Marianwood Health And Rehabilitation
MARIANWOOD HEALTH AND REHABILITATION in ISSAQUAH, WA — inspection on August 1, 2024.
Found 5 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
Review of the 04/26/2023 Level 1 PASRR showed this PASRR did not include Resident 28's dementia diagnosis.
This PASRR included a handwritten note showing reviewed but no dx (diagnosis) of dementia.
In an interview on 07/31/2024 at 10:24 AM, Staff E (Social Services Director) stated it was important for PASRRs to be available in the chart and accurately reflect the resident's current condition.
In an interview on 08/01/2024 at 11:55 AM Staff E stated it was important for PASRRs to be accurate and updated with changes.
<Resident 45>
According to the 06/17/2024 Quarterly MDS, Resident 45 admitted to the facility on [DATE] and had medical conditions including depression and anxiety.
Review of Resident 45's Physician Orders (POs) showed a 01/12/2024 order for daily administration of AD and AA medications since the resident's facility admission.
A 04/11/2024 social services progress note showed staff reviewed and updated Resident 45's Level 1 PASRR and referred the resident to the PASRR office for a Level 2 evaluation due to the presence of SMI.
Review of Resident 45's medical records did not show the resident's Level 1 PASRR form was accessible to staff.
505418
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 505418 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029
Findings included .
<Resident 189>
According to a 06/12/2024 Admission MDS, Resident 189 admitted to the facility on [DATE].
Review of a 06/23/2024 Discharge MDS showed Resident 189 was transferred to an acute care hospital with their return to the facility anticipated.
Upon Resident 189's return to the facility 12 days later, staff completed a 07/05/2024 Entry Tracking MDS and indicated the resident's type of entry was an admission, rather than a reentry as required.
In a joint interview with Staff T (MDS Coordinator) and Staff X (MDS Coordinator) on 08/01/2024 at 2:25 PM, Staff X stated it was their expectation an Entry Tracking MDS be coded as a reentry if a resident was hospitalized less than 30 days.
Staff X stated it was important to accurately code reentry versus an admission on an Entry Tracking MDS and stated, it is the Medicare rules.
Staff X stated having accurate coding also assists with the continuity and coordination of care for a resident.
Staff T reviewed Resident 189's 07/05/2024 Entry Tracking MDS and stated, I did it wrong, it should be coded as a reentry.
42203
<Resident 28>
According to the 05/20/2024 Quarterly MDS, Resident 28 exhibited no delusions during the assessment period, and had a diagnosis of depression.
The MDS did not identify Resident 28 with a diagnosis of psychosis.
The MDS showed Resident 28 received an antipsychotic medication.
Review of the Physician's Orders showed a 05/25/2023 order for an antipsychotic medication to be given twice daily for delusions.
Record review showed Resident 28 had an 04/03/2023 potential for violence due to [ .] paranoia/delusions about staff Care Plan (CP), a 07/24/2020 History of delusions . CP, and a 05/31/2022 psychotropic medication CP that addressed Resident 28's use of an antipsychotic medication use.
In an interview on 08/01/2024 at 9:05 AM Staff B (Director of Nursing) stated Resident 28 had a diagnosis of a psychosis.
Staff B stated this should be reflected on the 05/20/2024 Quarterly MDS but was not.
<Resident 68>
505418
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 505418 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029
Findings included .
<Facility Policy>
According to the facility's 01/2022 Transfer or Discharge and Ombudsman Notification policy, when a facility resident was temporarily/emergently hospitalized , a notice of transfer must be provided to the resident or their representative as soon as practical.
The policy showed copies of all transfer notices were provided to the LTCO office on at least a monthly basis.
<Resident 32>
According to the 05/07/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 32 had severe memory impairment.
The MDS showed Resident 32 had diagnoses including Alzheimer's disease (memory impairment) and Diabetes Mellitus (a condition making regulating blood glucose more difficult).
According to a 06/14/2024 progress note, at 1:05 PM, Resident 32 experienced an acute change in condition including elevated blood glucose, rapid heart rate, and involuntary movements.
The progress note showed Resident 32 was sent to the hospital emergently at 1:35 PM. A 06/18/2024 progress note showed Resident 32 was readmitted to the facility.
Record review showed no evidence a transfer notice was completed and given to Resident 32 of their representative as required.
In an interview on 07/31/2024 at 12:28 PM, Staff S (Health Information Manager) stated they were unable to find a written transfer notification for Resident 32's 06/14/2024 hospitalization .
Staff S stated the facility should have notified the resident or their representative but could not demonstrate this happened.
Staff S stated as the notice did not exist, it could not be sent to the LTCO office.
46471
<Resident 20>
505418
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 505418 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029
Findings included .
<Facility Policy>
The Enteral Nutrition policy, revised 01/2023, showed it was a nursing responsibility to document the amount of feeding given on each shift in the Medication Administration Record (MAR).
The policy showed the facility would label TF bags with the date, time, initial of the nurse hanging the feeding, and the amount hung to prevent contamination when open feeding systems were used.
The policy showed new formula would not be added to formula already hanging, and formula would not hang for longer than eight hours.
The Weight and Nutrition Monitoring policy, revised 10/2021, showed the intent was to ensure no resident would have significant unplanned weight loss or gain, unless clinically unavoidable.
The policy showed all weights would be recorded in the resident's medical records, to be reviewed and monitored by designated clinicians, including those residents who were identified as at nutritional risk.
<TF Volume and Weight Monitoring>
<Resident 45>
According to the 06/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 had clear speech, intact memory, and had medical conditions including heart and kidney failure, uncontrolled blood sugar levels in the body, and a brain injury with resulting weakness in one side of the body and difficulty swallowing.
The MDS showed Resident 45 received TF via a surgical opening in their stomach during the assessment period.
Review of a 01/16/2024 Nutrition Care Plan (CP) showed Resident 45 was on TF for nutritional support because of the resident's swallowing difficulty. A CP intervention directed the nursing staff to administer the TF as ordered.
Review of Resident 45's Physician Orders (POs) showed a 05/17/2024 TF order that read: [a type of TF formula] 1.5 Cal Suspension- Soy Protein, Infuse 30 milliliters/hour via Enteral Tube three times daily for supplement from 8:00 PM to 5:00 AM
505418
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 505418 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029
Findings included .
<Hot Water Temperature>
<Facility Policy>
The facility's Domestic Water Policy, revised 01/2019, showed the facility's domestic hot water would be checked monthly to ensure a hot water temperature of 105 to 115 F was maintained.
<Centers for Medicare and Medicaid Service (CMS) Hot Water Guidelines>
According to revised 02/03/2023 CMS guidelines: A third-degree burn would occur after five minutes of exposure to a hot water temperature of 120 F, after three minutes of exposure to a hot water temperature of 124 F, after one minute of exposure to a hot water temperature of 127 F, and after 15 seconds of exposure to a hot water temperature of 133 F.
Observation on 07/23/2024 at 10:57 AM showed room [ROOM NUMBER] had two sinks, one labeled for Resident 33, and the other for Resident 68 who shared the room.
When temperatures were taken, the hot water from Resident 33's sink became hot very quickly after turning on the faucet and felt uncomfortable for hand washing.
The temperature measured at that time was 127 F. At the same time, Resident 68's sink's hot water measured 125 F.
505418
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 505418 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Marianwood Health and Rehabilitation 3725 Providence Point Drive Southeast Issaquah, WA 98029