Accura Healthcare of Pierce

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview, the facility failed to ensure Resident 7's Pre-admission Screening and Resident Review (PASRR-screening used to determine if a person had or was suspected of having Mental Illness (MI), Intellectual Disability (ID), or a Related Condition (RC)) was completed accurately. The sample size was 2 and the facility census was 36.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09(H)Based on record review and interview; the facility failed to provide monitoring and treatment related to changes in bowel elimination for Resident 13. The sample size was 4 and the facility census was 36.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(H)(ii)(1) Based on record review and interview; the facility failed to employ a qualified Dietary Manager (DM). This had the potential to affect food service provided to all residents who were served food from the kitchen. The facility census was 33.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.06(A) Based on record review and interviews; the facility failed to notify residents of the resolution for grievances for 2 (Resident 11 and 16) of 21 sampled residents. The facility census was 33.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview; the facility failed to accurately code 2 (Resident 22 and 29) of 12 sampled residents' Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) to accurately reflect their Preadmission Screening and Resident Review (PASRR-federally mandated preadmission screening designed to determine appropriate placement and services for residents with mental illness (MI), intellectual disability (ID), or developmental disability (DD) status.). The facility census was 33.

Inspectors wroteBased on record review and interview; the facility failed to complete a new Preadmission Screening and Resident Review (PASRR- federally mandated preadmission screening to determine appropriate placement and services for those residents with Mental Illness/Intellectual Disability or Related Disorders (MI/ID/RD)) for 1 (Resident 29) of 2 sampled residents when the initial PASRR approval time expired. The facility census was 33.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on record review and interview; the facility failed to implement nutritional interventions for the prevention of weight loss for 1 (Resident 21) of 3 sampled residents. The facility census was 33.

Inspectors wroteBased on record review and interview; the facility failed to develop and implement individualized interventions to prevent or to minimize the effects of potential trauma triggers for 1 (Resident 23) of 21 residents sampled. The facility census was 33.

Inspectors wroteBased on record review and interview; the facility failed to identify and monitor specific target behaviors, to have documented non-pharmacological interventions to address potential behaviors and to attempt a Gradual Dose Reduction (GDR) and/or have a documented contraindication for the GDR related to use of a psychotropic (a drug or substance that affects how the brain works) medication for 1 (Resident 26) of 5 sampled residents. The facility census was 33.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observations, record review and interview, the facility failed to ensure measures were implemented to prevent the potential of food borne illnesses related to food storage and unserviceable cookware items. This had the potential to affect all residents who consumed food from the kitchen. The facility census was 35.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to accurately code Residents 3, 16, 23, 26, and 30's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) to reflect the resident's current nutritional interventions. The sample size was 15 and the facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide 1 (Resident 28) of 3 sampled residents with the cost of continuing to receive skilled Medicare Services, a choice of whether to appeal the facilities Medicare determination to discontinue services, or the reason for the discharge from skilled Medicare services. The facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C Based on record review and interview, the facility failed to ensure individualized Care Plans were developed to address: 1) changes in fluid restriction amounts and current discharge status for Resident 26 and 2) current discharge status and hospice services for Resident 30. The sample size was 2 and the facility census was 35.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D8 Based on record review and interview, the facility failed to ensure Resident 31's weight loss was reported to and reviewed by a facility dietitian to ensure the resident was receiving the required calories and nutrition. The sample size was 13 and the facility census was 34. Review of the facility policy Weight Changes dated 6/2015 revealed the following; -The nutritional statuses of residents were evaluated routinely, and appropriate nutrition interventions were implemented to prevent weight loss. -Weight changes were evaluated and monitored by the nutritional services staff and appropriate interventions were implemented. -For unplanned weight loss the facility evaluated the resident and calculated the estimated nutritional needs. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure as needed psychotropic (medications which alter consciousness, mood and thoughts) medications were limited to 14 days or had a defined duration of administration for Resident's 23 and 32. The total sample size was 15 and the facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview, the facility failed to: 1) prevent the potential spread of Covid-19 infection related to two residents (Resident's 26 and 35) who had potential symptoms and were not tested according to current guidelines and 2) track pathogens [an organism causing disease to its host] to identify potential trends related to infection surveillance. The total sample size was 15 and the facility census was 35.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04A3d Based on record review and interview, the facility failed to complete the required background checks for 1 (Cook-N) of 5 sampled staff. This had the ability to affect all residents. The facility census was 34.

Inspectors wroteBased on observation, record review and interview; the facility failed to ensure the daily posting of nursing hours included the required information. This had the potential to affect all residents. The facility census was 34.