Avalon Care Center Federal Way, L.L.C.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice for 5 (Residents 11, 82, 69, 13, & 7) of 25 residents reviewed. The nursing staff's failure to clarify and/or follow Physician Orders (PO) and follow medication parameters placed residents at risk for unmet care needs, risk for medication errors, delayed treatment, and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 6 of 32 medications for 3 of 4 residents (Resident 8, 119, & 120) observed during medication pass resulted in a medication error rate of 18.75%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. The facility failed to follow precautions signs for 3 of 4 residents (Residents 52, 78, & 7) for Transmission-Based Precautions (TBP) and 2 of 2 residents (Residents 67 & 12) for Enhanced Barrier Precautions (EBP) as posted outside resident's rooms and failed to follow hand hygiene (HH) practice for 2 of 3 residents (Residents 8 & 12) during medication administration. These failures to wear PPE (Personal Protective Equipment - gown, gloves and goggles) as instructed on the signs outside resident's rooms and poor hand hygiene practice placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR - a mental health screening required prior to nursing home admission) evaluation was incorporated into the Care Plan (CP) for 1 of 5 residents (Resident 13) reviewed for PASRR. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and/or revise Care Plans (CP) as needed for 3 of 25 sample residents (Residents 91, 2 & 69) whose CPs were reviewed. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' ability to communicate was maintained for 2 of 3 sampled residents (Resident 13 & 69) when reviewed for communication. This failure placed the residents at risk of inability to communicate needs, social isolation, feelings of worthlessness, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 3 (Residents 70, 17 & 52) of 5 sample residents and 1 supplemental (Resident 69) resident reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with bathing, nail care, and shaving, placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 2 of 3 residents (Resident 15 & 69) reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative/functional maintenance services for 2 of 4 residents (Residents 5 & 70) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the gastrostomy tube (surgically placed tube through the abdominal wall into the stomach to provide nutrition) placement prior to initiating an enteral feeding (feeding through a tube), provide formula timely as scheduled, and failed to follow the physician orders for 1 of 1 residents (Resident 13) reviewed for tube feeding management. This failure placed residents at risk for alteration in nutrition, dehydration, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmacy recommendations for 2 of 6 residents (Residents 8 & 69) reviewed for pharmacy recommendations. These failures placed residents at risk of medication errors and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 2 medication storage rooms (West Station Medication Room) and 1 of 3 medication carts (West Two Medication Cart) reviewed for medication storage. This failure placed residents at risk for medication errors or receiving expired medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and obtain consent prior to implementing bed rails for 2 (Residents 1 & 2) of 3 sample residents reviewed for bed rails. The failure to assess and obtain consent prior to implementing bed rails resulted in Resident 1 sustaining a cut to their eyebrow and placed Resident 2 at risk for injury. These failures placed all residents at risk for injury and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of Antibiotics (ABO), reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 6 of 6 sample residents (Resident 204, 80, 77, 64, 47, & 3) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 7 of 7 residents (Residents 94, 31, 1, 20, 26, 23, & 59) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wrote<Resident 6> According to the 06/07/2024 Quarterly MDS Resident 6 was independent with lying to sitting on side of bed, sit to stand, chair-to-bed/bed-to-chair transfer, toilet transfer, and walked ten feet. This MDS showed Resident 6 had intact cognition. During an interview on 07/16/2024 at 9:07 AM Resident 6 stated they transferred from their bed to their wheelchair or walker and back to their bed independently. Review of Resident 6's Potential for Alteration in Activities of Daily Living CP on 07/18/2024 at 8:46 AM showed the CP had contradicting information. One intervention stated the resident required supervision or partial assistance of one staff for transferring. Another intervention stated Resident 6 was able to transfer on their own. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 7 of 8 residents (Residents 47, 20, 40, 41, 61, 32, & 59) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, and served under sanitary conditions. Facility staff failed to: consistently perform hand hygiene when preparing resident meal trays; label food items and discard expired food items from unit refrigerators; keep the kitchen dishwasher machine free from grime and debris build up; and maintain accurate documentation for the dishwasher temperature and chlorine chemical logs. These failures contributed to an unsanitary kitchen environment, placed residents at risk for food borne illness, and/or contaminated food.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: consistently performed Hand Hygiene (HH) before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP- implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms; and implement interventions to prevent Legionnaires disease (a serious severe respiratory infection caused by inhalation of bacteria growing in the water system) within the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents or their assigned representatives in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 residents (Residents 61 & 34) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' and/or their representative's ability to exercise their right to make an informed decision about proposed treatments, and prevented the residents and their representative from exercising their right to decline the treatments/therapies.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the appropriate Advanced Directives (AD) in place for 2 (Residents 61 & 6) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, and offered assistance to formulate an AD (Resident 61 and 6), and to obtain guardianship for Resident 61. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on interview and record review the facility failed to initiate a grievance for 2 (Resident 1 & 47) of 2 resident's reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform the resident of their findings and the actions taken, precluded the facility from identifying grievance trends and placed the resident at risk of feeling frustrated, unimportant, and with a decreased self-worth and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to document they communicated necessary resident information to the receiving health care institution or provider for 2 of 7 residents (Resident 1 & 31) reviewed for hospitalizations. Failure to ensure necessary resident information was communicated to the hospital placed residents at risk for decreased quality of care, inadequate care/treatment, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish a system that ensured residents who were transferred to the hospital or went on therapeutic leave were provided a written notice of bed hold that specified the duration of the bed hold policy upon transfer or attempted to contact the resident and/or the resident representative within 24 hours from an emergency transfer for 2 (Resident 59 & 23) of 7 sampled residents reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days from the date of determination for 1 (Resident 68) of 1 resident reviewed for significant changes in status. The failure to identify the need for a SCSA when Resident 68 had a decline in condition and was started on hospice services placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed accurately for 1 (Resident 61) of 5 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice for 4 (Residents 66, 32, 59, & 67) of 20 residents reviewed. The nursing staff's failure to follow and/or clarify Physician Orders (POs), and notify the provider of resident refusals of treatment, placed residents at risk for unmet care needs, and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident 61) of 3 sampled residents reviewed for communication, including language and speech, were provided a functional system to address their communication needs. Failure to identify and provide services which enhanced and or ensured effective communication, placed residents at risk for unmet care needs, social isolation, and a diminished sense of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 2 (Residents 61 & 62) of 20 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 61), and nail care (Resident 62), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 20 residents (Residents 41, 67, & 59) reviewed, received the necessary care and services in accordance with professional standards of practice, and the comprehensive person-centered care plan. The facility failed to complete weekly skin checks and provide the treatment for 2 of 4 residents (Residents 41 & 67) reviewed for non-pressure ulcers and failed to accurately set air mattress setting according to resident's weight for 1 of 4 residents (Resident 59) reviewed for air mattress setting. These failures placed residents at risk for decline in medical status, unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident 41) of 5 residents reviewed for Pressure Ulcers (PU's) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to consistently complete weekly skin assessment, assess skin integrity to identify PUs timely, and implement interventions to include updating the Care Plan (CP), placed Resident 41 at risk to develop new PU, and diminished quality of life. <Facility Policy> According to the facility's 08/2018 Quality of Care- Skin Integrity policy, the facility would assess residents upon admission and thereafter, to identify if the resident had existing PU's or was at risk for developing PUs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 1 of 8 (Resident 68) sample residents reviewed for accident hazards. The failure to assess devices such as wedges placed Resident 68 at risk for accidents, injury, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain consent for Bed Rails (BR) for 3 (Residents 1, 297, & 20) of 3 residents reviewed for BR's. Facility failure to attempt alternatives before implementing BR's, assess residents for safe use of BR's, or obtain informed consent for the use of BR's placed all residents at risk for harm or injury and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and carried out in a timely manner for 3 of 5 residents (Residents 32, 67, & 34) whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects, and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (Residents 24 & 32) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1 of 5 nurses (Staff N - Licensed Practical Nurse) to properly administer 2 of 25 medications for 1 (Resident 203) of 8 residents observed during medication pass resulted in a medication error rate of 8%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured for 3 (Resident 90, 23, & 52) of 21 sample residents observed with medications in their rooms. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed, self-administration of medications by residents.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure 1 out of 1 walk-in freezers was maintained in satisfactory working condition. The freezer temperature logs indicated the temperature was elevated for a month prior to the start of the survey and there was a leak in a pipe resulting in substantial ice buildup in the freezer. Although service visits were made a couple of weeks prior to the survey, the freezer continued to be out of temperature range and with significant ice buildup, without additional follow-up being implemented. This failure placed residents at risk for spoiled food.

Inspectors wroteBased on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 161 & 162) of 4 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the State Office of the Long-Term Care Ombudsman (LTCO) for 2 of 3 residents (Residents 110 & 109) reviewed for discharge. The failure to have an established system of discharge notification to the LTCO placed all discharged residents at risk for lack of information about discharge, access to an advocate who could inform them of their options and rights, and risk for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the bed-hold notice (a document detailing the duration, cost, and conditions of return, when holding a bed while the resident was at the hospital) for 2 of 2 residents (Residents 57 & 62) reviewed for hospitalization. This failure placed residents at risk for being uninformed and unable to exercise the right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food served to residents was palatable, attractive and at a safe and appetizing temperature for 8 of 34 sampled residents (Resident 23, 39, 37, 20, 54, 40, 65, & 35) and 22 residents who attended the food committee. The failure to obtain and act on feedback from residents regarding food and failure to ensure food temperatures were maintained during transport from the kitchen to the resident placed residents at risk for decreased intake, weight loss, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and exiting staff as identified in the Facility Assessment. The failure to ensure new staff received orientation and were evaluated for skill sets within their scope of practice, evaluate staff skills annually, and provide annual training on abuse/neglect, mandated reporting, resident rights, communication, person-centered care, dementia care, and behavioral health, for 9 of 10 (Staff J, K, L, M, N, BB, G, Z, and I) staff placed residents at risk for unmet needs, inadequate quality of care and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notices (SNF-ABN) and/or a Notice to Medicare Provider Non-Coverage (NOMNC) for 2 of 3 residents (Resident 102 & 262) reviewed for SNF ABN and NOMNC notification. The failure to provide residents information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: ensure 1 (Resident 82) of 1 residents reviewed for positioning was positioned correctly in their wheelchair; ensure care was coordinated with hospice services for 1 (Resident 78) of 1 residents reviewed for hospice services. Facility failure to ensure correct positioning left Resident 82 at risk for discomfort, and negative health outcomes. The facility's failure to coordinate care with hospice left Resident 78 at risk for receiving unnecessary care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with urinary catheters received appropriate treatment and services for 2 of 4 (Residents 37 & 75) residents reviewed for indwelling urinary catheters. The failure to obtain and follow physician orders for catheter care placed residents at risk for infection and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a system of records for accurate reconciliation of narcotic drugs for 1 of 3 medication carts. The failure to accurately count and verify the inventory of controlled substances - narcotic drugs through reconciliation at shift change, placed residents at risk for potential financial loss, not receiving narcotic pain medication, and possible drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to identify and monitor resident-specific behaviors for the use of Antipsychotic (AP) medication and document the rationale for the use of an as needed (PRN) AP medication. The facility failed to implement non-pharmacological interventions for 1 of 5 residents (Resident 361) reviewed for unnecessary medications. This failure placed residents at risk for unmet behavior needs and a diminished quality of life.