state of washington department of social ......lori madison, rn kathy nibler, ba kara mitchell, rn...

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

Aging and Disability Services Aging and Long-Term Support Administration

PO Box 45819, Olympia, WA 98504-5819

November 21, 2019

AdministratorRegency Olympia1811 E 22nd AveOlympia, WA 98501

Dear Administrator:

The Department of Social and Health Services (DSHS), Residential Care Services, isaccepting your electronic Plan of Correction (ePOC) dated October 28, 2019 and thecredible information submitted by you as evidence that violations dated October 4,2019, are in fact, corrected effective November 12, 2019.

Based on this information, DSHS will notify the Centers for Medicare and MedicaidServices (CMS) Region X that your facility is in substantial compliance with participationrequirements effective November 12, 2019, and recommend that your facility'scertification for Medicare and/or Medicaid participation continue.

If you have any questions please contact me at 360-664-8422.

Sincerely,

Sonya ConwayField Manager - Region 3C Residential Care Services

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as prepared by Residential Care Services for the Locator website.

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

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PRINTED: 02/27/2020FORM APPROVED

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

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

1811 EAST 22ND AVENUEREGENCY OLYMPIA REHABILITATION AND NURSING CENTER

OLYMPIA, WA 98501

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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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 Long Term Care Off-Hours Survey and Complaint Investigation conducted at Regency Olympia Rehabilitation & Nursing Center on 10/01/19, 10/02/19, 10/03/19 and 10/04/19. The survey included data collection on 10/03/19 from 5:00 AM to 2:30 PM. A sample of 23 residents was selected from a census of 21. The sample included 20 current residents and the records of 3 discharged residents.

The following complaints were investigated as part of this survey:36704943670632

The survey was conducted by: Lori Madison, RNKathy Nibler, BAKara Mitchell, RNTeri Germann, RN

The survey team is from:Department of Social and Health ServicesAging and Long Term Support AdministrationResidential Care Services, Region 3, Unit CP.O. Box 45819Olympia, Washington 98504-5819

Telephone: 360.664.8420Fax: 360.664.8451

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

10/25/2019Electronically 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 IL0Q11Event ID: Facility ID: WA33700X If continuation sheet Page 1 of 38

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F 550SS=D

Resident Rights/Exercise of RightsCFR(s): 483.10(a)(1)(2)(b)(1)(2)

§483.10(a) Resident Rights.The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her

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F 550 Continued From page 2 F 550rights and to be supported by the facility in the exercise of his or her rights as required under thissubpart.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 1 of 1 sampled residents (#71) reviewed for abuse. This failure placed residents at risk for psychosocial distress and a diminished sense of dignity.

Findings included...

Resident #71 was admitted to the facility on /19 with diagnoses including .

Resident #71's "at risk for behavior symptoms" care plan, dated 09/20/19, included an intervention to "approach resident in a calm manner, re-approach at a later time if agitated or uncooperative."

Resident #71's "impaired cognitive function/dementia or impaired thought process" care plan, dated 09/26/19, documented Resident #7 was moderately cognitively impaired.

A facility incident report, dated 09/30/19, documented, "[Resident #71] told [day shift Certified Nursing Assistant] she had recorded a conversation through her cell phone the night shift staff conversation they had with [Resident #71]... [Director of Nursing Services (DNS)] and Social Worker visited resident to hear the recording... DNS and Social Worker heard the recording and heard a dialogue occurring about

The plan of correction is prepared and submitted as required by law. By submitting this plan of correction Regency Olympia Rehabilitation Center does not admit that the deficiencies listed exist nor does the community admit to any statements, findings, facts or conclusions that form the basis of the alleged deficiencies. Regency Olympia Rehabilitation Center reserves the right to challenge in legal proceedings all deficiencies, statements, findings, facts, and conclusions that form the basis of the alleged deficiency.

SPECIFIC RESIDENTSResident #71, an investigation was completed and staff J was provided 1:1 counseling.

OTHER RESIDENTSOther residents were interviewed and none were found to be in a similar situation. Residents will be provided care in a dignified manner.

SYSTEMIC CHANGESNursing staff was educated on providing care to residents in a dignified manner and dealing with difficult residents.

MONITOR3 residents will be interviewed weekly by


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F 550 Continued From page 3 F 550resident accusing night shift licensed nurse that she had stolen [Resident #71's] dress... After about 5-6 minutes in the recorded conversation, the resident was screaming and accusing staff they had stolen her dress and told her 'she was an elephant' ... staff reassured her she was not an elephant and they did not call her an elephant... resident was persistent telling the staff they were telling her she was an elephant. [Staff J, Nursing Assistant] repeated what resident said and told resident she was an elephant."

On 10/01/19 at 9:57 AM, Resident #71 was observed in a wheelchair in her room. When asked if she was treated with dignity and respect, the resident stated, "There are some that do and some that don't." When asked for more information, Resident #71 stated, "I don't want to talk about that. I've talked about it until I am blue in the face."

On 10/02/19 at 2:52 PM, when asked about the incident on 09/30/19, Staff B, Registered Nurse (RN) and Director of Nursing Services, said when she heard the recording "the resident was repeating [what she was saying] over and over and [the resident] wouldn't allow staff to say they weren't. [Resident #71] was overriding everything they were saying. [The resident] seemed to be targeting [Staff J], and out of shock [Staff J] said 'you are an elephant.' It wasn't hateful. It was a spontaneous response."

At 2:55 PM, when asked if Resident #71 was treated with dignity and respect in that situation, Staff B stated, "No, she was not treated with dignity."

Social Services for 3 months to ensure they are receiving care in a dignified manner. Any identified issues will be addressed. Findings from the audits will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.

TITLE OF PERSON RESPONSIBLE FOR CORRECTIONAdministrator/ designee

DATE OF COMPLIANCE 11/12/2019


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F 550 Continued From page 4 F 550At 2:56 PM, Staff P, RN and Vice President of Clinical Services, stated, "[The staff] should have just walked away."

Reference WAC 388-97-0180 (1-4).

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.This REQUIREMENT is not met as evidenced

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F 561 Continued From page 5 F 561by: .Based on interview and record review, the facility failed to ensure bathing frequency and medication regimen preferences were honored for 2 of 4 sampled residents (#4 & 9) reviewed for self-determination. This failure placed residents at risk for poor hygiene, inability to participate in decisions about their care, and a diminished quality of life.


1) Resident #9 was admitted to the facility on /19. The Minimum Data Set (MDS), an

assessment tool, dated 08/23/19, showed the resident was cognitively intact and required one person to physically assist with bathing.

The Activities of Daily Living care plan, initiated 9/13/19, showed an intervention for showers on Wednesday and Sunday.

Review of Resident #9's shower documentation showed, between 09/13/19 and 10/02/19, the resident received 4 of 6 scheduled showers.

On 10/01/19 at 10:48 AM, Resident #9 said she was scheduled to get a shower on Wednesday and Sunday. The resident said she had not been getting the Sunday shower.

On 10/02/19 at 1:24 PM, Staff F, Nursing Assistant, said the daily shower list was in their point of care charting. Staff F said showers and refusals were charted in the computer and reported to the nurse. Staff F said Resident #9 rarely refused showers.

SPECIFIC RESIDENTSResidents� #9 was interviewed and bathing preference was updated as indicted.Resident #4 is no longer residing in the facility.

OTHER RESIDENTSResidents were interviewed on bathing preferences and the bathing schedules updated as indicated. Residents will receive baths per preference. Other residents were reviewed for frequent medication refusals and follow-up completed as indicated.

SYSTEMIC CHANGESNursing staff was educated on completion of bathing per resident preference and documentation. Licensed Nurses were educated on resident medication refusals, reasons and follow-up with physician on potential order changes. IDT was educated on completing any needed follow-up per care conference.

MONITORBathing documentation will be audited weekly for 3 months by Medical Records/ designee to ensure residents are receiving bathing per their preference. Medication refusals will be audited weekly by DNS/ designee for 3 months to ensure follow-up completed. Any identified issues will be addressed.Findings from the audits will be presented to the QAPI meeting for 3 months to


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F 561 Continued From page 7 F 561

On 10/01/19 at 10:29 AM, when asked if staff included her in decisions about her medications and care, Resident #4 stated, "No, and I say no, because they have given me my Miralax without telling me. I found out when I had diarrhea, and I had taken before my stroke, and I know what's going on with my body. I have regular bowel movements, and I knew when it came without warning that something wasn't right. Now I keep my own cup for water so they can't sneak it in there."

On 10/02/19 at 11:19 AM, when asked about Resident #4's Miralax not being given per her choice, Staff C, Licensed Practical Nurse and Resident Care Manager, stated, "It might have been a communication problem or we might have noticed she was refusing so much." When asked why it was not changed when the resident requested it, Staff C stated, "It was probably just not communicated to the doctor."

On 10/03/19 at 8:24 AM, when asked about her expectation for when the order should have been changed, Staff B, Registered Nurse and Director of Nursing Service, stated, "Yeah, I agree that the expectation is that it should have been changed sooner."

Reference WAC: 388-97-0900 (1-4).

F 578SS=D

Request/Refuse/Dscntnue Trmnt;Formlte Adv DirCFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to

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F 578 Continued From page 8 F 578formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.This REQUIREMENT is not met as evidenced by:


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F 578 Continued From page 9 F 578 .Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing Advanced Directives (AD) for 1 of 3 sampled residents (#16) reviewed for Advanced Directives. This failure placed residents and/or legal representative at risk of being denied the opportunity to make desired choices regarding end of life care.


Resident #16 was admitted to the facility on /07. The Minimum Data Set, an

assessment tool, dated 09/06/19, documented the resident was cognitively intact and required extensive assistance with activities of daily living.

Resident #16's medical record contained a Power of Attorney (POA), dated 10/08/08. The POA did not document health care decision-making or advance directive instructions.

On 10/02/19 at 9:43 AM, Staff D, Social Services Director, said ADs were discussed with residents upon facility admission and again in quarterly care conferences. Staff D said the care conferences with Resident #16 did not include AD discussions. Staff D said she thought a POA always included language regarding an AD.

Reference WAC 388-97-0280 (3)(c)(i-ii).

SPECIFIC RESIDENTSResident 16 was offered assistance with completing an advanced directive and was noted in the resident�s medical file.

OTHER RESIDENTSOther residents without proof of discussions of advanced directives were reviewed and were assisted in obtaining advanced directives as indicated.

SYSTEMIC CHANGESSocial services will be educated on advanced directives and will provide assistance to residents and/or their representative to obtain them if desired.

MONITORAdvanced directives will be audited upon admission, quarterly to ensure information has been obtained or information has been provided to resident and/or family and documentation in place. Findings from the audits will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.




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F 607SS=E

Develop/Implement Abuse/Neglect PoliciesCFR(s): 483.12(b)(1)-(3)

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,This REQUIREMENT is not met as evidenced by:

F 607 11/12/19

.Based on interview and record review, the facility failed to operationalize policies and procedures for screening potential employees for a history of abuse, neglect or mistreatment of residents for 3 of 5 sampled employees (Staff H, J & N) reviewed. This failure placed residents at risk for abuse, neglect and mistreatment.


The facility's Abuse/Neglect/Misappropriation/Exploitation policy, revised 05/2019, documented the facility "screens employees for a history of abuse, neglect or mistreating residents by checking references..."

Record review of employee files showed no documentation of reference checks were found for Staff H, Staff J, and Staff N.

SPECIFIC RESIDENTSNo residents were named in this citation. Reference check(s) were obtained for staff members H, J, and N.

OTHER RESIDENTSNew employee hires will have a least 1 reference check obtained.

SYSTEMIC CHANGESManagers have been educated on the facility system for newly hired staff inclusive of obtaining needed reference check.

MONITORThe Business office manager will monitor/audit new hires paperwork to ensure reference check has been obtained.Findings from the audits will be presented to the QAPI meeting for 3 months to


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F 607 Continued From page 11 F 607On 10/04/19 at 10:18 AM, Staff O, Business Office Manager, said department heads were responsible for calling references.

At 10:19 AM, Staff A, Administrator, said it was her expectation that at least one reference check was completed.

Refer to F-550

Reference WAC 388-97-0640(2) .

ensure ongoing compliance and identify need for further education and/ or system revision.



F 656SS=D

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 medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR

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F 656 Continued From page 12 F 656recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.(iv)In consultation with the resident and the resident's representative(s)-(A) The resident's goals for admission and desired outcomes.(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to develop, review and/or revise individualized comprehensive care plans that accurately reflect resident care needs and provide direction to staff for 2 of 14 sampled residents (#222 & 9) reviewed for care plans. This failure placed residents at risk of unmet care needs, adverse outcomes and a diminished quality of care.


1) Resident #229 was admitted to the facility on /19. The Minimum Data Set (MDS), an

assessment tool, dated 09/19/19, documented the resident was cognitively intact without behaviors, required extensive assistance with activities of daily living (ADLs), and had no

SPECIFIC RESIDENTSResident #222 the care plan was reviewed and revised to include monitoring for behaviors and side effects of psychotropic medications. The diagnosis for the use of Divalproex sodium was updated. Resident #9 care plan was updated to address dental care.

OTHER RESIDENTSResident on psychotropic medications were reviewed to ensure appropriate diagnosis for medication, care plan to monitor behaviors and side effects of psychotropic medication. Any identified issues were corrected. Residents with dental care needs were reviewed to ensure plan of care in place


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F 656 Continued From page 14 F 656natural teeth.

The resident's comprehensive care plans, initiated 09/13/19, did not include and address dental care.

On 10/01/19 at 10:54 AM, Resident #9 was observed to have multiple missing, broken and discolored teeth.

On 10/02/19 at 10:49 AM, Staff C, Licensed Practical Nurse and Resident Care Manager, said the resident had been at the hospital; and when she returned, the care plan did not carry over.

Reference WAC 388-97-1020(1), (2)(a)(b).

F 693SS=D

Tube Feeding Mgmt/Restore Eating SkillsCFR(s): 483.25(g)(4)(5)

§483.25(g)(4)-(5) Enteral Nutrition(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and

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F 693 Continued From page 15 F 693services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.This REQUIREMENT is not met as evidenced by: .Based on observation, interview and record review, the facility failed to ensure physician orders for nutrition were followed consistently for 1 of 1 residents (#223) reviewed for tube feedings (a medical device used to provide nutrition not by mouth). This failure placed residents at risk for inadequate nutritional support, adverse consequences and a diminished quality of life.


Resident #223 was admitted to the facility on /19.

Resident #223's Hospital Discharge Medication Orders, dated /19, documented an order for Fibersource 1.2 to run at 70 ml (milliliters) per hour continuously.

A physician order, dated 09/27/19, changed to Jevity 1.2 to run at 70 ml per hour continuously.

A physician order, dated 09/28/19, changed to Fibersource 1.2 to run at 70 ml per hour continuously.

On 10/01/19 at 1:26 PM, the resident was observed receiving Fibersource 1.2 via the feeding tube.

SPECIFIC RESIDENTSResident #223 is no longer residing in the facility.

OTHER RESIDENTSResidents requiring Tube Feeding, nutrition will be provided per physician orders.

SYSTEMIC CHANGESLicensed Nurses educated on providing tube feed to residents per physicians orders.

MONITORResidents on TF will be audited weekly for 3 months to ensure physician orders for formula is followed. Any identified issues will be addressed. Findings from the audits/observations will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.

TITLE OF PERSON RESPONSIBLE FOR CORRECTIONDirector of Nursing/ designee



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On 10/02/19 at 9:22 AM, Resident #223 said he wasn't feeling well. The resident said the facility had run out of his usual formula in the middle of the night and substituted another one, which made him feel sick. The resident said the nurse had to decrease the flow of the substitute formula so he would not vomit.

An observation at 9:25 AM showed the resident was receiving Jevity 1.2 at 50 ml per hour via the feeding tube.

A nursing progress note, dated 10/02/19 at 5:25 PM with an effective date of 10/02/19 at 6:45 AM, documented, "Informed by NOC [overnight] shift LN [licensed nurse] that Fibersource 1.2 had run out. Shipment was due to arrive late AM 10/02/19. RCM [Resident Care Manager] had originally spoken to RD/MD [Registered Dietitian/Medical Doctor] and received ok to use Jevity 1.2 if Fibersource not available. Spoke to resident to let him know and asked if we could use Jevity until supply shipment arrived. Resident was in agreement and Jevity was started per order."

A physician order, dated 10/02/19 at 7:25 AM, documented, "OK per RD/MD to use Jevity 1.2 if Fibersource 1.2 is not available."

On 10/03/19 at 5:27 AM, Staff E, Registered Nurse (RN), said the facility ran out of Fibersource 1.2 at about 4:00 AM on 10/02/19. Staff E said she knew Resident #223 had been on Jevity 1.2 upon admission, so when the Fibersource 1.2 ran out she used Jevity 1.2. Staff E said she informed the RCM when he arrived


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F 693 Continued From page 17 F 693about 6:00 AM on 10/02/19.

At 12:44 PM, Staff C, RCM and Licensed Practical Nurse, said Resident #223 admitted with an order to use Fibersource 1.2. Staff C said the facility usually used Jevity 1.2 so on /19, Staff C called the RD, who approved substituting Jevity. Staff C said he did not document the conversation with the RD. Staff C said the facility found a case of Fibersource on 09/27/19, so the order to use Jevity was discontinued. Staff C said when Staff E administered the Jevity on 10/02/19, only the order to use Fibersource was current.

On 10/03/19 at 12:58 PM, Staff B, Director of Nursing Services and RN, said Staff E should have obtained an order for Jevity prior to administering it.

Reference WAC 388-97-1060 (3)(f).

F 726SS=F

Competent Nursing StaffCFR(s): 483.35(a)(3)(4)(c)

§483.35 Nursing ServicesThe 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).

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F 726 Continued From page 18 F 726§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to ensure Licensed Nurses (LN) and Nursing Assistants (NA) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 6 of 6 sampled staff (Staff C, E, G, J, K & L) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life.


1) Staff K, Registered Nurse (RN), was hired by the facility on 08/12/19. Staff K's training records

SPECIFIC RESIDENTSNo residents were named in this citation. Staff C, E, G, J, K and L have had their records reviewed to ensure they had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment.

OTHER RESIDENTSOther facility LN and NAC�s records were reviewed to ensure they had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident and areas of needed corrections/improvements have been completed.


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F 726 Continued From page 19 F 726did not include documentation she was assessed to be competent to provide nursing services to the facility's resident population.

2) Staff C, Licensed Practical Nurse (LPN), was hired by the facility on 03/12/19. Staff C's training records did not include documentation he was assessed to be competent to provide nursing services to the facility's resident population.

A form entitled, "Licensed Nurse Annual Competency Checklist," was signed by Staff C on 04/19/19. The form did not include documentation on how Staff C was assessed to be competent in the skills reviewed.

3) Staff E's, RN, training records included the Licensed Nurse Annual Competency Checklist, signed by Staff E on 02/13/19. The form did not include documentation on how Staff E was assessed to be competent in the skills reviewed.

An untitled test taken by Staff E, dated 02/13/19, was incomplete and ungraded.

A competency post-test entitled, "Respiratory, Cardiovascular, Integumentary, Gastro-Intestinal, Neurological Assessments," was taken by Staff E on 02/13/19. The test was not graded to determine competency.

4) Staff L's, LPN, training records included the Licensed Nurse Annual Competency Checklist signed by Staff L on 02/21/19. The form did not include documentation on how Staff C was assessed to be competent in the skills reviewed.

An untitled test taken by Staff L, dated 02/13/19,

SYSTEMIC CHANGESThe facility has reviewed and updated as needed; needed competencies, skills sets and proficiencies to ensure staff have been trained and assessed.Nursing management staff were educated on process to review needed competencies, skills and the follow up review system of ensure staff are proficient.

MONITORNeeded competencies and skill sets will be reviewed monthly by the Director of Nursing Services or designee to ensure staff are showing proficiency.

Findings from the audits will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.




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F 726 Continued From page 20 F 726was ungraded.

A competency post-test entitled, "Respiratory, Cardiovascular, Integumentary, Gastro-Intestinal, Neurological Assessments," was taken by Staff L on 02/13/19. The test was not graded to determine competency.

A test entitled, "Documentation 101: The Basics of Documentation," was taken by Staff L on 08/28/19. The pre-test and post-test grade (%) section on the test was not completed.

5) Staff G's, NA, training records included a form entitled, "CNA/RA [Certified Nursing Assistant/Restorative Aide] Orientation/Training Checklist," signed by Staff G on 02/14/19. The form did not include documentation on how Staff G was assessed to be competent in the skills reviewed.

An untitled test taken by Staff G, dated 06/21/19, was ungraded.

6) Staff J, NA, was hired by the facility on 02/28/19. A CNA/RA Orientation/Training Checklist was signed by Staff J on 03/07/19. The form did not include documentation on how Staff C was assessed to be competent in the skills reviewed.

On 10/04/19 at 11:17 AM, Staff B, RN and Director of Nursing Services, said new staff members were teamed up with another staff member and they completed the skills check list. Staff B said the facility did a skills fair during the past year, and the skills check list was used. StaffB said the facility had a skills validation checklist.


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F 726 Continued From page 21 F 726Staff B was not able to provide documentation of how staff competencies were validated.

Reference WAC 388-97-1080 (1), -1090 (1), -1680 (2)(a)(b)(i-ii)(c) .

F 732SS=F

Posted Nurse Staffing InformationCFR(s): 483.35(g)(1)-(4)

§483.35(g) Nurse Staffing Information.§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:(i) Facility name.(ii) The current date.(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:(A) Registered nurses.(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).(C) Certified nurse aides.(iv) Resident census.

§483.35(g)(2) Posting requirements.(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.(ii) Data must be posted as follows:(A) Clear and readable format.(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to

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F 732 Continued From page 22 F 732exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.This REQUIREMENT is not met as evidenced by: .Based on observation, interview and record review, the facility failed to ensure nursing hours were posted and updated each shift. This failure placed residents, resident representatives and visitors at risk for not being informed of the current staffing levels and census information.


The Daily Nursing Department Staffing Information sheet, dated 09/27/19, showed three NAs worked on evening shift.

Payroll data, dated 09/27/19, showed two NAs worked on evening shift.

On 10/01/19 at 8:00 AM, the Daily Nursing Department Staffing Information form was observed on the wall next to the dining room. The posting included an area for the date, resident census for that day, and each shift's number of Registered Nurses (RN), Licensed Practical Nurses and Nursing Assistants (NA) with the total number of hours worked for each per shift.

On 10/04/19 at 11:20 AM, Staff A, Administrator, said the staff posting was incorrect and should have been updated.

SPECIFIC RESIDENTSStaff posting on 9.27.19 was updated with accurate information.

OTHER RESIDENTSFacility has reviewed staff posting from 9.27.19 to current and have ensured staff postings reflect the accurate census and staff levels actually worked on those days.

SYSTEMIC CHANGESThe facility has reviewed and updated the staff posting sheet to capture the census per shift as opposed to capturing a daily census. Additionally the facility has updated the process to reflect the planned hours worked for LN/RN and NAC at time of posting and as the shift happens, update posting with actual hours worked.

Licensed Staff have been educated on process to complete and reviewing staff posting sheets by the Administrator.

MONITORThe Administrator or Designee will complete a retrospective review weekly


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At 1:30 PM, Staff B, RN and Director of Nursing Services, said the census was not updated on the posting if it changed during the day.

No Associated WAC.

x4 weeks and monthly X2 months to ensure staff postings are completed accurately. Findings from the audits will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.



F 758SS=D

Free from Unnec Psychotropic Meds/PRN UseCFR(s): 483.45(c)(3)(e)(1)-(5)

§483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:(i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

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F 758 Continued From page 24 F 758§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to ensure psychotropic medications were used for appropriate diagnosis and monitoring was completed for effectiveness and adverse side effects of psychotropic medications for 2 of 6 sampled residents (#18 & 222) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for adverse side effects and a diminished quality of life.

SPECIFIC RESIDENTSResidents #18, diagnosis updated for the use of antidepressant medication. Resident #222, diagnosis was updated for the use of Divalproex Sodium and Invega Sustenna, side effect monitoring was implemented, care plan was updated to include monitoring for behaviors and medication side effects and an AIMs was completed.


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1) Resident #18 was admitted to the facility on /19 with diagnoses including . The

Minimum Data Set (MDS), an assessment tool, dated 09/17/19, showed the resident had severe cognitive impairment and took an antidepressant medication daily during the assessment period.

Resident #18's physician orders showed she was taking two antidepressants, Mirtazapine and Sertraline, daily for dementia with behavior disturbances.

On 10/03/19 at 12:54 PM, Staff D, Social Services Director, said traditionally antidepressants would be used to treat depression and not dementia.

2) The Prescriber's Digital Reference (PDR), a drug handbook, dated 2019, documented, "Invega Sustenna is an atypical antipsychotic. Side affects can include CNS (central nervous system) depression, drowsiness, blurred vision, and dizziness, which could lead to falls; and tardive dyskinesia, a syndrome of potentially irreversible, involuntary movements. Periodic evaluation (Abnormal Involuntary Movement Scale, or AIMS test) for movement disorders is recommended." The PDR documented, "Divalproex Sodium side effects can include dizziness, diarrhea, tardive dyskinesia, rashes, and severe hepatoxicity (kidney disease)."

Resident #229 was admitted to the facility on /19. The MDS, dated 09/19/19,

documented the resident was cognitively intact,

OTHER RESIDENTSOther resident on psychotropic medications were reviewed for diagnosis, side effect monitoring, behavior monitoring, care plan and AIM�s. Any identified issues were addressed. SYSTEMIC CHANGESLicensed nurses and SS were educated on the use of psychotropic medication, behavior monitoring, side effect monitoring, and completion of AIMs test as indicated for residents with psychotropic medication use.

MONITORNew psychotropic medications will be audited by Medical Records/ designee weekly to ensure medication includes appropriate diagnosis, behavior monitoring, side effect monitoring, careplan and AIMS as indicated. Any issues identified will be corrected. Findings from the audits/ observations will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.

TITLE OF PERSON RESPONSIBLE FOR CORRECTIONSocial Services/ designee

DATE OF COMPLIANCE11/12/2019


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F 758 Continued From page 27 F 758diagnosis. Staff C said monitoring for psychiatric medication side effects should have been documented on the resident's MAR.

At 1:00 PM, Staff B, Director of Nursing Services and Registered Nurse (RN), said it was her expectation residents on psychotropic medications would have appropriate diagnoses listed in their medical charts. Staff B said Resident #222 should have had behavioral interventions and medication side effect monitoring in the MAR, and should have had an AIMS test completed upon admission to the facility.

Reference WAC 388-97-1060 (3)(k)(i).

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;

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F 838 Continued From page 28 F 838(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 food 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 undercontract), 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


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F 838 Continued From page 29 F 838community-based risk assessment, utilizing an all-hazards approach.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to thoroughly evaluate the resident population in order to develop, evaluate and implement a facility assessment which incorporated the components to meet each resident's care and service needs including to identify the number of staff required to provide care for the facility's resident population, and failed to include a community based risk assessment to identify infection control concerns and where Legionella (a bacteria that can cause pneumonia) and other waterborne pathogens could grow and spread in the facility water system. These failures place residents at risk for unidentified and unmet care needs, infection, and a diminished quality of life.


<Staffing Assessment>

The Facility Assessment, dated October 2018 - October 2019, documented the type of nursing staff required to meet the assessed needs of the facility's residents, for example Registered Nurse, Licensed Practical Nurse, Nursing Assistant. The assessment did not include the number of nursing staff required to meet those needs.

On 10/04/19 at 2:10 PM, Staff B, Registered Nurse and Director of Nursing Services, said she did not think the actual numbers of nursing staff needed were included in the facility assessment.

SPECIFIC RESIDENTSThe facility assessment was updated to include details on the care requirements of residents and the needed staff to complete this care. The assessment was also updated to include documentation of a facility and community based risk assessment utilized an all hazards approach with regards to areas of infection control and prevention and Legionella water management program.

OTHER RESIDENTSOther residents are at risk from not completing a thorough Facility assessment.

SYSTEMIC CHANGESThe administrator and DNS have reviewed the process to complete and review the facility assessment and the process to review and update as needed and annually per the regulation.

MONITORThe facility assessment will be forwarded to the QAPI committee for review annually and with changes to ensure it�s complete and inclusive of all required elements. The Oversight of the QAPI committee will ensure ongoing compliance.

TITLE OF PERSON RESPONSIBLE FOR


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F 838 Continued From page 30 F 838When asked how the facility determined how they were meeting their staffing needs when the assessment did not identify the numbers required, Staff B stated, "I can see where it should be included."<Facility-Based and Community-Based Risk Assessment>

The facility's infection prevention and control program showed no documentation a facility-based and community-based risk assessment utilizing an all-hazards approach was completed and used to establish and update the facility's infection prevention and control program and Legionella water management program.

On 10/03/19 at 1:14 PM, Staff Q said he could not provide documentation to show a facility-based and community-based risk assessment utilizing an all-hazards approach was completed.

No Associated WAC.

CORRECTIONAdministrator/ designee


F 880SS=F

Infection Prevention & ControlCFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection ControlThe facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.

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F 880 Continued From page 31 F 880The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:(i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;(ii) When and to whom possible incidents of communicable disease or infections should be reported;(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;(iv)When and how isolation should be used for a resident; including but not limited to:(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct


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F 880 Continued From page 32 F 880contact with residents or their food, if direct contact will transmit the disease; and(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to conduct facility and community-based infection control and Legionella (a waterborne organism that can cause pneumonia) risk assessments and failed to include all required aspects in the facility's Legionella water management program. These failures placed residents at risk for contracting Legionella, other diseases and/or infectious organisms.


The facility Legionella water management program, undated, did not included how the facility would implement monitoring to confirm the program was being implemented as designed, establish procedures to validate/confirm the program was effectively controlling the identified

SPECIFIC RESIDENTSThe Infection Control Program was updated to include documentation of a facility and community based risk assessment and Legionella water management program.

OTHER RESIDENTSOther residents are at risk from not completing an Infection Control assessment and Legionella water management program.

SYSTEMIC CHANGESThe DNS has been educated on the Infection Control assessment process to review and update as needed and annually. The Maintenance Director has been educated on Legionella water


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F 880 Continued From page 33 F 880potentially hazardous conditions, how the facility would communicate the water management plan to residents, staff and/or others. The water management plan did not include how facility staff responsible for implementing and monitoring the program would be trained, how the facility would investigate Legionnaire's disease cases, and policies and procedures related to processes identified in the water management program.

Review of the facility infection prevention and control program showed no documentation a facility-based and community-based risk assessment utilizing an all-hazards approach was completed and used to establish and update the facility's infection prevention and control program.

On 10/03/19 at 10:39 AM, Staff Q, Maintenance Director, said he could not provide documentation showing the required elements were included in the facility's water management program.

At 1:12 PM, Staff Q said he reviewed the Center for Disease Control's Legionella water management toolkit and would complete the missing sections of the program.

Refer to F838

Reference WAC 388-97-1320 (1)(a).

management program.

MONITORThe facility Infection Control Assessment and Legionella water management program will be reviewed by the QAPI committee as its updated no less than annually to ensure its accurate and complete. The Oversight of the QAPI committee will ensure ongoing compliance.



F 883SS=D

Influenza and Pneumococcal ImmunizationsCFR(s): 483.80(d)(1)(2)

§483.80(d) Influenza and pneumococcal immunizations

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F 883 Continued From page 34 F 883§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;(iii) The resident or the resident's representative has the opportunity to refuse immunization; and(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative


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F 883 Continued From page 35 F 883has the opportunity to refuse immunization; and(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.This REQUIREMENT is not met as evidenced by: .Based on interview and record review, the facility failed to ensure the the pneumococcal vaccines were administered for 1 of 5 sampled residents (#18) reviewed for immunizations. This failure placed residents at risk of contracting pneumococcal pneumonia.


Resident #18 was admitted to the facility on 19. The Minimum Data Set, an

assessment tool, dated 09/17/19, showed the resident's pneumococcal vaccination was not up to date.

An Immunization Consent/Acknowledgement form, dated 09/12/19, showed the resident's representative gave consent for the influenza vaccine. The section for the pneumococcal vaccines was not checked and there was no documentation the vaccines were refused.

On 10/03/19 at 12:44 PM, Staff C, Licensed

SPECIFIC RESIDENTResident #18 was offered pneumococcal vaccination, and was given as indicated.

OTHER RESIDENTSOther resident were reviewed for consenting and/ or receiving pneumococcal vaccination. Those residents consenting to vaccination, received vaccination per guidelines.

SYSTEMIC CHANGESNursing Management was educated on pneumococcal vaccination including obtaining consent, administering vaccinations and documentation.

MONITORWeekly audits of new admissions and residents with annual MDS�s will be completed by medical records/ designee to ensure pneumococcal vaccination are administered per consent and CDC


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F 883 Continued From page 36 F 883Practical Nurse and Resident Care Manager, said an immunization assessment was completed on admission. Staff C said the pneumococcal vaccine must have been overlooked on Resident #18's admission.

Reference WAC 388-07-1340 (1), (2), (3) .

guidelines for 3 months. Any identified issues will be corrected. Results of the audits will be reported to the QAPI committee monthly to ensure ongoing compliance and to identify need for further education and/ or system revision.

TITLE OF PERSON RESPONSIBLE FOR CORRECTIONDirector of Nursing/ designee


F 947SS=F

Required In-Service Training for Nurse AidesCFR(s): 483.95(g)(1)-(4)

§483.95(g) Required in-service training for nurse aides. In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.This REQUIREMENT is not met as evidenced by:

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F 947 Continued From page 37 F 947 .Based on interview and record review, the facility failed to ensure Nursing Assistants (NAs) received 12 hours of in-service training per year based on the NA's date of hire for 1 of 3 sampled NAs (Staff G) reviewed for 12 hours of inservice training. This failure placed residents at risk of receiving less than adequate care.


Staff G, NA, was hired at the facility on 06/01/15.

Training/in-servicing records for Staff G showed he had 6.25 hours of training/in servicing between June 2018 and June 2019, 5.75 hours fewer than required.

On 10/04/19 at 11:17 AM, Staff B, Registered Nurse and Director of Nursing Services, said the business office manager tracked the training hours. Staff B said she was not sure if the required 12 hours per year of training was based off the date of hire or calendar year.

Reference WAC 388-97-1680 (2)(a-c) .

SPECIFIC Staff G received 12 hours of required training.

OTHER Nursing Assistants training records were reviewed for required 12 hours training and training completed as indicted.

SYSTEMIC CHANGESDNS was educated by Regional Nurse/designee on the process to track and monitor the completion of nursing assistants required training hours. . MONITORNursing assistant training hours will be audited monthly by business office to ensure on track for required hours. Identified issues will be addressed.Findings from the audits will be presented to the QAPI meeting for 3 months to ensure ongoing compliance and identify need for further education and/ or system revision.

TITLE OF PERSON RESPONSIBLE FOR CORRECTIONDirector of Nursing / Designee

DATE OF COMPLIANCE11/12/2019


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NAME OF PROVIDER OR SUPPLIER

REGENCY OLYMPIA REHABILITATION AND NU

STREET ADDRESS, CITY, STATE, ZIP CODE

1811 EAST 22ND AVENUEOLYMPIA, WA 98501



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L 000 WAC - Initial Comments

Note: According to RCW 18.51.060, the Department is authorized to deny, suspend or revoke a license and/or assess monetary fines for deficiencies cited in this report.

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L 000

This report is the result of an unannounced Washington State Licensing Off-Hours Survey and Complaint Investigation conducted at Regency Olympia Rehabilitation & Nursing Center on 10/01/19, 10/02/19, 10/03/19 and 10/04/19. The survey included data collection on 10/03/19 from 5:00 AM to 2:30 PM. A sample of 23 residents was selected from a census of 21. The sample included 20 current residents and the records of 3 discharged residents.

The following complaints were investigated as part of this survey:36704943670632

The survey was conducted by: Lori Madison, RNKathy Nibler, BAKara Mitchell, RNTeri Germann, RN

The survey team is from:Department of Social and Health ServicesAging and Long Term Support AdministrationResidential Care Services, Region 3, Unit CP.O. Box 45819Olympia, Washington 98504-5819

Telephone: 360.664.8420Fax: 360.664.8451

State Form 2567LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

10/25/19Electronically Signed

If continuation sheet 1 of 66899STATE FORM IL0Q11

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L1080Continued From page 1 L1080

L1080 WAC 388-97-1080 Nursing Services

(1) The nursing home must ensure that a sufficient number of qualified nursing personnel are available on a twenty-four hour basis seven days per week to provide nursing and related services to 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.

(2) The nursing home must:

(a) Designate a registered nurse or licensed practical nurse to serve as charge nurse who is accountable for nursing services on each shift; and

(b) Have a full time director of nursing service who is a registered nurse.

(3) Large nonessential community providers must have a registered nurse on duty directly supervising resident care twenty-four hours per day, seven days per week.

(4) The department may permit limited exceptions to subsection (3) of this section if the nursing home can a demonstrate good faith effort to hire a registered nurse for the last eight hours of required coverage per day. The department may not grant exceptions for coverage that are less than sixteen hours per day. When considering an exception, the department may consider the following:

(a) Wages and benefits offered by the nursing home; and

L1080 11/12/19

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(b) The availability of registered nurses in the nursing home's geographical area.

(5) The department may grant a one-year exception that may be renewable for up to three consecutive years.

(6) If a registered nurse is not on-site and readily available to complete full assessments during a shift, the department may limit the admission of new residents based on the resident's medical conditions or complexity during this period only for the particular shift that a registered nurse is not on-site or readily available.

(7) If the department grants an exception for a nursing home, the department must include this information in its nursing home locator.

(8) Essential community providers and small nonessential community providers must have a registered nurse on duty who directly supervises resident care a minimum of sixteen hours per day, seven days per week, and a registered nurse or a licensed practical nurse on duty who directly supervises resident care the remaining eight hours per day, seven days per week.

(9) The nursing home must ensure that staff respond to resident requests for assistance in a manner that promptly meets the resident's quality of life and quality of care needs.

(10) The director of nursing services is responsible for:

(a) Coordinating the plan of care for each resident;


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(b) Ensuring that registered nurses and licensed practical nurses comply with chapter 18.79 RCW; and

(c) Ensuring that the nursing care provided is based on the nursing process in accordance with nationally recognized and accepted standards of professional nursing practice.

This Washington Administrative Code is not met as evidenced by:.Based on interview and record review, the facility failed to maintain 16 hours of Registered Nurse (RN) coverage to assess and supervise resident care seven days a week for 6 of 30 days reviewed for RN coverage. This failure placed residents at risk for lack of assessment and care planning, care and services not provided by registered nurses and a delay in care and treatment for residents to attain and maintain their highest practicable physical, mental and psychosocial wellbeing.


Record review of the "Staffing Pattern" form, for 09/01/19 thru 09/30/19, showed six of 30 days did not have the required 16 hours of RN coverage.

On 10/04/19 at 1:20 PM, Staff B, RN and Director of Nursing Services, said during the weekdays she was immediately available in the facility and directly supervised resident care, and on "some weekends we have RN coverage for 16 hours, but not all of them. We need to work on that.".

SPECIFIC RESIDENTSNo specific residents were identified

OTHER RESIDENTSResidents have the potential to be affected by this practice.

SYSTEMIC CHANGESFacility is pursuing aggressive recruiting efforts to hire and retain RNs to ensure 16 hours of Registered Nurse coverage seven days per week. Recruiting efforts include sign-on, referral and/or relocation bonuses.Director of nursing/ designee to review, interview and hire qualified candidates as able in a timely manner.

MONITORAdministrator to review applicants to ensure follow up and appropriate managing of potential new hires.Staffing will be reviewed at QAPI monthly for 3 months to ensure adequate staffing and monitoring recruiting efforts.

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CORRECTIONAdministrator / designee


L1380 WAC 388-97-1380 Tuberculosis - Testing Required

(1) The nursing home must develop and implement a system to ensure that facility personnel and residents have tuberculosis testing within three days of employment or admission.

(2) The nursing home must also ensure that facility personnel are tested annually.

(3) For the purposes of WAC 388-97-1360 through 388-97-1580 "person" means facility personnel and residents.

This Washington Administrative Code is not met as evidenced by:

L1380 11/12/19

.Based on interview and record review, the facility failed to ensure tuberculosis (TB) testing was performed in accordance with standards set by Centers for Disease Control (CDC) and applicable state law for 4 of 5 sampled staff (C, H, J & K) reviewed for TB testing. This failure placed residents, staff and visitors at risk for exposure to a communicable disease.


1) Staff C, Licensed Practical Nurse and Resident Care Manager, was hired at the facility on 03/12/19. The facility did not have

SPECIFIC RESIDENTSTuberculosis (TB) testing was completed for staff C, H, J, and K.

OTHER RESIDENTSAn audit of staff TB testing was done and any required tests were completed.

SYSTEMIC CHANGESThe DNS was educated on the system to ensure that staff have tuberculosis testing upon hire and are read within 48-72 hours of administration and second step completed within 3 weeks.


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documentation Staff C received TB testing.

2) Staff H, Cook, was hired at the facility on 02/28/19. TB testing was started on 05/31/19, 91 days after the date of hire.

3) Staff J, Nursing Assistant, was hired at the facility on 02/28/19. TB testing was started 04/03/19, 34 days after the date of hire.

4) Staff K, Registered Nurse (RN), was hired by the facility on 08/12/19. The facility did not have documentation Staff K received TB testing.

On 10/04/19 at 10:30 AM, Staff B, RN and Director of Nursing Services, said new employees should get TB testing done the day they start. .

MONITORBusiness Office Manager to audit new hire documentation for 3 months to ensure tuberculosis testing is completed. Any identified issues will be corrected. Findings from the audits/ observations will be presented to the QAPI meeting for 3 months to ensure on-going compliance and identify need for further education and/ or system revision.

TITLE OF PERSON RESPONSIBLE FOR CORRECTIONDirector of Nursing / designee



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state of washington department of social ......lori madison, rn kathy nibler, ba kara mitchell, rn...

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