Alaska Gardens Health And Rehabilitation

Findings included .

<POLICY>

Review of the facility's Managing Falls and Fall Risk policy, revised [DATE], showed the facility would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.

The facility, physician, and consultant pharmacist would identify and adjust medications known to increase the risk of falls or indicate rationale why the medications could not be adjusted, even for a trial period.

Review of the facility's Assessing Falls and Their Causes policy, revised [DATE], showed the facility would timely notify the physician and family when a fall occurred.

They would monitor for delayed complications and document their findings in the clinical record.

The facility would initiate an incident report with details defining the fall including the preceding chain of events to identify potential causes for the fall.

The physician would examine the resident after a fall. A Post-Fall Evaluation would be conducted.

After the fall, the facility would document in the clinical record: the condition in which they were found, assessment data, medical interventions implemented, notifications of physician and family, completion of a fall risk assessment, appropriate interventions taken to prevent future falls, and their response to the interventions.

Review of a The Fall Prevention Program (undated, one page document) showed the facility would place blue tags on the doors that said FALL PROGRAM, blue arm bands on the residents that say Resident on the fall program, non-skid socks were available for residents on the fall program, a blue information sheet above the patient's bed that would list their specific fall intervention codes (D=Dysum, T=Tipper bars, L=low bed, FW=Footwear, FM=Floor mat, and assistive device they needed), and a fall binder would be kept each nurse's station.

The nurses would also enter orders for the specific fall interventions and add the tasks into the POC (Point-of-Care -electronic documentation system for the Certified Nursing Assistants, CNAs).

Review of the facility's Alert Charting/Skilled Charting Guidelines, updated [DATE], showed when a resident fell , nurses were required to monitor and document their status by placing them on Alert Charting with vital signs every shift for 72 hours to monitor for: pain, injury, change in level of consciousness or mentation, problems with balance or functional abilities, and implement nursing interventions to prevent falls. If there was an injury with the fall, they would also do routine neurological checks (for head injury or unwitnessed fall) and skin evaluations.

505483

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 505483 B.

Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

F-F689 Free of Accident Hazards/supervision/devices:

potential for actual harm and skilled notes.

Staff A stated Medical Records staff conducted the audits.

Staff A stated they reviewed the clinical alert list in PCC (the computer charting program), and the 24-hour log to see who was on alert

The facility did not self-identify their failure to consistently implement fall care plans, initiate incident reports, or consistently document monitoring following resident falls.

4.

Refer to CFR: S483.95

F-F692 Nutrition/Hydration Status Maintenance:

During an interview on 03/04/2025 at 2:11 PM, Staff A stated in the December 2024 and January 2025 QAPI meetings the residents who triggered for significant weight changes were consistent, monitored, and the variance reports showed improvement.

When asked if the committee had identified any tube feeding dependent resident's that experienced weight loss or other hydration/electrolyte problems, Staff A stated No.

The facility did not self-identify their failure to ensure residents received the nutrition they required and consistently monitored the residents response to interventions.

505483

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 505483 B.

Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

Findings included .

Review of the facility's Adverse Consequences and Medication Errors policy, revised April 2014, showed the Interdisciplinary Team (IDT) would evaluate medication usage to prevent and detect adverse consequences and medication-related problems like adverse drug reactions and side effects.

Adverse outcomes would be reported to the appropriate entities.

The facility would follow clinical guidelines, manufacturer's instructions, ensure appropriate indications for use, and determine whether the resident has a known allergy to the medication.

The IDT would review the resident's medication regimen for efficacy and actual/potential medication-related problems on an ongoing basis.

The facility would notify the physician of medication errors promptly and monitor the resident closely for 24-72 hours or as directed, documented in the clinical record, and complete an incident report.

The Quality Assurance Performance Improvement (QAPI) committee would conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps, and compare results over time to determine that system improvements were effective at reducing errors.

Review of the facility's Admission Assessment and Follow-Up: Role of the Nurse policy revised September 2012 showed the policy had not been reviewed/revised or updated since 2012.

The policy showed the facility would reconcile the list of medications from their medication history, admitting orders, and the discharge summary.

They would contact the physician to communicate and review findings of their initial assessment and obtain admission orders based on their assessment and finding.

They would contact outside services as necessary and follow professional standards of practice.

<RESIDENT 26>

Review of Resident 26's hospital Discharge Summary dated 12/16/2024 showed they had a history of a stroke, heart attack, and long-term use of blood thinners.

The discharge summary medication list included orders dabigatran 150mg twice daily, an oral blood thinner.

Review of Resident 26's 12/22/2024 Admission Minimum Data Set (MDS-assessment tool) showed they admitted [DATE] and were not on blood thinners during the observation period.

Review of Resident 26's facility Admission orders dated 12/16/2024 showed the order for dabigatran was not transcribed to the admission orders and implemented.

505483

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 505483 B.

Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

Review of the facility history showed the facility failed to ensure administration of a prescribed respiratory medication (a medication used to treat breathing problems) and received a citation 01/22/2025.

The facility alleged compliance on 01/27/2025.

The facility did not identify their failure to ensure newly admitted resident's medications were readily available in a timely manner upon admission and the orders were accurate, complete, and reconciled.

2.

Refer to CFR: S483.25(g)(1)

During an interview on 03/04/2025 at 2:11 PM, Staff A stated the trainings were logged and they kept track of the hours.

Staff A stated they expected the facility to meet the required annual in-service hours for CNAs.

The facility did not self-identify they were not in compliance with the training requirements.

REFERENCE: WAC 388-97-1760(1)(2).

505483

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 505483 B.

Wing 03/19/2025

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

Alaska Gardens Health and Rehabilitation 6220 South Alaska Street Tacoma, WA 98408

Findings included .

Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, revised March 2020, showed that quality of care deficiencies was identified through feedback and data, and would undergo appropriate corrective action.

Corrective actions were monitored against established goals and benchmarks by the QAPI committee.

1.

Refer to Code of Federal Regulations (CFR): S483.45(f)(2)