Madison Post Acute

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

Review of Resident 11's July 2024 care record on 08/05/2024 confirmed that Staff K had documented providing care to Resident 11 on two days following the grievance report, on 07/09/2024 and 07/11/2024.

In an interview on 08/06/2024 at 10:30 AM, Staff J, Infection Preventionist, stated they had received the grievance form and completed the in-service with Staff K.

Staff J stated they had verbally reviewed what they had done with Resident 11 and they were okay with the education, but they still did not want Staff K to be their aid, (Resident 11) was not comfortable, they said.

Staff J stated they forgot to mark the box on the grievance that stated the resident was notified of the action taken and satisfied with the outcome.

In an interview on 08/06/2024 at 2:14 PM, Staff I, Scheduler, stated they were aware that Staff K was not supposed to be scheduled to care for Resident 11, but stated sometimes staff would be assigned to a certain section, but they would just trade a resident, such as if one resident on a section preferred only female aids, they may have a male aid on that section but they would just trade one resident with another aid who was female.

Staff I stated they recalled it being sometime in July that there had been an allegation and even though Staff K was assigned on that section, they knew they were not supposed to have Resident 11 and were supposed to trade with another staff.

In an interview on 08/07/2024 at 10:17 AM, Staff B, Director of Nursing Services stated there should have been grievances for the missing item and noisy roommate concern but had not been aware of those issues.

They reviewed grievances every day in their stand-up meeting.

Staff B stated that they had not been aware that Staff K had Resident 11 on their care assignment on those dates.

Staff B stated that they had provided education to Staff K related to the grievance and when they had done their investigation regarding the allegation that Staff K had come back to the room stating, do you have a problem with me?, they had denied that allegation, and they had not been able to substantiate it.

Staff B stated they became aware of that allegation at the July 23,2024 resident council meeting, and it was reported as an allegation of potential abuse.

Staff B stated they have been working on their grievance process but needed to continue education.

Refer to WAC 388-97-0460(1)(2)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

Findings included .

Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, showed the RAI consists of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information).

Once a CAA has been triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether or not to care plan for it.

The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident. Resident 30 admitted to the facility on [DATE] with diagnoses to include fracture of the right upper leg. Resident 30 was admitted to hospice services on 03/15/2024.

Review of Resident 30's Annual CAA assessment, dated 03/25/2024, showed they triggered for functional abilities.

The CAA worksheet for functional abilities showed no evidence a comprehensive analysis of findings was thoroughly completed and did not contain Resident 30's goals, preferences, strengths, needs or input from the resident or their representative.

The CAA contained a narrative that read, Continue to care plan to slow or minimize decline in ADL's (Activities of Daily Living).

In an interview on 08/07/2024 at 10:28 AM Collateral Contact 2 (CC 2), contracted Registered Nurse, stated they are completing the MDS's for the facility to include the CAA and care plans. CC 2 stated they had daily telephonic meetings with the facility's Resident Care Manager (RCM) and Director of Nursing Services (DNS) to discuss the residents. CC 2 stated the process for completing CAAs included a review of information that was gathered from notes and their sources and do a shorter description to proceed to the care plan.

Cross Reference to: CFR 483.21(a), (a)(1)(i)(ii), F-F655 - Baseline Care Plan CFR 483.21(b), (b)(1),(c)(3)(i - iv), F-F656 - Develop/implement Comprehensive Care Plan CFR 483.21(b),(b)(2)(i-iii), F-F657 - Care Plan Timing And Revision Refer to WAC 388-97-1000 (1)(a)(2)(q)(5)(a)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

checked.

When asked about the strap to the wedge, Staff I stated they did not know if there was a

In an interview on 08/07/2024 at 12:06 PM Staff B, Director of Nursing Services, stated they were not

This is a repeat citation from 10/16/2023.

Refer to WAC 388-97-1020 (1)(2)(a)(b)(e)(5)(a)(b)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

diet and texture with thin liquids.

to fatigue initiated on 04/18/2023.

Interventions for oral care showed Resident 3 had an upper partial,

09/14/2023.

In an interview on 08/02/2024 at 09:57 AM, Staff L, Certified Nursing Assistant (CNA) stated Resident 3 did not have a partial.

Staff L reviewed Resident 3's Kardex and stated: I stand corrected, resident has an upper partial and wears it.

Staff L stated Resident 3 does their own oral care.

In an interview on 08/02/2024 at 10:18 AM, Staff M, Registered Nurse (RN) stated Resident 3 was wearing their upper partial when they had checked on the resident.

In an interview and observation on 08/02/2024 at 10:21 AM Resident 3's mouth was observed and showed no upper partials in place. Resident 3 stated their partials were sent to a dentist to be repaired before the COVID pandemic and had not been returned.

In an interview on 08/05/2024 at 11:05 AM, Staff O, Licensed Practical Nurse (LPN) stated that Resident 3 did not have their partials but was going to the dentist to get fitted with one.

Staff O stated they would review the care plan.

In an interview on 08/02/2024 at 11:38 AM, spoke to Staff N, LPN/Resident Care Manager, stated they were working with European Dentures and [NAME] Dental in replacing the partials. Resident 3 had an appointment scheduled on 09/24/2024 and their clerk was calling the clinic to see if they can move up the appointment and would continue to keep trying.

Staff N stated they and the nurses update the care plan.

Staff N confirmed Resident 3 was not currently wearing a partial.

This is a repeat citation from 10/16/2023.

Refer to WAC 388-97-1020 (1)(2)(a)(b)(e)(5)(a)(b)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

Review of Resident 21's Medication Administration Record (MAR) for July 2024 showed they were prescribed a medication to manage their high blood pressure.

The order was for Amlodipine Besylate Tablet 0.5 milligrams (mg) by mouth for high blood pressure and to hold the medication if Resident 21's systolic blood pressure was below 100 millimeters of mercury (mm Hg).

The order was dated 10/04/2023 and discontinued on 07/19/2024 and the MAR showed had documented blood pressures.

The July 2024 MAR showed the same order dated 07/20/2024 with no documented blood pressures.

Review of Resident 21's August 2024 MAR showed an order for Amlodipine Besylate Tablet 0.5 milligrams (mg) by mouth for high blood pressure and to hold the medication if Resident 21's systolic blood pressure was below 100 millimeters of mercury (mm Hg).

The August MAR contained no documented blood pressures from 08/01/2024 through 08/05/2024.

Review of Resident 21's provider progress note dated 07/18/2024 showed the provider ordered an A1C (lab test that measures the average level of blood sugar over the previous three months).

Review of Resident 21's electronic medical record showed there were no labs were completed for A1C on 7/18/2024. A review of Resident 21's progress notes dated 08/02/2024 that a lab slip was completed for an A1C, 15 days after it was ordered by the provider.

In an interview on 08/06/2024 at 2:00 PM Staff B, Director of Nursing Services (DNS) stated they had changed times on medications to broaden the range in which medications could be administered and the blood pressure monitor was somehow left off.

Staff B stated the blood pressure monitor was placed back on after they caught the error.

Staff B stated the blood pressure should have been taken prior to the administration Amlodipine for Resident 21.

Staff B stated the provider for Resident 21 had placed the order for their A1C in the wrong section of the electronic health record and would not have been processed by the nursing staff as this was not their practice.

In an interview on 08/07/2024 at 12:06 PM CC 3, facility consultant, stated the transition to the electronic medical record was difficult and contributed to the errors. CC 1 stated the nurse managers were responsible for ensuring provider notes were and processed. CC 1 stated the provider notes were not fully integrated and were previously scanned into the medical record, causing a delay in availability of the note to the nurse manager by a few days.

Refer to WAC 388-97-1620 (2)(b)(i)(ii)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

over a flaky loose piece of skin on their lower lip.

Their lips were dry and flaky, and their tongue had

who do not eat and drink normally throughout the day.) Resident 26 stated they thought there was a

mouth.

There was a cup of pink toothettes (oral swabs- non glycerin) noted in a cup on top of the dresser on the opposite side of the room.

In an interview on 08/05/2024 at 2:00 PM, Staff P, NAC, stated Resident 26 was able to swab their mouth if they handed them the swab and stated they should offer them one every day and after they eat in case they had anything left in their mouth.

They said they used the toothettes, the pink ones.

In an interview on 08/07/2024 at 10:04 AM, Staff B, Director of Nursing, stated oral care should be done for resident 26 upon rising, after meals related to their swallow issues, and at night.

Refer to WAC 388-97-1060 (2)(c)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

hours to keep them off their hip and buttocks.

Staff S stated they rolled Resident 30 toward the

to three hours.

Staff P stated Resident 30 often sleeps and wants to be pulled up all the way with their feet positioned higher than their head.

Staff P stated that they placed pillows on each side of Resident 30's.

Refer to WAC 388-97-1060(1)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

Findings included .

Staff K was hired on 07/06/2023.

Review of Staff K's employee file showed there was no current employee evaluation done.

There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff K.

Review of the staff roster printed on 07/31/2024 on the first day of survey showed various hire dates for staff beginning on 06/12/1987 to 07/26/2024.

In an interview on 08/06/2024 at 12:59 PM, Staff J, Staff Development Coordinator said they would be doing new performance evaluations, but everyone's start date was May 1st and they were all new employees.

In an interview on 08/06/2024 at 2:48 PM, Staff B Director of Nursing Services said all staff completed new hire paperwork on 05/01/2024 so they needed to do the performance evaluations again.

In a phone interview on 08/07/24 at 10:08 AM, Staff Q, Credentialing Compliance Coordinator said they were responsible for completing new hire paperwork.

Staff Q said the facility had a new owner on May 1st, but they were not sure if staff were keeping their original hire dates, or the May 1st hire date.

Staff Q said the prior administrator told them to ask the new administrator, but they hadn't asked Staff A, Administrator yet.

Refer to WAC 388-97-1680 (2) (a-c) .

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

During the observation there was Jello, uncovered, on the trays being delivered.

the meal trays should have been covered.

On 08/05/2024 at 12:30 PM observed a dessert being placed on a tray uncovered.

When asked Staff X, DM, if the dessert should be covered, they stated they should. <UNIT REFRIGERATOR> In an observation in the assisted dining room on 07/31/2024 at 12:30 PM, the nourishment refrigerator was observed to contain a plastic container of oats with no name or date, a zip lock bag of cheese slices with no date, a bottle of ketchup in the door with an expiration date of 7/7/2024, and two bags of muffins and pastries with a resident name but no date.

In an observation on 08/01/2024 at 9:28 AM, the nourishment refrigerator had been moved from the assisted dining room to the main dining room.

There was a new temperature log taped to the front of the refrigerator for the month of August.

Inside the refrigerator, it was observed that the same items remained from the day prior (expired ketchup in the door, unlabeled cheese slices, container of oats, muffins and pastries.) In an interview on 08/01/2024 at 9:25 AM, Staff H, Certified Nursing Assistant, stated the kitchen brought down nourishments and put them in the refrigerator and if residents had personal snacks, the staff would label them with name and date and put them in the refrigerator.

Staff H stated they did not know who was responsible to check to ensure items were labeled and to remove old or expired items but they thought it was the kitchen.

In an observation on 08/05/2024 at 8:58 AM, the refrigerator contained the same expired and unlabeled items (expired ketchup in the door, unlabeled cheese slices, container of oats, muffins and pastries.) Additionally, there was now an unlabeled, undated plastic container of white rice and there were observed to be two boxes of Capri Sun drinks in the cupboard which had expiration dates of December 2023.

In an observation and interview on 08/06/2024 at 12:56 PM, the nourishment refrigerator was observed with Staff F, Dietary Aide, who stated they checked and logged the refrigerator temperatures, made sure the refrigerator was clean, and looked to make sure there was enough of the different types of snacks for the residents every day.

Staff F stated they were supposed to check for labels and dates and if items were not properly labeled, old or expired they were supposed to throw them out.

Staff F confirmed the kitchen staff were supposed to do this every day and noted the observed items needed to be thrown out.

Staff F did not know why the items had remained in the refrigerator days in a row without anyone noticing they were expired or not properly labeled or dated.

Reference WAC: 388-97-1100 (3)

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

505463 08/07/2024

Madison Post Acute 2520 Madison Everett, WA 98203

Findings included . room [ROOM NUMBER] 142 Square Feet (Sq.Ft.) (2 beds) room [ROOM NUMBER] 154 Sq. Ft. (2 Beds) room [ROOM NUMBER] 154 Sq. Ft. (2 Beds) room [ROOM NUMBER] 153 Sq. Ft. (2 Beds) Review of the facilities census showed that Rooms107, 302, 305, and 307 all had two beds in each room.

Surveyor's observations of residents residing in the affected rooms determined that neither health nor safety of the residents in these rooms was compromised due to the size of the rooms.

This is a repeat citation from 10/16/2023.

Refer to WAC 388-97-2440(1)

Findings included .

Review of the Facility Assessment, undated, showed the facility utilizes the following training topics during all staff in-services or department meetings at multiple times throughout the year: - Communication - effective communications for direct care staff with residents/family.

Resident's rights and facility responsibilities - educate staff members on the rights of the resident and the responsibilities of a facility to properly care for its residents. - Abuse, neglect, and exploitation - educate staff on: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. - Infection control - education of staff on infection prevention and control standards, policies, and procedures, including proper hand hygiene and the use of personal protective equipment (PPE) in following isolation precautions as necessary. - Culture change (that is, person-centered and person-directed care). - Required in-service training for nurse aides (CNAs and NARs). ln service training must: be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. -lnclude dementia management training and resident abuse prevention training. &lt;EMPLOYEE FILE REVIEW&gt; Review of the emplolyee file for Staff K, NAC, showed they had 6.3 hours of training rather than documented evidence of the required 12 hours of in-servicing.

Review of the in-service records showed the facility failed to document how long the in-service lasted or the time it started.

In an interview on 08/06/2024 at 12:59 PM, Staff J, Staff Development Coordinator stated they were working on the education piece to ensure the staff had the 12 hours of education. At 3:00 PM, Staff J said they were able to locate the 12 hours for the other 4 NACs requested but not for Staff K.

Staff K said the expectation was for NACs to have at least 12 hours of education yearly.

Refer to WAC 388-97-1680 (2)(a-c)

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Madison Post Acute 2520 Madison Everett, WA 98203

F-F655 - Baseline Care Plan

CFR 483.21(b), (b)(1),(c)(3)(i - iv),

F-F656 - Develop/implement Comprehensive Care Plan

CFR 483.21(b),(b)(2)(i-iii),

Findings included .

Resident 13 readmitted to the facility on [DATE] with diagnoses to include fall, high blood pressure, fracture of right upper leg.

In an interview and observation on 07/31/2024 at 2:54 PM, Resident 13 stated they had fallen out of their bed around eight months ago. Resident 13 stated they had been asleep in their bed when they had moved the bed control and started to fall over to the right side and fell from their bed.

During the observation a blue foam wedge was noted at the foot of Resident 13's bed.

Review the incident report, dated 01/02/2024, showed that Resident 13 sustained a fall at 2:45 AM and was assisted back to bed after they refused to be sent to the hospital.

The incident report showed Resident 13 voiced being disproportionate in their hip and legs which had them leaning to the right side which led to the fall while they were asleep. Resident 13's care plan was updated.

The incident summary dated 01/05/2024, showed therapy assessed Resident 13 and determined the cause of the fall was related to their poor trunk control. Resident 13 was assessed by therapy, and they recommended a positioning wedge be placed under the resident's right hip/leg and secured with a strap that is attached to the bed frame.

In a follow up interview and observation on 08/07/2024 at 11:15 AM, Resident 13 stated the blue wedge was to assist them in not falling out of bed. Resident 13 was observed to use their cane to pull the blue wedge from the foot of their bed to them and positioned it under their right hip/leg.

There was no strap observed on the wedge. Resident 13 stated the wedge worked well as an arm rest. Resident 13 stated they had not used the wedge the night before and required no reminders from staff to use it.

Review of Resident 13's care plan dated 01/04/2024 and revised 06/12/2024 showed they were at high risk for falls and they had a positioning wedge with secure strap for safety and comfort to be positioned on their right side (hip/leg).

The care plan directed staff to notify the nurse if the wedge was not secured and to unstrap the wedge while Resident 13 was awake and per their request.

There was no information in the care plan that addressed Resident 13's poor trunk control.

Review of Resident 13's treatment administration record for July 2024 showed no information about the use of the positioning wedge.

505463

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505463 B.

Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Post Acute 2520 Madison Everett, WA 98203