and plan of correction