Avalon Care Center - Federal Way

F-F812 - Food Procurement, Store/Prepare/Serve - Sanitary

Refer to

F-F881 - Antibiotic Stewardship

REFERENCE: WAC 388-97-1320(1)(c)(2)(b).

45720

45941

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 56 505510 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 47836 potential for actual harm Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Residents Affected - Many Program (ASP), to promote appropriate use of Antibiotics (ABO), reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 6 of 6 sample residents (Resident 204, 80, 77, 64, 47, & 3) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 56 505510 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 <Residents 64>

Level of Harm - Minimal harm or Review of Resident 64's order summary showed they were admitted on an ABO for colitis (inflammation of potential for actual harm the colon), but review of hospital history and physical showed the colitis was resolved and Resident 64 was placed on the ABO for Pneumonia (inflammation of the lungs). Review of Resident 64's hospital records Residents Affected - Many showed a chest X-ray which was clear of pneumonia.

<Residents 47>

Review of Resident 47's records showed they had completed an ABO without any assessment or ABO time-out.

<Residents 3>

Review of Resident 3's records showed they had completed an ABO without any assessment or ABO time-out.

In an interview on 07/22/24 at 8:09 AM Staff C (Infection Preventionist) stated they did not maintain an ASP binder with meeting minutes, tracking information, and logs for comparison and review. Staff C stated they did not have the ASP up to date and did not have residents who are on ABO's, or were on an ABO, logged for July 2024. Staff C stated they had three job titles, Assistant Director of Nursing, Staff Development Coordinator, and Infection Preventionist, which made it difficult to keep up with their workload. Staff C stated

they did not complete a McGeer's or Loeb's assessment on any resident that used to be or was currently taking an ABO. Staff C stated the facility had a software with a question . meets McGeer's or Loeb's criteria? Yes or no, but the software did not document the data that qualified the resident to take an ABO. Staff C stated it was important to complete a McGeer's & Loeb's assessment to ensure the resident was receiving

the correct ABO and to ensure the ABO was necessary.

REFERENCE: WAC 388-97-1060(3)(k)(i),-1320(2)(a-c).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 56 505510