Avalon Care Center Federal Way, L.l.c.
Avalon Care Center Federal Way, L.L.C. in FEDERAL WAY, WA — inspection on July 24, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F812 - Food Procurement, Store/Prepare/Serve - Sanitary
Refer to
Findings included .
<Facility Policy>
According to a facility policy titled, Infection Prevention and Control ABO Stewardship, revised 03/2019, the program would validate that antibiotics were prescribed for the correct indication, the correct dose, the correct route and the correct duration.
The policy showed the program would implement a data gathering system and analyze the collected data to ensure unnecessary ABO prescribing did not take place.
The policy showed the facility would monitor the use of ABO's using the McGeer's (a set of signs and symptoms that verify active infection) and Loeb's (tool used to assess antibiotic appropriateness) criteria as a guide for protocols for prescribing ABO's.
This policy showed when a resident was admitted on an ABO regimen, the facility would review for appropriateness of the ABO.
The policy titled, Antibiotic Stewardship Program, revised 04/2022, showed documentation related to the ASP, including meeting minutes, tracking information, and logs would be maintained in a binder to facilitate comparisons and review.
The policy showed within 48 -72 hours following initiation of an ABO, an ABO Time-Out Checklist would be completed and reviewed with the prescriber.
Record review on 07/22/2024 showed incomplete and inaccurate antibiotic line listing for the facility's ASP.
Review of the ASP showed no documentation of a positive McGeer's or Loeb's criteria to meet the need of ABO use for Residents 204, 80, 77, 64, 47, or 3.
The facility was unable to provide accurate and complete ABO line listing documentation from the last survey to the current survey.
<Residents 204>
Review of Resident 204's records showed two ABO's that were not documented on the ASP line listing and had no documentation of McGeer's or Loeb's data.
<Residents 80>
Review of Resident 80's records showed they had completed an ABO without any documentation of symptoms that met McGeer's or Loeb's criteria.
<Residents 77>
Review of Resident 77's records showed they had completed an ABO without any documentation of symptoms that met McGeer's or Loeb's criteria.
505510
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 505510 B.
Wing 07/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Avalon Care Center - Federal Way 135 South 336th Street Federal Way, WA 98003