Avamere Transitional Care of Puget Sound

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to prevent the development and/or promote healing of PU/PI (Pressure Ulcers/Pressure Injuries) for 1 of 3 Residents (Resident 1) reviewed for PU/PIs. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 3 residents (Resident 1) reviewed for assessments. The failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet care needs and diminished quality of care/quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure treatment and medication carts were secured/locked when unattended for 4 of 4 treatment carts (Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall) and for 4 of 4 medication carts (Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall) when reviewed for medication storage. This failure placed residents at risk for drug diversion and potential loss of medications/treatments.

Inspectors wroteBased on interview and record review, the facility failed to consistently offer/provide showers and oral care for 3 of 4 sampled residents (Residents 14, 84 and 88) when reviewed for activities of daily living (ADL). These failures placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to provide care in a timely manner and complete activities of daily living for 1 of 4 halls (300 hall) when reviewed for sufficient staffing. This failure placed residents at risk for unmet needs, decreased self-worth and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's request for mobility bars for 1 of 6 sampled residents (Resident 93) when reviewed for choices. This failure placed the resident at risk of fear of falling, inability to sleep, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a care conference meeting with a resident or responsible party for 1 of 19 sampled residents (Resident 74) when reviewed for care plans and care planning. This failure placed Resident 74 at risk for unmet needs, not being involved or informed of their plan of care, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a provider order and interventions in place for 1 of 1 sampled resident (Resident 91) when reviewed for a life vest (a device worn under clothing with an attached monitor, designed to protect a person from sudden cardiac arrest/heart stop beating, by monitoring the hearts electrical activity and automatically delivers an electrical shock to correct a dangerous heart rhythm, preventing a potentially fatal event), and failed to ensure care and services were in place to treat a non-pressure skin issue for 1 of 3 sampled residents (Resident 68) when reviewed for general and/or skin conditions. These findings placed residents at risk of unmet needs, worsening conditions, clinical complications, and a decreased quality of life. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 sampled residents (Residents 88 and 101) when reviewed for respiratory care. Failure to follow physician orders for oxygen (O2) therapy placed the residents at risk for unmet needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely medication regimen review on admitting to the facility for 1 of 5 sampled residents (Resident 9) when reviewed for medication regimen review. This failure placed the resident at risk of allergic reaction, receiving contraindicated medication, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) and to have pain level parameters in place prior to giving as needed pain medication for 1 of 5 sampled residents (Resident 45) when reviewed for unnecessary medication use. This failure placed a resident at risk of receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to implement the appropriate use of transmission-based precautions (TBP) for 1 of 4 hallways (North front) when reviewed for TBP. This failure placed residents and staff at an increased risk for communicable diseases and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow prepared menus and ensure any changes were reviewed with the registered dietician when reviewed for kitchen. This failure placed residents at risk of not receiving adequate nutritional intake, decrease in weight, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify and report an allegation of abuse for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed all residents at risk for unidentified and ongoing abuse/neglect and lack of protection from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the correct texture of food was served to a resident with a prescribed therapeutic diet for 1 of 1 residents (Resident 1) reviewed for prescribed therapeutic diets. This failure placed the resident at risk for choking, aspiration pneumonia (a lung infection that occurs when food, liquids, or other substances are inhaled into the lungs instead of being swallowed), hospitalization, and a decreased quality of life. The facility had corrected the above deficiency prior to the complaint survey, and it is constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.

Inspectors wroteBased on interview and record review, the facility failed to investigate an unexpected death to rule out mistreatment for 1 of 4 sampled residents (Resident 52) and failed to investigate an allegation of abuse for 1 of 4 sampled residents (Resident 114) when reviewed for Abuse. This failure placed residents at risk of abuse, neglect, avoidable death, retaliation from staff, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 2 of 12 sampled residents (Residents 107 and 307) reviewed for resident assessment. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 12 sampled residents (Residents 113, 44, 108, and 306) reviewed for Care Plan. This failure placed residents at risk for unidentified outcomes or goals, inconsistent or lack of interventions, and diminished quality of life.

Inspectors wroteSurveyor: [NAME]BR/>Based on observation, interview and record review, the facility failed to follow provider's orders, ensure medications had safe monitoring and hold parameters, and notify the provider of changes in condition and medication errors for 8 of 10 sampled residents (Residents 52, 44, 206, 8, 112, 1, 107, and 9) when reviewed for Quality of Care. These failures placed residents at risk of decline in condition, lack of timely interventions to prevent death, avoidable side effects, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a working doorbell for handicap residents visiting the courtyard for 1 of 1 courtyard reviewed for accident hazards. This failure placed residents at risk for accidents, anxiety, feelings of entrapment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide nonpharmacological interventions before administrating as needed pain medications for 2 of 5 sampled residents (Residents 44 and 1) when reviewed for unnecessary medications. This failure placed residents at risk of taking unnecessary medications, experiencing avoidable side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications in 2 of 2 medication rooms (North and South medication rooms) and 2 of 2 medication carts (South High and South Low) when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective medications, risk for drug diversion and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 months (April, May and June 2024) reviewed for Infection Control. The facility also failed to implement transmission-based precautions (TBP) for 1 of 2 halls (200 hall) reviewed for TBP. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the infection prevention and control program (IPCP) was overseen by a qualified individual with the time and training necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as Quality Assurance and Performance Improvement (QAPI) for 1 of 1 infection control preventionist (ICP, Staff Z) reviewed for infection preventionist qualifications. This failure placed residents, family members and staff at risk of contracting communicable diseases and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide education on the benefits and potential side effects of the Covid-19 vaccination prior to offering the vaccine for 4 of 5 sampled residents (Residents 14, 15, 20 and 34) when reviewed for vaccinations. This failure placed residents and their representatives at risk of not being given the opportunity to make an informed decision regarding their medical care, potential complications of a communicable disease, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party and/or to properly notify the Office of State Long-Term Care Ombudsmen (an advocacy group for residents in a nursing home) of discharges to the hospital for 2 of 2 residents (Residents 22, and 75) reviewed for Hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and ensure that the Offices of the State Long-Term-Care Ombudsmen was aware of the facility practices and activities related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice in writing, at the time of transfer/discharge to the hospital and/or within 24 hours of transfer/discharge to the hospital for 2 of 2 residents (Residents 22 and 75) reviewed for Hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized .

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or implement comprehensive person-centered care plans (CPs) for 5 of 12 sampled residents (Residents 22, 24, 69, 18, and 130) whose CPs were reviewed. Failure to develop and implement CPs that were individualized, and accurately reflected resident care needs related to edema/swelling, nail care, use of blood thinning medications, and falls, placed residents at risk for unmet care needs and potential negative outcomes. Findings Included . Resident 22 Review of the 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 22 readmitted to the facility on [DATE] with a diagnosis of lymphedema (swelling due to buildup of fluid in the body) and was able to make needs known. It further showed that Resident 22 received diuretics (medication that help reduce fluid buildup in the body). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary goods and services to prevent development of avoidable pressure ulcers (PU), and/or promote healing of identified PUs for 2 of 3 residents (Resident 177 and 24) reviewed for pressure injuries. The failure to ensure assessment and ongoing monitoring of PUs were conducted, placed the residents at risk for unidentified wound development/decline, a delay in treatment, infection, and other potential negative outcomes. Resident 177 Resident 177 admitted to the facility on [DATE]. According to the 08/14/2023 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, required extensive assistance with bed mobility, and demonstrated no behaviors or rejection of care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently maintain the medication refrigerator temperature log in 2 of 2 medication rooms (North and South) reviewed for medication storage. This failure placed the residents and/or staff at risk for receiving compromised or ineffective medications with unknown potency.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by completing the collection and analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for three of three months (May, June, and July 2023) reviewed for Infection Control. Also, the Facility failed to implement recommended control measures for an active Covid-19 disease outbreak for 07/16/2023 through 08/18/2023 and failed to implement the facility's water management program. These failures placed residents, visitors, and staff at risk for communicable diseases, related complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program for 1 of 1 resident (Resident 61) reviewed for antibiotic use and to promote appropriate use of antibiotics and reduce the risk of antibiotic resistant organisms and unnecessary antibiotic use for 3 of 3 months (May, June, and July 2023) Reviewed for infection control. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the State Agency within 24 hours and to log the incident in the facility's reporting log as required for 2 of 3 residents (Resident 230) when reviewed for abuse/neglect and/or falls. In addition, the facility failed to report Covid-19 (a highly communicable respiratory infection) cases for 1 of 1 outbreak (Dated 07/16/2023 - 08/18/2023) to the State Agency within 24 hours and log the incident in the facility's reporting log when reviewed for Infection Control. These failures placed the residents at risk for potential unrecognized abuse, spread of infection, delayed investigation, delayed corrective actions, recurrence of the incidents and a diminished quality of life.

Inspectors wroteResident 177 Resident 177 admitted to the facility on [DATE]. Review of the resident's physician's orders showed a 08/09/2023 order to administer daptomycin (an antibiotic medication) intravenously (IV) every 24-hours for left upper extremity cellulitis (bacterial skin infection.) Review of Resident 177's 08/14/2023 admission MDS showed the resident received no IV medications during the assessment period (08/08/2023- 08/14/2023.) Review of Resident 177 's August 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed the resident was administered IV daptomycin on 08/09/2023, 08/11/2023, 08/12/2023 and 08/14/2023. During an interview on 08/17/2023 at 11:03 AM, Staff C, Resident Care Manager, stated that Resident 177s MDS was inaccurate and needed to be corrected to reflect the administration of IV medication. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessment was accurately completed for 1 of 5 residents (Resident 22) reviewed for Unnecessary Medications. This failure placed the resident at risk for unidentified mental health care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet residents immediate care needs for 1 of 9 residents reviewed (Resident 177) who had recently admitted to the facility. This failure placed the resident at risk for medical complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 3 of 15 residents (Residents 55, 72 and 26) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 15 sample residents (Residents 177, 55 and 26) reviewed. This failure of the facility to obtain, follow, implement and/or clarify physicians' orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication and treatment errors, and other potential adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one of one resident (Resident 24) reviewed for ADLs. Failure to provide Resident 24 who was dependent on staff for grooming placed the resident at risk for decreased quality of care and diminished quality of life. Resident 24 admitted to the facility on [DATE] with a diagnosis of stroke with hemiplegia (paralysis of one side of the body). Resident 24's quarterly Minimum Data Set assessment (MDS), dated [DATE], showed the resident required extensive assistance with dressing and personal hygiene. Observation and interview on 08/15/2023 at 11:44 AM, showed Resident 24 lying in bed with short hair above their ears. Resident 24 stated that they were unhappy with the recent haircut they had received 2 days prior. [...]

Inspectors wroteResident 69 Observation and interview on 08/15/2023 at 12:32 PM, showed Resident 69 sat in their wheelchair next to their bed with their spouse. Resident 69 had bruising noted to both of their forearms and the resident stated that they bruise very easily. Review of Resident 69's Electronic Health Record on 08/15/2023 at 12:37 PM, showed an order for an anticoagulant (medication the keeps the blood from clotting) every evening for 30 days with a start date of 07/28/2023. Review on 08/16/2023 at 3:15 PM of Resident 69s Electronic Health Record showed an order to monitor/document/report to the provider any signs or symptoms of anticoagulant complications to include bruising and document a plus sign if present and a negative sign if not present. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe resident environment was maintained, free of accident hazards, for 3 of 4 residents (Residents 177 and 31) reviewed for accidents. The failure to ensure resident equipment was safe, functional and in good repair, placed residents at risk for avoidable falls, fractures, pain and other potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 1 resident (Resident 23) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received, was reconciled with the amount they were ordered to receive. This prevented staff from identifying that the facility consistently administered Resident 23 less than the ordered amount of enteral formula and placed the resident at risk for inadequate nutrition, hydration, and other adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 2 residents (Resident 177) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 1 of 5 residents (Resident 22) reviewed for Unnecessary Medication. Failure to provide non-pharmacological (approaches, therapies, or treatments that do not involve drugs) interventions prior to giving as needed pain medications placed residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary antidepressant medications for 1 of 5 residents (Residents 22) reviewed for Unnecessary Medications. Failure to ensure Resident 22's behaviors were consistently monitored and documented placed the resident at risk for receiving unnecessary medications, adverse side effects and poor quality of life.