Everett Transitional Care Services

Inspectors wroteBased on observation, interview and record review the facility failed to prevent an accident for 1 of 1 sampled resident (Resident 1) reviewed for burns. Resident 1 experienced harm when facility staff heated food and then failed to ensure safe temperatures prior to serving the resident, resulting in second degree burns. The facility failed to report to the appropriate state agencies at the time of the incident. This failure also placed other residents at risk of serious injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care and services were provided in accordance with accepted professional standards of practice for 3 of 4 sampled residents (Residents 14, 15, and 41) reviewed for respiratory care. Failure to change oxygen (O2) tubing routinely, failure to have appropriate orders for O2 administration and failure to have warning signs posted on resident's doors placed residents at risk for respiratory complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans to include all provided nursing services for 2 of 3 sampled residents (Resident 41 and 15) reviewed for oxygen (O2) and 1 of 5 sampled residents (Resident 41) reviewed for unnecessary medications related to mental health. These failures placed residents at risk of unmet care needs, decline in condition, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage and labeling of insulin (a medication that controls blood sugars) in 1 of 4 medication carts (Cart 4) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise care plans for four of 14 residents (Residents 3, 11, 43 and 57) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for weight loss, dehydration, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for five of five employees (J, P, Q, R, and S) reviewed, who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs, and the quality of care provided to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and at a palatable temperature on 1 of 2 floors (5th Floor). Failure to ensure timely meal delivery could negatively impact the residents' nutritional status, appetite, and meal acceptance.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 of 5 nurse aides (Staff P and S) had their required 12 hours of in-service training, and 5 of 5 nurse aides (Staff J, P, Q, R and S) failed to receive the required dementia training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training and required dementia training placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary assistance for eating, and drinking, for 2 of 2 residents (Residents 16 and 57) dependent on staff to ensure their needs were met. The failed practice placed residents at increased risk for medical complications, poor quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (Resident 21) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to assess and alert the physician of elevated blood sugar levels and hold medications as directed for abnormal vital signs. This placed the residents at increased risk of unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 21) reviewed for dialysis services received consistent, ongoing communication and collaboration with the dialysis facility regarding care and services for dialysis residents. These failures failure had the potential to cause unmet care needs, medical complications, inadequate quality of care, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Resident 43) reviewed for unnecessary medication use. This failure placed the resident at risk for experiencing medication related complications and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 5 sampled residents (Resident 460) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors and update the care plan. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan, for 3 of 4 sampled resident (Residents 38, 152 and 248) whose care plans were reviewed for dialysis (medical procedure to purify the blood) care. Failure to establish care plans that were timely, individualized, accurately reflected assessed care needs, and provided direction to staff placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and to ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (Fourth floor and Fifth floor) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 3 residents (Residents 5 and 22) sampled for hospitalization. This failed practice placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed use of a respirator (N-95 mask that provides more protection) and Personal Protective Equipment (PPE, equipment to protect staff from contact with potentially harmful germs such as gown and gloves) for 1 of 2 rooms (room [ROOM NUMBER]) reviewed for Transmission Based Precautions (TBP, list of precautions staff were to use based on the type of disease or condition). Failure to follow TBP put staff and residents at risk for the transmission of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation that staff were provided education regarding the benefits and potential risks associated with the COVID 19 (an infectious disease of a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) Vaccine for 2 of 2 staff (Staff F and G) reviewed for immunizations. This failure put staff at risk of not having adequate information to decide if the COVID 19 vaccination was appropriate for them.