Deficiencies (last 4 years)
Deficiencies (over 4 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
190% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were properly followed and available for certain residents.
Complaint Details
The visit was complaint-related due to concerns about failure to follow POLST instructions and availability. The complaint was substantiated as the facility failed to properly identify and follow POLST orders during a Code Blue event and lacked POLST forms for some residents.
Findings
The facility failed to follow POLST instructions for Cardiopulmonary Resuscitation (CPR) for Resident 32 and failed to ensure POLST forms were readily available for Residents 16 and 60, placing residents at risk of unwanted CPR and other negative health outcomes. The root cause was identified as the POLST book being organized by room rather than resident name.
Deficiencies (1)
Failure to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were implemented for 2 of 22 sample residents and one supplemental resident, related to lifesaving treatment orders.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Infection Preventionist | Observed and called out during Code Blue event; reviewed POLST and provided correct information. |
| Staff B | Interim Director of Nursing | Interviewed regarding the incident and confirmed failures in POLST identification and communication. |
| Staff C | Regional Director of Clinical Services | Interviewed and confirmed root cause of miscommunication related to POLST book organization. |
| Staff K | Licensed Practical Nurse | Alerted Staff I about Resident 32 being unresponsive. |
| Staff L | Confirmed lack of POLST for Resident 16. |
Inspection Report
Routine
Deficiencies: 21
Date: Mar 18, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with state and federal regulations related to resident care, rights, safety, infection control, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and care conference notification, consent for treatments and devices, care planning and implementation, infection control practices, medication management, staff training, and environmental safety. Specific failures included lack of consent for COVID-19 vaccinations and psychotropic medications, inadequate care planning and care conferences, improper medication storage and expired medications, failure to monitor water temperatures, and failure to provide adequate hydration and respiratory care.
Deficiencies (21)
Failed to honor resident's right to dignified existence and communication during care conferences.
Failed to obtain resident consent for COVID-19 vaccination, psychotropic medication, and use of tilt-in-space wheelchair.
Failed to ensure residents were fully informed and understood their health status, care, and treatments.
Failed to ensure advanced directives were in place or residents were informed about their rights to formulate advanced directives.
Failed to provide a safe, clean, comfortable, and homelike environment including maintaining hot water temperatures within safe limits and repairing room damages.
Failed to provide timely notification to residents and representatives before transfer or discharge and failed to notify the Long-Term Care Ombudsman.
Failed to provide written notice of bed hold policy to residents and representatives at time of transfer or within 24 hours.
Failed to coordinate assessments with PASRR program and refer for services as needed.
Failed to complete PASRR screening for mental disorders or intellectual disabilities accurately and timely.
Failed to develop and implement comprehensive care plans that meet all resident needs.
Failed to facilitate quarterly care conferences and revise care plans as required.
Failed to ensure physician orders were clarified and pain medication parameters were in place for residents with multiple PRN pain medications.
Failed to provide care and assistance with activities of daily living, specifically bathing assistance.
Failed to provide necessary communication assistance for residents where English was a second language.
Failed to provide basic life support and implement POLST orders correctly, including CPR directives.
Failed to employ sufficient qualified dietary staff including a fulltime Registered Dietician.
Failed to ensure medication refrigerator temperatures were monitored, expired medications were disposed of, and medications were secured properly.
Failed to provide and implement an infection prevention and control program including proper use of transmission based precautions and safe storage of respiratory equipment.
Failed to provide education and proper documentation for influenza and pneumococcal vaccinations.
Failed to develop, implement, and maintain an effective training program for all new and existing staff members including specialized training for hospice care.
Failed to ensure nurse aides received required annual training for continued competency including dementia care and abuse prevention.
Report Facts
Days without bathing assistance: 17
Medication refrigerator temperature: 49
Expired medication use-by date: 2023
Weight monitoring opportunities missed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Social Services Assistant | Named in findings related to care conference notification, PASRR referrals, and hospice coordination |
| Staff B | Director of Nursing | Named in findings related to consent expectations, care planning, infection control, and staff training |
| Staff F | Unit Care Coordinator | Named in findings related to care planning, medication monitoring, and PASRR referrals |
| Staff I | Infection Preventionist | Named in findings related to vaccination education and medication refrigerator temperature |
| Staff H | Unit Care Coordinator | Named in findings related to care conferences, oxygen therapy, and infection control |
| Staff C | Regional Director of Clinical Services | Named in findings related to staff training and medication monitoring |
| Staff J | Dietary Manager | Named in findings related to dietary qualifications |
| Staff Q | Registered Dietician | Named in findings related to dietary qualifications |
| Staff X | Licensed Practical Nurse | Named in findings related to medication storage |
| Staff M | Certified Nursing Assistant | Named in findings related to infection control and hydration |
| Staff S | Certified Nursing Assistant | Named in findings related to infection control and vaccination education |
| Staff T | Housekeeping Assistant | Named in findings related to infection control |
| Staff BB | Senior Director of Rehab Services | Named in findings related to wheelchair safety assessment |
| Staff DD | Staffing Coordinator | Named in findings related to staff training |
| Staff AA | Registered Nurse | Named in findings related to hospice care |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 31, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide written notice and explanation for facility-initiated room changes and failure to properly assess and manage the use of air mattresses, resulting in resident harm and risk.
Complaint Details
The complaint investigation substantiated that the facility failed to provide written notice and explanation for room changes for 4 residents and failed to properly assess and manage air mattress use for 7 residents. Resident 1 experienced an actual harm fall due to staff not following the care plan requiring two caregivers during incontinence care on an air mattress.
Findings
The facility failed to provide written explanations and proper notification to residents for room changes affecting 4 residents, violating resident rights. Additionally, the facility failed to develop and implement a system to assess, monitor, and educate staff and residents on the use of air mattresses for 7 residents, resulting in a resident fall with injury due to inadequate staff adherence to care plans and lack of training.
Deficiencies (3)
Failure to provide written explanation and notification for facility-initiated room changes for 4 residents.
Failure to develop and implement a system to assess, monitor, and educate on air mattress use, including lack of consent, care planning, staff training, and monitoring for 7 residents.
Failure to ensure staff provided care according to resident's care plan to prevent accidents, resulting in a fall with injury for 1 resident.
Report Facts
Residents affected by room change deficiency: 4
Residents affected by air mattress deficiency: 7
Shifts with only one caregiver for bed mobility: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Social Services Director | Interviewed about room change notification forms and facility policy |
| Staff M | Medical Records Coordinator | Interviewed about scanning and locating room change notification forms |
| Staff K | Regional Director of Clinical Services | Interviewed about lack of room change notification forms and air mattress policies |
| Staff F | Registered Nursing Assistant | Interviewed about Resident 1's care and fall |
| Staff G | Registered Nurse | Interviewed about monitoring air mattress and care plan adherence |
| Staff B | Float Director of Nursing | Interviewed about Resident 1's care plan and air mattress policies |
| Staff C | Assistant Director of Nursing | Interviewed about Resident 1's air mattress order and consent |
| Staff E | Resident Care Manager | Interviewed about Resident 1's air mattress use and consent |
| Staff H | Central Supply Coordinator | Interviewed about air mattress replacement and staff training |
| Staff I | Certified Nursing Assistant | Interviewed about training and care related to air mattress use |
| Staff J | Certified Nursing Assistant | Interviewed about training and care related to air mattress use |
| Staff D | Licensed Practical Nurse | Interviewed about Resident 1's fall and care plan adherence |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to thoroughly investigate incident reports related to injuries of unknown origin for two residents (Residents 4 and 7).
Complaint Details
The complaint investigation found that the facility did not conduct thorough investigations for injuries of unknown origin for Residents 4 and 7. Resident 4 had a large facial bruise that was not properly investigated or reported timely. Resident 7 had a bruise near the eye, and the investigation lacked necessary information and safety interventions. The facility was unable to substantiate abuse or neglect but failed to meet investigation requirements.
Findings
The facility failed to ensure incident reports were completely and thoroughly investigated for Residents 4 and 7, leaving residents at risk for unidentified abuse or neglect, repeated incidents, and decreased quality of life. Documentation was incomplete, investigations lacked vital information, and required safety interventions were not identified or implemented.
Deficiencies (1)
Failure to ensure incident reports were completely and thoroughly investigated for 2 of 3 residents with injuries of unknown origin.
Report Facts
Bruise size: 6
Bruise size: 1.5
Incident report documentation period: 10
Days late reporting: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Regional Director of Clinical Services | Stated the Director of Nursing was responsible for incident report log completeness and presented all investigations available |
| Staff B | Interim Director of Nursing | Reviewed incident reports, stated investigations were incomplete and late reporting occurred |
| Staff C | Assistant Director of Nursing | Stated complete and accurate investigations help prevent reoccurrence and ensure safety interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate pressure ulcer care and prevention at Life Care Center of Federal Way, focusing on treatment failures for residents with pressure ulcers and skin injuries.
Complaint Details
The investigation was complaint-driven, focusing on allegations that pressure ulcers were not adequately cared for, leading to worsening wounds and harm. Resident 1's representative reported lack of repositioning and worsening of the pressure ulcer without proper notification. Staff interviews confirmed failures in implementing ordered treatments and preventive measures.
Findings
The facility failed to provide necessary treatment and preventive care for pressure ulcers to two residents, resulting in actual harm including a Stage 4 pressure ulcer with osteomyelitis in Resident 1 and untreated wounds in Resident 2. The care plans lacked proper instructions for turning, repositioning, and off-loading, and treatments ordered by wound care providers were not consistently implemented.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to residents.
Report Facts
Pressure ulcer measurements: 4
Pressure ulcer measurements: 5.5
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 4
Treatment dates: 10
Treatment dates: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding failure to implement pressure ulcer treatments |
| Staff B | Director of Nursing | Interviewed regarding failure to implement pressure ulcer treatments and care plans |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care for Resident 1, specifically related to monitoring, assessment, and timely implementation of physician orders for a suspected urinary tract infection (UTI).
Complaint Details
The complaint investigation revealed that Resident 1 was not properly monitored for UTI symptoms, urine samples were not collected as ordered, and the practitioner was not notified of the failure to collect samples. Resident 1 was hospitalized with severe sepsis due to untreated bladder and kidney infections. The resident representative confirmed lack of communication and treatment. The Director of Nursing and Administrator acknowledged failures in monitoring, documentation, and follow-up.
Findings
The facility failed to consistently monitor and assess Resident 1's condition and did not implement physician orders timely, resulting in Resident 1 developing a severe bladder and kidney infection that progressed to systemic sepsis requiring ICU hospitalization. Staff made only one unsuccessful attempt to collect a urine sample, failed to notify the practitioner or resident representative timely, and did not document or follow up on the urine collection order after it dropped from the electronic medical record.
Deficiencies (1)
Failure to provide resident-focused care through consistent monitoring, assessment, evaluation, and timely implementation of physician orders for a suspected UTI.
Report Facts
Residents reviewed for quality of care: 5
Date of admission Minimum Data Set: Jun 21, 2024
Date of Care Plan: Jun 27, 2024
Date of urine lab test order: Jul 9, 2024
Date of unsuccessful urine sample collection: Jul 11, 2024
Date of hospital admission: Jul 15, 2024
Resident 1 hospital temperature: 103.1
Resident 1 hospital blood pressure: 85
Resident 1 hospital blood pressure: 63
Resident 1 hospital heart rate: 113
Resident 1 hospital respirations: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Interviewed regarding monitoring and urine sample collection procedures |
| Staff A | Administrator | Interviewed regarding documentation and electronic medical record issues |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 3, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse between residents, including physical abuse and failure to report and investigate abuse allegations properly.
Complaint Details
The complaint investigation involved allegations of physical abuse between residents, including Resident 1 punching Resident 2 and Resident 4 allegedly throwing objects at Resident 3. The facility failed to protect residents, report the abuse allegations timely, and conduct thorough investigations. Some residents reported feeling unsafe around Resident 1. The facility was working on discharging Resident 1 but had no interim protective plan.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to report an allegation of abuse to the State Survey Agency, and failed to thoroughly investigate abuse allegations. The facility also lacked interim protective measures while working on a resident's discharge. These failures placed residents at risk of abuse and diminished quality of life.
Deficiencies (3)
Failed to protect Resident 2 from physical abuse by Resident 1 who punched Resident 2 twice on the shoulder.
Failed to timely report an allegation of abuse by Resident 4 towards Resident 3 to the State Survey Agency.
Failed to thoroughly investigate allegations of abuse by Resident 4 towards Resident 3 and by Resident 1 towards Resident 2, and failed to implement preventative measures.
Report Facts
Residents affected: 6
Residents interviewed: 4
Residents responding no to feeling safe: 3
Residents responding no to feeling safe when Resident 1 yelled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Social Services Director | Observed Resident 1 hitting Resident 2 and conducted interviews during the investigation. |
| Staff F | Registered Nurse, Resident Care Manager | Interviewed regarding Resident 2's condition and history of behaviors. |
| Staff E | Social Services Assistant | Interviewed regarding Resident 2 and Resident 3's abuse allegations. |
| Staff C | Administrator in Training | Interviewed about preventative expectations and discharge plans. |
| Staff B | Director of Nursing | Interviewed about abuse allegations and facility response. |
| Staff A | Administrator | Interviewed regarding failure to log and investigate abuse allegations. |
Inspection Report
Routine
Deficiencies: 22
Date: Jan 10, 2024
Visit Reason
Routine inspection of Life Care Center of Federal Way to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, failure to honor resident dignity and preferences, incomplete advance directives, unresolved grievances, inadequate incident investigations, incomplete assessments and care plans, failure to provide necessary care and services including oral hygiene, restorative nursing, respiratory care, and infection control practices. Several residents were affected by these deficiencies.
Deficiencies (22)
Failed to inform residents of risks and benefits of psychotropic medications and obtain consent for 2 of 7 residents.
Failed to ensure residents' right to dignity and privacy for 2 of 20 residents.
Failed to honor resident choices for bathing and hair care for 4 of 4 residents reviewed.
Failed to obtain, renew, and assist with advance directives for 3 of 10 residents reviewed.
Failed to timely complete, investigate, and resolve grievances for 3 of 19 residents reviewed.
Failed to timely report suspected abuse and neglect for 1 of 1 closed death record reviewed.
Failed to initiate and thoroughly investigate incidents for 1 of 1 closed death record and 1 of 4 residents reviewed for falls.
Failed to ensure PASRR assessments accurately reflected mental health conditions for 2 of 5 residents reviewed.
Failed to implement and revise care plans as needed for 8 of 19 residents reviewed.
Failed to clarify physician orders for 2 residents and complete required AIMS assessments for 1 of 7 residents reviewed for behavior.
Failed to provide assistance with activities of daily living including dressing, shaving, bathing, oral care, and nail care for 4 of 14 residents reviewed.
Failed to provide individualized activity programs for 3 of 5 sampled residents and 1 supplemental resident.
Failed to provide care and services consistent with care plans for 5 of 20 residents reviewed including failure to follow physician orders, provide pressure injury prevention, blood sugar monitoring, and range of motion care.
Failed to provide and maintain respiratory care consistent with physician orders for 4 of 5 residents and 2 supplemental residents reviewed.
Failed to ensure safe storage of medications and resident rooms free of medications for 1 of 20 residents; failed to ensure medication carts free of expired medications for 2 of 4 carts reviewed.
Failed to provide care according to physician orders and facility policy for 1 of 2 residents reviewed for tube feeding medication administration.
Failed to ensure residents were free from accident hazards including unsafe bed and inadequate supervision for 2 of 7 residents reviewed.
Failed to provide behavioral health services for 1 of 7 residents reviewed for behavioral-emotional health.
Failed to provide trauma-informed and culturally competent care for 1 of 7 residents reviewed for mood/behavior.
Failed to administer influenza and pneumococcal vaccinations within recommended timeframe for 5 of 7 residents reviewed.
Failed to maintain complete, accurate, and readily accessible medical records for 4 of 20 residents reviewed.
Failed to implement an effective infection control program including accurate outbreak reporting, symptom monitoring, PPE use, transmission based precautions, hand hygiene, cross contamination prevention, and removal of noncleanable surfaces.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 8
Residents affected: 2
Residents affected: 4
Residents affected: 4
Residents affected: 7
Residents affected: 6
Medication carts: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Care Manager | Named in failure to obtain consent for psychotropic medications and failure to implement resident preferences |
| Staff D | Unit Care Coordinator | Named in failure to ensure dignity, care plan revisions, restorative nursing, and infection control |
| Staff B | Director of Nursing | Named in multiple findings including failure to implement care plans, follow physician orders, and infection control |
| Staff F | Social Services Assistant | Named in failure to obtain advance directives and trauma-informed care |
| Staff G | Registered Nurse | Named in failure to follow physician orders and respiratory care |
| Staff J | MDS Coordinator | Named in failure to complete assessments and care plan accuracy |
| Staff AA | Restorative Nursing Aide | Named in failure to provide restorative nursing services |
| Staff V | Licensed Practical Nurse | Named in failure to follow tube feeding medication administration policy |
| Staff BB | Infection Preventionist | Named in failure to report outbreaks and ensure infection control |
| Staff Z | Certified Nursing Assistant | Named in failure to follow infection control and communication care |
| Staff O | Nursing Assistant Registered | Named in failure to follow infection control during incontinence care |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 5
Date: May 10, 2023
Visit Reason
The inspection was conducted due to a Norovirus outbreak at the facility, focusing on infection prevention and control practices to prevent transmission of communicable disease among residents and staff.
Complaint Details
The visit was complaint-related due to a Norovirus outbreak. The facility had symptomatic residents and staff, incomplete staff illness monitoring, and inadequate infection control measures. The complaint investigation found the outbreak was not effectively controlled and that infection prevention practices were insufficient.
Findings
The facility failed to implement effective infection control practices, including monitoring and tracking resident and staff illnesses, enforcing Transmission Based Precautions, and ensuring staff compliance with hand hygiene and PPE use. Several residents and staff were symptomatic, and lapses in precaution signage and PPE use were observed, placing residents and staff at risk of spreading Norovirus.
Deficiencies (5)
Failed to implement infection control practices to prevent transmission of communicable disease for 15 of 30 residents reviewed.
Failed to implement a system for monitoring and tracking resident and staff illnesses.
Failed to implement and evaluate Transmission Based Precautions for residents.
Failed to ensure staff followed posted Transmission Based Precautions signs and performed hand washing.
Staff did not wear gowns and gloves as required when providing care or housekeeping services to residents on contact precautions.
Report Facts
Residents symptomatic: 10
Residents observed in dining room: 16
Residents reviewed for infection control: 30
Residents affected by deficiency: 15
Staff absences with symptoms: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Provided information about the Norovirus outbreak and infection control status |
| Staff B | Director of Nursing | Discussed outbreak management, infection control rounds, and hand hygiene education |
| Staff C | Infection Preventionist | Responsible for infection control rounds and education; was out during the survey |
| Staff D | Registered Nurse, Resident Care Manager | Provided surveillance documentation and information on resident precautions |
| Staff E | Licensed Practical Nurse, Admission Nurse | Provided information on resident precautions and infection control signage |
| Staff F | Licensed Practical Nurse, Staff Development Coordinator | Conducted hand hygiene training and observation |
| Staff G | Licensed Practical Nurse | Reported on staff reporting of symptoms and resident precaution signage |
| Staff H | Certified Nursing Assistant | Observed not following posted contact precautions during resident care |
| Staff J | Staffing Coordinator | Responsible for monitoring sick calls from staff |
| Staff K | Housekeeping Director | Reported housekeeping staff training on following precaution signs |
| Staff L | Housekeeper | Observed not following posted precaution signs while providing housekeeping services |
| Staff M | Registered Nurse | Called off sick with nausea and vomiting |
| Staff N | Certified Nursing Assistant | Called off sick with vomiting and diarrhea |
| Staff O | Certified Nursing Assistant | Called off sick with diarrhea and vomiting and notified Infection Control Preventionist |
Inspection Report
Routine
Deficiencies: 15
Date: Sep 15, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident assessments, PASRR screening, care planning, nursing services, infection control, medication management, and other care standards.
Findings
The facility failed to ensure accurate resident assessments, timely and accurate PASRR screenings, comprehensive care plans, professional nursing services, appropriate pressure ulcer care, adequate nutrition monitoring, infection prevention and control, antibiotic stewardship, and COVID-19 testing and vaccination tracking. Deficiencies were noted in multiple areas including resident assessments, care planning, medication administration, infection control practices, and staff training.
Deficiencies (15)
Failure to ensure Minimum Data Set (MDS) assessments were complete and accurate for multiple residents, leading to inaccurate information and risk for unmet needs.
Failure to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed and accurate for residents, placing them at risk for inappropriate placement and unmet mental health care needs.
Failure to maintain, revise, and update Care Plans for residents, leaving them at risk for unmet needs and diminished quality of life.
Failure to provide nursing services within professional standards, including medication administration errors and failure to clarify physician orders.
Failure to provide appropriate treatment and care for pain monitoring and other needs according to physician orders.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including inconsistent wound assessment and treatment.
Failure to provide restorative nursing services as assessed, placing residents at risk for decline in range of motion and mobility.
Failure to provide adequate nutrition monitoring and timely intervention for residents with weight loss.
Failure to provide safe and appropriate dialysis care, including failure to monitor access site, weigh resident consistently, and complete required documentation.
Failure to provide necessary behavioral health care and services, including failure to identify mental health needs and provide staff training on behavior management.
Failure to provide medically-related social services to address residents' refusals of care and essential care needs.
Failure to establish and maintain an infection prevention and control program, including failure to implement aerosol generating procedure precautions, transmission based precautions, and proper use of PPE and hand hygiene.
Failure to implement an antibiotic stewardship program, including failure to conduct monthly surveillance and analyze antibiotic use, and failure to reduce unnecessary antibiotic use.
Failure to perform required COVID-19 testing on staff as per facility policy and CDC recommendations.
Failure to implement an accurate system to track staff COVID-19 vaccination status, leading to inaccurate reporting and risk of exposure.
Report Facts
Residents sample size: 20
Deficiencies with severity: 15
Weight loss: 7
Weight loss: 16.6
Wound measurements: 5
Wound measurements: 4
Wound measurements: 1.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse - RN/MDS Coordinator | Named in multiple findings related to inaccurate assessments and care planning |
| Staff C | Resident Care Manager | Named in findings related to wound care, refusals, and care planning |
| Staff B | Director of Nursing | Named in findings related to medication administration and pharmacist recommendations |
| Staff H | Social Services Director | Named in findings related to PASRR screening and behavioral health assessment |
| Staff F | Activities Director | Named in findings related to resident preferences and care planning |
| Staff W | Infection Control Preventionist | Named in findings related to infection control and COVID-19 testing and vaccination |
| Staff D | Resident Care Manager | Named in findings related to care planning and resident positioning |
| Staff CC | Director of Rehab Services | Named in findings related to restorative nursing and wheelchair issues |
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