PRINTED: 04/10/2009 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO. 0938-0391 Srateweror oericences — [or) pRovengurruewcun [ou mucnPi= CONSTRUCTION Jos) onre sunvey [AND PUN OF CORRECTION [DENTPIGATION NUMeEte COURSED ; a Bute 506325 feo 04/03/2009, ‘NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GIy, STATE, ZP CODE {85 MADISON AVENUE NORTH Laced erie ce a ll BAINBRIDGE ISLAND,WA 98110 7 SURRY STATEMENT OF DEFCENOES | PROVIDERS PLAN OF conneCTION 2 Park | (GACH DBFIGENGY NlST Be PRECEDED BY FULL PRE (Aan connecTvencronsioubee | couttron Tae’ | AECUATORY Of LSC DENTICVNG FORMATION Tae | cAOSGREPERENGED fore aPpnopeiare || “OAT DECENCY F 000] INITIAL COMMENTS F 000 This report is the result of an unnannounced Quality Indicator Standard Survey conducted at Quality indicator Survey included the following information gathering: 16 interviews of residents that were cognitively aware, 3 family interviews for residents that were not cognitively aware, a brief record review of 40 in house residents, 40, ~-peer-ebservations and-20 admission record-— reviews. lnvestigatory Stage Il included 23 ‘The Stage Il sample included 24 current residents, the records of 2 former and/or discharged residents, This survey was conducted by: Elaine Odom RN, MSN Darryl Luyt RN, BSN Carolyn Hundley RN, BSN Bennetta Shoop RN, BSN ‘The survey team is from: Department of Social & Health Services Aging and Disabilty Services Administration Residential Care Services Region 5, Unit A 1949 South State Street MS: N27-24 ‘Tacoma, Washington 98405-2860 Telephone: (253) 983-3800 FAX: (253) 689-7240 | Island Health and Reabiltative Center on 3/30/09, 3/31/08, 4/1/09, 4/2/09 and 4/3/09. Stage 1 of the residents that were selected from a census of 57. Preparation and or execution ofthis Plan lof Corrections do not constitute the iprovider’s admission offor agreement with the facts alleged, or conclusions set forth nthe statement of deficiencies. This Pian of Correction is prepared and/or lexecuted solely based on the requirements under the provisions of 42 (CFR 405.1907 and State Regulations. Islan ‘and Rehabilitation will ~~ continue to maintain its high standard of |quality healthcare services delivered to Jour community. RECEIVED APR 3.6 2009 DSHS -ADSA ROS - REGION 5 UABORATORY/DIRECTORS OR PROVIDERBUPPLIER REPRESENTATIVES SIGNATURE ajRTE Adie rode YirUot ‘Ap “ficiency statement ending with an astarsk (?) denotes a deficiency which the insiution mey be excused rom corectng providing is determined that :feguards provide sufficient protection tothe patients. (See instructions.) Except for nursing home, the findings stated above are disclceable 90 days o program participation, FORM GlS-2567(2.00) Previous Versions Obsolete Eventi: FROTHI acy 1: W580 fon....ig the date of survey viether or net a plan of corracton is provided. For nursing homes, the above findings and plans of correction are ciscosable 14 days folowing the date these documents ere made avallable tothe faclily. Wdeficencies ae an approved plan of corraction is requisite to continued Weontination shest Page 1 of 21PRINTED: 04/10/2009 about aspects of his or her ife in the facility that are significant to the resident, Based on observations, resident and staff interviews and record review, the faciity failed to give 1 of 3 Sampled Residents (#27) a choice about what diet he was on in the facility. Three ) | residents were reviewed for the care area of “| choice during Stage If of the survey. Findings include: him a smaller portion meal and a controlled carbohydrate meal. The resident indicated,'No one asked me, | have taken care of my diabetes for a long time and | can continue taking care of It, My blood sugars have been running low in this place, but that dietician has not come into talk to me, she just decided to put me on small portions. ‘They ere even controling my carbohydrates." The resident continued, “they told me they put me ‘back on regular size but | stil do not lke being on RESIDENT #27 | On 3/80/08 at 2 p.m., Resident #27 reported he | had been upset when the dietician decided to give DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO. 0838-0391 STATEMENT OF DEFICIENCIES |xi) PROVDERISUPPLIERICLA (x MULTIPLE CONSTRUCTION [oo pare saver AND PLAN OF CORRECTION ‘DENTICATION NUMBER, ‘couPLEteD [A suLoING { 505325 pene 04/03/2009 ‘Nave OF PROVIDER OR SUPPLIER STREET ADDRESS, OMY, STATE, 2p GODE_ £835 MADISON AVENUE NORTH Teer oer eeeee BAINBRIDGE ISLAND, WA 98110 a8 "SUWUARY STATEMENT OF DEFICIENCIES © PROVDERS PLAN OF CORRECTION 2 Prerx | (GACH DERCIENGY MUST BE PRECEDED BY FULL PRERK. EACH CORRECTIVE ACTION SHOULD Be _—_ | cowtEroN “TaG. | REGULATORY OR LSC IDENTIFYING INFORMATION) Tae CROSSREPERENGED TO THE APPAOPRIATE |“ OATE DERGENCY F 242) 483,15(5) SELF-DETERMINATION AND F242 ‘S8=D | PARTICIPATION The resident has the right to choose activites, schedules, and health care consistent with his or 24 ‘inatior fase aces cea ee 5242 speteminaton nd fat interact with members of the community both inside and outside the facility, anc make choices individual Residents Resident #27's meal preferences willbe obtained and his diet order will reflect his, preferences. Re similar Situations | Residents will be asked about satisfaction with diet orders and food service by Caring Partners. Anyone expressing disagreement or dissatisfaction will be scheduled to meet with the dietition, Measures to Prevent Reoccurrente 1. The Registered Dietition or designee will consult each resident prior to recommending new diet orders and new orders will reflect residents’ choices. 2, Resident Council agenda will Include ‘an opportunity for the Council to discuss ‘ood serviceldiet order issues. Ongoing Monitoring Caring Partners rounds will routinely check in with residents about the food they are served. Concerns wil be reviewed by the Quality Assurance this carbohydrate controlled diet and the regular Committee for trends. size portions are stil small. | just want to talk with the dietician.” L FORON ONS 23670200) Previous Versions Gbelee Eve: FROTHT ec D:WA23900 i continuation sheet Page 2 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES [STATEMENT OF DEFICIENCIES [¢x3) PROVIDERISUPPLIERICLIA [AND PLAN OF CORRECTION IDENTIFICATION NUMBER. f 505325 PRINTED: 04/10/2009 FORM APPROVED OMB NO. 0938-0394 [ee MULTIPLE CONSTRUCTION Ja BuLONG. B. wine, oc) pare suavey ‘COMPLETED 04/03/2008 | howe OF PROVIDER OF SUPPLER ISLAND HEALTH & REHAB CENTER ‘STREET ADORESS, CITY, STATE, ZIP CODE ‘885 MADISON AVENUE NORTH BAINBRIDGE ISLAND, WA 98110 ‘SUMMARY STATEMENT OF DEFICIENGIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (44) PREF ‘Tas. © PREAK Tas PROVIDER'S PLAN OF CORRECTION. (GAGH CORRECTIVE ACTION SHOULD 8 ‘CROSS-REFERENCED TO THE APPROPRATE DEFICIENCY) 2 ote F 242| Continued From page 2 was on a carbohydrate controlled diet The dietician notes dated 3/18/09 included, "Goal is for the pt to gradually decrease weight of 1 to 2 pounds a week for ideal body weight of 124 gain." Re always hungry succumbing to eating his own purchased snacks. He is aware of his diabetic ~\ | regular portions on 3/23/09. raised his voice and pointed at his food and ‘On 4/4/09 at 9:30 a. m., the dietician indicated she had decreased the resident's portion size at 9:26 a. m. Resident #27 told the dietician he ‘wanted larger portions and he wanted off his controlied carbohydrate diet 483.20, 483.20(b) COMPREHENSIVE ASSESSMENTS F212 ss=D ‘a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, ‘The dieticians 2/4/09 notes indicated the'resident Pounds to 16 pounds or to prevent further weight| On 3/20/09, the nursing notes indicated, resident "a ting to have full sized portions of meals status and currently his weight is not of concern to him." The resident's portions were increasad to On 4/1/09 during breakfast, Resident #27 stated, “Look at my food, one cold pancake, one piece of ‘bacon, some cold cereal and milk". The resident indicated, "| would like to talk with that dietician.” without talking with him first. The surveyor asked the dietician to talk with Resident #27, On 4/4/09 ‘The facility must conduct initially and periodically F272 F242 Indivici anc ‘The Administrator or designee will monitor for compliance FORM GHS-2567(02.00) Provo Versons Obecite Event: FROTH Fac: WAZSG00 eontinuaton sheet Page 8 of 21: 7 PRINTED: 04/10/2000 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO. 0938-0391 STATEMENT OF DEFGIENCES —[(Xi) PROVDDERISUPPLEERICUA na) NULTIPLE CONSTRUCTION oc ave suRveY JAND PLAN OF CORRECTION. IDENTFICATION NUMBER” cowetereD JA BuLOING L 505825 fee 04/03/2009 ‘NewtE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, iP CODE £835 MADISON AVENUE NORTH See BAINBRIDGE ISLAND, WA 98110 oT) ‘SUMRARY STATEMENT OF DEROIENGIES D PROVIDERS PLAN OF CORRECTION 2, Ferm | GACH DEFICIENCY MUST BE PRECEDED BY FULL PREF Ach conRective rion sHouDee | cownon REGULATORY OR USC IDENTIFYING INFORMATION) 708 CHOSSREFERENGED TOTMEAPEROPRATE | "UATE DECENCY) F 272| Continued From page 3 F272! ‘Afacilty must make a comprehensive assessment of a resident's needs, using the RAI specified by the State. The assessment must include at least the following: F272 Comprehensive Assessments |#/27167] Identification and demographic information; : ‘Customary routine; Individual Residents, Cognitive patterns; A pain assessment will be completed on Communication; Resident #79 with care plan to be revised Vision; 5 necessary to enure any pain f wo .,liloed and behavior pattems; _ managed... Psychosocial well-being: Physical functioning and structural problems; Residents in Similar Situations. Continence; | Disease diagn Pain assessments with associated care plan revisions will be completed on residents receiving routine or PRN tions; ( Activity pursuit; medication for pain. Medications; Special treatments and procedures; Measures to Prevent Reoccurrence Discharge potential; 1. Licensed Nurses will be inserviced on Documentation of summary information regarding pain eseeseront. pan flow sheet pal | the additional assessment performed through the Iedicatio procece and care planing for resident assessment protocols; and pee ea Documentation of participation in assessment. : 2. Pain assessments and Comprehensive Care Pian reviews will be ‘This REQUIREMENT is not met as evidenced ‘conducted quarterly or as new pain issues by. Based on observation, interview, and record iirc review the facility falled to comprehesively ‘Ongcing Monitoring ‘assess a resident for pain and for the managment ‘of pain symptoms for 1 of 23 Sampled Residents (#79), Failure to comprehensively assess Caring Partners rounds will routinely ask resident's pain had the potential to place Resident residents about pain issues, which will be 79 atrrisk of having unrecognized and/or {racked and trended and reviewed by the untreated pain events, QA Committee. Findings include: FORM GMS. 228710200) reds Venione Oba Event OsFROTHE acy WA23300 'Weontinuaton sheet Page 4 of 21PRINTED: 04/10/2009 DEPARTMENT OF HEALTH AND HUMAN SERVICES TORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO. 0938-0394 STATEMENT OF DERIGENCES |e) FROVDERSUPPLEERCUA | a) MULTPLE CONSTRUCTION oc pare survey |aNO PLANO CORRECTION [DENTGATION NUMBER. couPLsteD lA eutons Li) 505825 Leheeaet 04/03/2009 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, Oy, STATE, ZP CODE {35 MADISON AVENUE NORTH Regeeee cere BAINBRIDGE ISLAND, WA 98110 rT} SUiRIARY STATEMENT OF DEROIENOES % PROVIDERS PLAN OF COMAECTION = Fateh | (exch Dericlency wust Be pREcEDED BY FULL Par EACHCORRECTIE ACTION SHOUD BE | couBEnon Tae" | RECKRATORY OR LOC IDENTIOVING IFOTIHATION) TAs | cROSOREFERENGED FOTHE aremormiaTe || “BATE DEFICIENCY) F 272| Continued From page 4 F272! RESIDENT #78 ' Resident #78 was admitted to the facility on ‘3/5/2008 with primary diagnosis of strokes which affected moby to hs ift side of his body. The Quarterly Minimum Data Set (MDS) assessment |ndividual to Ensure Compliance tool, dated 1/4/09, indicated ths resident required “The Director of Nursing or designee wi extensive assistance for actives of daily living, monitor for compliance had limitations in his range of motion to one side of his body and he had partial loss of voluntary 4 .---ptevement.te one. side of his body Reviewofthe |_| most recent Pain Collection and Assessment tool, dated 1/7109, indicated Resident #78 exhibited no signs and symptoms of pain During an interview with Resident #79, conducted ;~ | 04/1709 at 11:50 a.m., he said he endured pain ) | on a daily basis which he said was due to his stroke and his left side loss'of function for both the legifoot and armihand. He said he asked for | pain medications as he needed them and when he could not alleviate his pain by other methods. He demonstrated using his non-effected right side hanc/arm to stretch out his hand on the left effected side. He said he does this himself many times throughout the day and at night when he sleeps he wears a splint to the left arrm/hand, He | said pain had been an issue for him since he had his strokes. Resident #79 said facilty staff | “never have really asked me about my pain or _| what relieves its" but were "good about giving me my pain medication when | ask fori." On 4/1/09, at 12:10 p.m., in interviews with direct care Staff Members C and D. Both Staff Members reported that Resident #79 occasionally requested pain medications and they would inform the nurses. Staff member C said if the resident requested pain medications it was FOROM GNS-2557(020) Previus Vrsone Obits Event OFROTH Feely 0: WA23900 Weontinvatlon sheet Page 5 of 21PRINTED: 04/10/2009 DEPARTMENT OF HEALTH AND HUMAN SERVICES ~ FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0384 STATEMENT OF DEFICIENCIES | (X1) PROVDERSUPPLIERCUA [oa MULTPLE CONSTRUCTION x) bare sunvey [AND PLAN OF CORRECTION JBENTIPGATION NUMBER COMPLETED a. unin lf 505325 eee 04/03/2009 ‘Nsw OF PROVIDER OF SUPPLIER [STREET ADDRESS, GY, STATE, 2 CODE {885 MADISON AVENUE NORTH ISLAND HEALTH & REHAB CENTER Reroee Laas Wa bra ma "SIMMIARY STATEMENT OF DEROIENGES D PROVIDERS FLAN OF CORRECTION = Fitex | (each Denclency must PRECEDED BY FULL PRERUC (EACH CORRECTHE ACTION SHOULD Be. | coutenon Tae | REGULATORY OR LS IDENTIYING INFORMATION) Te CROSSIREFERENGED To ne aPeROPmUATE | "DATE DEFICIENCY) F 272| Continiied From page § | Fare] usually just prior to getting him up for a meal or ; before care. F 279| 4833 20(), 489.20(9(1) COMPREHENSIVE F 279|F278 Comprehensive Care Plans apn ‘88D | CARE PI indwvideat ‘A feciity must use the results of the assessment Care Pian Reviews, with associated to develop, review and revise the residents assessments, will be completed on ‘comprehensive plan of care. Residents #79, #8, and #25 with care : plans to be revised as indicated to best +; The facility. must develop a.comprehensive.care_.|........._|meet-the residents needs. plan for each resident that includes measurable objectives and timetables to meet a resident's Residents in tuations ‘medical, nursing, and mental and psychosocial needs that are identified in the comprehensive | assessment. }Care Plan reviews, yith associated ‘assessments, wil be completed on residents receiving pain medication on a (J. | The care plan must describe the services that are | routine or PRN basis, those who have to be furnished to attain or maintain the resident's, |expertenced a fal, and those who are at highest practicable physical, mental, and high risk for skin issues. | psychosocial wel-being as required under §483.25; and any services that would otherwise Measures to Prevent Reoccurrence be required under §483.25 but are not provided | 1, Licensed Nurses wil be inserviced on due to the residents exercise of rights under the policies for new assessments and §483.10, including the right to refuse treatment [care plan updates. Under §483.10(b)(4). 2, Care Plan reviews will be conducted uarterly of as needed to meet residents’ This REQUIREMENT Is not met as evidenced needs, by: Based on observations, interviews, and record Ongoing Monitoring reviews the faciliy failed to develop comprehensive plans of care for 3 of 23 Sampled Residents (#s 8, 25, & 79) which identified Random Care Pian audits will be resident issues of pain symptoms and/or relief ‘completed by the DNS or designee. ‘methods for those residents who experienced Audits will be tracked and trended and pain signs and/or symptoms. Fallure to develop a reviewed by the QA Committee. Plan of Care (POC) for residents who ‘experienced chrenic and/or acuts pain symptoms i FORM GMS 2567(02.00) Provous Versone Obes Even iFROTHY ety 1: WA23900 \fcontination shost Page 6 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/10/2009 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES Jott) PROVIERSUPPLERIOUA [oc MULTIPLE CONSTRUCTION [os are suRveY AND PLA OF CORRECTION IDENTIFICATION NUMER couPisteD A. BULOINS | 505325 a No aoar2009 ‘NAME OF PROVIDER OR SUPPLIER [STREET ADDRESS, GY, STATE, IP CODE {35 MADISON AVENUE NORTH Peer BAINBRIDGE ISLAND, WA 98110 rr} SUIARY STATEMENT OF DEAENGIES D 'PROVDERS PLAN OF CORRECTION Sie | ceactoerrcencr nust Be precepeD By FULL panic EACH CORRECTIVE ACTION SHoULDEE | coWetron Tae’ | REGULATORY On {SC IDENTIFVING INFORMATION) The | chOSSREPENENGeD ToTHeAPPROPRNTE || "ONE DEFICIENCY) F 279 | Continued From page 6 F279 placed them at risk for untreated andior lieved . ' Unrelleved pain events, eed Findings include: RESIDENT #8 Resident #8 wes admitted to the facility in July 2007. She required the assistance of staff for her ly care which included trensfers and bed ‘mobility. Her diagnoses included diabetes and | spinal stenosis which caused chronic pain The... resident did not have a pressure sore when admitted to the facility. (On 4/1/09 at 11 am. Staff| and U provided personal care. A pressure sore was observed on the residents cocoyx. The sore did not have @ | dressing. Observations of the resident's feet revealed a red/black scab on the right heel. Staff J, alicensed nurse, measured the scab as 1 om by 0.5 em, On 4/2/08 the resident's daughter stated she | knew her mother had 2 pressure sore on her coccyx. The facility notified her of the pressure sore “about six weeks toa month ago.” Her mother had a pressure sore on her right heel before the coccyx but that was healed. The daughter was not aware of the scab on the right heel, Review of the resident's care plan indicated the resident had a pressure sore on her right heel which was resolved in February 2008. The care plan was not revised to address the pressure sore| ‘on the resident's cocoyx or provide interventions. or guidance to staff on how to prevent the residents heels from developing pressure sores. The Director of Nursing or designee will ‘monitor for compliance FORM GhS-2567(0200) Provous Vewors Obata EventID FROTA Fae WAz2300 Wcontinuaion sheet Page 7 of 21: PRINTED: 04/10/2008 DEPARTMENT OF HEALTH AND HUMAN SERVICES ° FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO. 0938-0354 STATEMENT OF DEFICIENCIES — |>Kt) PROVIDERISUPPLIERICLA (pa) NULTIALE CONSTRUCTION [oss oare survey JAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A suLoins li) 505325 eee 04/03/2009 [NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CY, STATE, ZIP CODE 1835 MADISON AVENUE NORTH eee ee BAINBRIDGE ISLAND, WA 98140 : 2D ‘SUMMARY STATEMENT OF BERCIENGIES © PROVDERS PLAN OF CORRECTION m= Phere | (ACH DEFICEENGY MUST BE PRECEDED BY FULL ae AGH CORRECTIVE ACTION SHOULD aE _—_| cadtrow Tae | REGULATORY Of LS IDENTIFYING INFORIATION, TAS CROSS-REPERENCED TO THEAPPROPAIATE | “SATE DECENCY F 278 Continued From‘page 7 F279 RESIDENT #25 ; The facilty admitted Resident #25 in January 2004, She required the assistance of staff for her dally personal care which included transfers ‘between the bed and the wheelchair, On 4/1/09 at 8:30 a.m. the resident was observed being transferred from her bed to her wheelchair and required extensive assistance of one nursing assistant. The resident did support her own — weight during the fransfet-.—sunu ‘The record revealed the resident fell on 3/2/09 while attempting to open the curtains in her room, The curtains in the resident's room were closed ‘ 5 (on 3/30/09 at 3 p.m., during multiple observations throughout the day on 3/31, and at 10:30.a.m. on { 4/1/09. On the afternoon of 4/1/09, the curtains “| were closed and a soft, ow light lamp was on in the comer of the room. On 4/2/09 at 4:19 p.m., Staff B licensed nurse, stated the resident had a onetime fall. She indicated the resident had not attempted to stand | | or ambulate for years and the behavior that led to the fall was unexpected, ‘The care plan was not updated after the fall and did not address factors that could potentially ‘cause the resident to fall again, | RESIDENT #7: Resident 79 did not have a POC developed for the managment of his chronic pain issues. Refer to details in F272 regarding Resident #79. F 309 | 483.25 QUALITY OF CARE F 309 SS Each resident must receive and the facility must FOR MS-2507(02.00) Previous Versione Obie Event DsFROTH! acy BE WA23=00 Weontinuation sheet Page 6 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2000 FORM APPROVED OMB NO; 0938-0394 ISLAND HEALTH & REHAB CENTER ve {835 MADISON AVENUE NORTH BAINBRIDGE ISLAND, WA 98110 STATENENTOF DEFICIENCIES 0X1) PROVIDERISUPPLIERICUIA oc) MULTIPLE CONSTRUCTION (065) DATE SURVEY JAND PLAN OF CORRECTION IDENTIFICATION NUMER ‘COMPLETED A BuO f ‘505a26. B. WN, aio ‘NAME OF PROVIDER OR SUPPLIER [STREET ADDRESS, CITY, STATE, 2 CODE ‘SUNMARY STATEMENT OF DEFICIENCIES This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record... review, the facility faled to ensure the 1 of 4 Sampled Residents (#8) received adequate pain control during the provision of care, This failure resulted in the resident experiencing, Findings include: RESIDENT #8 ‘The facility admitted Resident #8 in July 2007. ‘She required the assistance of staff for her daily ‘care which included transfers and bed mobility Her diagnoses included diabetes and spinal stenosis which caused chronic pain. The resident did not have a pressure sore when admitted to the facility. On 4/1/09 at 11 am., Staff and Staff U, two nursing assistats, transferred the resident from | her wheelchair to her bed using a mechanical lt. ‘They proceeded to provide personal care to the resident which required roling her from side to | side a number of times. During the care a pressure sore was observed on the resident's coceyx. The sore did not have a dressing. ‘During the care the resident stated she was tired. ‘She expressed fear of roling off the bed onto the floor. Her left knee was bent at approximately @ Resident #8 with care plan to be revised ‘as necessary fo ensure any pain is well managed. Pain assessments with associated care plan revisions will be completed on residents receiving routine or PRN medication for pain, jcourrence ‘Lioensed Nurses will be inserviced on providing pain medication prior to ‘treatment, stopping treatment f resident exhibits signs/symptoms of pain, and the necessity to complete new pain assessments with new or worsening wounds, Ongoing Monitoring Caring Periner rounds wil include questions about pain control. Random care observactions will be completed by the DNS or designee. Information from the above sources will be tracked and trended and reviewed by the QA Committee. ma | _ PROVIDER'S Puan OF CORRECTION 2, Patax | (each DenGlency wut Be PRECEDED BY FULL PRE GACHCORRECTNEACTONSHOULD 2e | camftren TAS’ | REGULATORY OF LSC ENT=YING FORMATION The | GAOSSREFERENGED forme Appnopnimre | | “owe DEFICIENT) F 309] Continued From page 8 F 309 provide the necessary care and services to attain : or maintain the highest practicable physical, mental, and psychosocial well-being, in : accordance with the comprehensive assessment F309 Quality of Care ipy and plan of care. on ae A pain assessment will be completed on FORM CMS. 2567(02-98) Prodous Versone Obsolta Even :FROTH Fact 0: WAz3900 Ifcontinuation sheet Page 8 f21‘STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVI PRINTED: 04/10/2009 FORM APPROVED OMB NO. 0938-0391 ox) PROVDERISUPPLIERZOLIA IDENTIFICATION NUMBER: 508325 [oc MULTIPLE consTAUCTION 4. SURO lb. wins. Jos parE suRvev (COMPLETED 04/03/2009. | Nau OF PROVIDER OR SUPPLER ISLAND HEALTH & REHAB CENTER ‘STREET ADORESS, CITY, STATE, ZP CODE ‘835 MADISON AVENUE NORTH BAINBRIDGE ISLAND, WA 98410 (x4) 'SUMIARY STATENENT OF DEFICIENCIES PRerx | (GACH DEFICIENCY MUST BE PRECEDED BY FULL Tae REGULATORY OR LSC IDENTIFYING INFORMATION) © PREF 78 "PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (OROSS-REFERENGED TO THE APPROPRIATE : DEFICIENCY) cone onre F 309) Continued From page ® Jand Staff U rolled the resident onto her left side she groaned and said, "Oh, oh." | At 11:0 am. Staff J, a licensed nurse, entered the room after the nursing assistants had ‘completed the care and positioned the resident con her right side to rest. Staff J said she needed to see the resident's shoulder, Staff | told Staff J the resident did not have a dressing on her coceyx. Staff J left the room to get the dressing supplies. Staff J directed the the nursing assistants to place Resident #8 on her left side, The resident was moved to the edge of the bed and rolled to the left. During this movement the resident complained of hurting. She said, “Ow, oh, ow.” (Once the resident was on her left the nurse could not see the sore adequately. The resident was rolled back to the right side. During this ‘movement she groaned and grimaced as she rubbed her left thigh, Staff J measured the sore on the resident ' s ‘coceyx, which required placing a cotton-tisped | stick into the wound to measure depth. The resident said" Ow" in a louder voice, ‘Ones the dressing was in place on the coocyx | Staff J requested to see the resident's left shoulder. The resident was moved to a different position | The surveyor asked to see the resident's heels, ‘Staff J removed a blue cloth boot from the residents right foot. The resident had a deep red to black soab on the right heel with @ red surrounding area. ninety degree angle throughout care. When Staff F 309 to Ensure Complian ‘The Director of Nursing or designee will monitor for compliance ORI CiUS-2867(02.00) rede Vesone Obolle ‘Event O/FROT#® aot: WAD8800 ifeontinuation sneet Page 10 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID PRINTED: 04/10/2009 FORM APPROVED ‘OMB NO. 0938-0301 [STATEMENT OF DeFIcIENGIES ——_ [px:) PROVIDER/SUPPUER/CUA ‘AND PLAN OF CORRECTION. IDENTIFICATION NUMBER: ey 505325 foc pare survey [oc MULTIPLE CONSTRUCTION COMPLETED [A BUILDING fb. wise, o4io3/2009 [ Naw OF PROVIDER OR SUPPLER ISLAND HEALTH & REHAB CENTER [STREET ADDRESS, CITY, STATE, ZIP CODE ‘885 MADISON AVENUE NORTH BAINBRIDGE ISLAND, WA’98{10 ‘SUMMARY STATEMENT OF DEFICIENCES (EACH DECENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 46) 1D PREF Tas PROVIDER'S PLAN OF CORRECTION, (GACH CORRECTIVE ACTION SHOULD BE (CROSS REFERENCED To THE APPROPRIATE DEFICENCY) 0 2 PREFIX conden TAS ‘Ne F 309 | Continued From page 10 ‘Staff J measured the scab at 0.5cm by tom. After treating the area with a wound preparation, she placed a dressing over i. During this treatment the resident was groaning and rubbing her left thigh. Staff J told the resident it was necessary to do the dressing on her foot and it would soon be over. ‘The surveyor asked to see the resident's fect. | Staff identified areas.on both feet that required. ‘measurement and treatment, Throughout this process the resident repeatedly groaned and rubbed her left thigh. Staff J told the resident it was necessary to do the treatment and it would ‘s00n be over. ( As Staff J completed the measurements she told “| the resident that she would tell the medication nurse that Resident #8 "as needed" pain medication. The nursing assistants got the resident up for lunch. On 4/1/09 at 4:30p.m., the medication record indicated the resident had nat been given "as needed” pain medication, The record revealed | the resident had routine pain medication at 6'a.m. and at 2 p.m. | On the moming of 4/3/09, Staff G stated the resident had been given her 2 p.m. pain medication early that day, There was no notation cn the medication administration record or in the | progress notes to indicate thet the medication had been administered at earlier or if it had been effective. F314 S856) 483,25(c) PRESSURE SORES F 309 Fata FORM CH5.2557(02 90) Previous Varlone Ocala Evert :FROTH acl ib WAZS300 ‘fecontinustion sheet Page 17 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES PRTORM APPROVED CENTERS FOR MEDI & MEDICAID SERVICES. OMB NO. 0938-0394 STATENENT OF DEFCIENCIES |) PROVIDERISUPPUERILA, [oc maLTPLE CONSTRUCTION [asi aare survey AND PLAN OF CORRECTION. IDENTIFICATION NUMBER COMPETED Ja. sunona cat 505325 B.WiNG 04/03/2009 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, GIy, STATE, 2 CODE ‘ 835 MADISON AVENUE NORTH ISLAND HEALTH & REHAB CEN’ be BAINBRIDGE ISLAND, WA 98110 om “SUWARY STATEMENT OF DEFICIENCIES > 'PROVDERS PLAN OF CORRECTION 2. FRok | (GACH DERGENGY MUST BE PRECEDED BY FULL PRET (EACH CORRECTIVE ACTION SHOULD BE __| coNbLETON aS. | REGULATORY OR LSC IDENTIFYING INFORVATION) Tae CROSS-REFERENCED TO THE APPROPRIATE | © ONE DEFICENCY) F 314| Continued From page 11 F314 Based on the comprehensive assessment of a ; resident, the facilly must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuats clinical condition demonstrates that Fata Pressure Sores Karat they were unavoidable; and 2 resident having pressure sores receives necessary treatment and individual Residents, Services to promote healing, prevent infection and ‘Skin assessments will be completed on prevent new sores from developing. Resident #8 with care plan to be revised ‘2s necessary to ensure residents needs a by. aid Residents in Similar Situations Based on observations, interviews, and record reviews, the facility failed to ensure that 1 of 2 ‘Skin care plans willbe reviewed and | * residents (Resident #8) reviewed for pressure updated along with Care Delivery Guides ~, | sores, did not develop a pressure sore after the for residents at risk for developing facllty admitted the resident. Ths failure caused pressure ulcers or who are known to have Resident #8 to develop a Stage Ill pressure sore | | askin issue. fon her cocoyx. ie Measures to Prevent Reoccurrence RESIDENT #8 The faclity admitted Resident #8 in July 2007, eerpreee ty nesraad nitser onal She required the assistance of staff for her daily ae ees care which included transfers and bed mobil, @ She was unable to position herself independently. Her diagnoses included dlabetes and spinal tay cea nome ene ce stenosis which caused chronic pain. The resident a rei epee did not have a pressure sore when she admitted eee to the facility nan On 4/4/09, Resident #8 was in her wheelchair at ‘Skin issues, progress toward healing, 7:30 a.m.and facility staff took her to breakfast ‘current treatments will be reviewed and From breakfast, she wentto the beauty shop and ‘summarized weekly in a report to be she walted in the hallway at 9:45 a.m. for staff to reviewed by the Regionel Director of take her to the dining room to have her nails Clinical Services and the Registered polished, At 10:30 a.m, the resident had her nails Dietitician. This information wil be done. At 10:55 a.m., staff took her to her room to lie down. She wes up in her chair for three and a FORM CMS-2587(026) Previous Versions Obsolots EventID ROTH ecy WA23900 Tf continuation sheet Page 12 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2000 FORM APPROVED OMB NO. 0938-0304 STATEMENT OF DEFICIENCIES | (X1) PROVOERISUPPLIERICUA [a muLTiPL= CONSTRUCTION [oo Dare sunver JAND PLAN OF CORRECTION. IDENTICATION NUMER ona owPLETED i 505325 eet 4/03/2009 NaMé OF PROVIDER OR SUPPLIER [STREET ADDRESS, Cry, STATE, ZIP CODE EHAB CENTER 3835 MADISON AVENUE NORTH See eee BAINBRIDGE ISLAND, WA 98110 or “SUNNNARY STATEMENT OF DEFICIENCIES oy PROVOERS PLAN OF CORRECTION =, PRerk | (GACH OBFICENCY MUST BE PRECEDED BY FULL PRERK (EACH CORRECTIVE ACTION SHOULD 3é | couPlnow TAG. | REGULATORY OR LSC IDENTIFYING INFORMATION) TAS COROSSREFERENCED TO THE APPROPRATE | OATE DEFICIENCY) F 314] Continued From page 12 F314] half hours. : On 4/1/08, at 14 a.m. Staff and U, nursing {tacked ad tended and reviewed by the assistants certified (NACs), transferred the ion Commune, resident from her wheelchair to her bed using @ ‘mechanical lif. The two NACs provided personal care-to the resident. During the care, a pressure individual to Ensure Compliance sore was observed on the resident's cocoyx. The sore did not have a dressing. The resident had a fe | sides.ofhoth feet At 41:30 am. Staff J, a nurse (LN), entered the room and asked to see the resident's, shoulder. Staff told Staff J that Resident #8 had ‘no dressing on her coccyx. Staff J measured the ‘coccyx open area by placing the cotton tip part of ~ | astick into the sore. The depth measured 4 cm, ‘and there was a small amount of red, pink drainage on the cotton. The length of the open area was 3.5 om. Staff J said she did not ‘measure the width of the sore because it would cause the sore to split open more if she pulled the ‘crease open to measure it ‘Staff J applied *Solosite," a medication gel and dressing to the wound. A later review of the treatment sheet and physician orders revealed there was no oder for the "Solosite” medication gel ‘The surveyor asked Staff J to look atthe resident's feet. The resident had reddened areas and a scab on her right hee! which staff J measured and treated, On 4/3/09, Staff G, the Director of Nursing, looked at the resident's feet with the surveyor. Staff G removed the dressing on the right heel. ‘The scab had come off in the dressing. The heel scab on her right hee! and red areas on the outer | ‘monitor for compliance ‘The Director of Nursing or designee will FORO CMS-2367(0260) Pravous Version Obeclate Event FROTH Fac bs WAza200 continuation sheet Page 43 of 2DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2009 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES —— [p(1) PROVIDERISUPPLIERICLIA| ‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER 1505325 [oc maTIPLE CONSTRUCTION a Buon. b. wane. foc) one suRvEY (COMPLETED 04/03/2009 | NAME OF PROVIDER OR SUPPLIER ISLAND HEALTH & REHAB CENTER [STREET ADDRESS, CITY, STATE, ZIPCODE 1835 MADISON AVENUE NORTH BAINBRIDGE ISLAND, WA 98110 (4) 0 PREF Tae ‘SUMUARY STATEMENT OF DERGIENCES (GACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) > "PROVIDERS PLAN OF CORRECTION colt ‘ove PREFIX (GACH CORRECTIVE ACTION SHOULD BE TAG CGROSS-REFERENGED TO THE APPROPRIATE DEFICIENCY) F314 F323 S88=D .| were resolved, Continued From page 13, was dark pink. The red areas on the-outer feet ‘The 2/26/09 progress notes revealed that Resident #8 developed a Stage | sore on her coccyx. A notation made on 3/24/09 revealed the resident had a "Stage Ill..Open aree mild odorous smell, skin edges uneven. Lacey looking with brown mod amt excudate,..." Resident ##'s February 2008 treatment pian. indicated the facility was to cleanse the resident's right heel and apply Replicare every 3 days as needed." The last monitoring of the right heel was ‘on 2/8/09 and it was marked "Resolved", ‘The "Skin Grid-Pressure/Venous Insufficiency Uleer/Other' form indicated the resident developed a pressure sore on her cocoyx on 3/14/09, There were notations on this record for 3/14, 3122, and 4/1/08. Resident #8's care plan indicated she had a Stage Il wound on her right hee! that had resolved in February 2009. The care pian did not identify that the resident had three redden areas on her left foot, an open area below the left litte toe and a Stage Ill pressure sore her coocyx. ‘483.25(h) ACCIDENTS AND SUPERVISION ‘The facility must ensure that the resident ‘environment remains as free of accident hazards as is possible; and each resident receives ‘adequate supervision and assistance devices to prevent accidents. Fata F323 FORM OMS-2507(0266) Prova Versions Obslole ‘Event O-FROTHT Foxy: WA25200 Weontinuation sheet Page 14 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES, PRINTED: 04/0/2008 FORM APPROVED CENTERS FOR MEDI MEDICAID SERVICES ‘OMB NO. 0938-0304 -[evatewent or periciences [oxy PROVDERSUPPLIERICUA [oa MULTIPLE CONSTRUCTION Jos) oare survey JAND PLAN OF CORRECTION IDENTIFICATION NUMBER pease \cOUPLETED 505325 2. WIN, 04/03/2009 Tuan OF PROVDER OF SUPPLIER ‘STREET ADDRESS, CTY, STATE, 2P CODE {835 MADISON AVENUE NORTH Cee cone BAINBRIDGE ISLAND, WA 98110 ro ‘SUIMARY STATEMENT OF DEFICIENCIES D PROVIDERS PLAN OF CORRECTION = Fferm | (GACH OSFICENGY MUST BE PRECEDED BY FULL PREAK (EACH CORRECTIVE ACTION SHOULD BE» | COME TON Fae | REGULATORY Of (SC IDENTIFYING INFORMATION) TAS CAOSSREFERENCED TO THE APPROPRATE |" OATE DERIGENGY) F 323| Continued From page 14 F323 ‘This REQUIREMENT is not met as evidenced : by. pe F323 Accidents and Supervision Hott Based on observation, staff interviews and record review, the faci falled to provide supervision i rane | and assistive devices to prevent falis for 1 of 3 en Sampled Residents (#78) reviewed for the care Fal/injury Assessment: Prevention and area of falls. Management Pian of Care willbe reviewed and revised as indicated for Findings include: resident #78, RESIDENT #78 Residents in Similar Situations E Record review indicated that Resident #78 had i two non injury falls on 1/48/09 at 6 a.m, and. Fal/injury Assessment: Prevention and 3/20/09 at 11:16 p.m. The resident was found on Management Pian of Care wilbe ‘the floor both times while trying to independiy reviewed and revised as indicated for transfer on his own. The facility investigation | residents who have experienced 2 fall. Indicated the resident was confused and could not use a call light to summon help. After the Measures to Prevent Reoccurrence 3/20/09 fal, the facility assessed the resident for Licensed Nurses wil be inserviced on the use of an alarm. The alarm was to be implementing immediate interventions } attached to his clothes and the wheelchair or the ‘wit flls and fully completing an Accident bed. Resident required a one person assist with and Incident Report ‘ransfer on 4/1/09 at 10 a.m. and on 4/2/09 at 1:38 p.m. ‘Qngoing Monitoring | On 4/8/09 at 4:18 p.m., Resident #78 was Falls wil be reviewed next business day ‘observed sitting on the side of his bed with only by the Interdisciplinary Team and dally an incontinent brief on and with his legs dangling Clinical Meeting to ensure appropriate ‘over the side of the bed. His roommate turned on interventions are in place to prevent future the call light for him, The roommate stood in falls. Resident #78's doorway and told a nearby ! housekeeping staff, "He wants to get up and he Individual to Ensur i falls." The housekeeping staff immediately told ‘ Staff A, a licensed nurse, that Resident #78 eee cence required assistance in transferring to his because he had fallen. Staff A was at the medication cart in the middle of Resident #78's halway. Staff A explained to the housekeeping staf? that Staff U FORM CNS 258702 99) Proview Veins Obolt Bre BFROTIY Fcliy 0 WABSECE ‘continuation sbost Page 18 of 21: PRINTED: 04/10/2008 DEPARTMENT OF HEALTH AND HUMAN SERVICES ~ FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO. 0938-0391 fetaTeMENT oF pericencies — ]oXt) PROVIDERVSUPPLIERICLIA x2) MULTIPLE CONSTRUCTION [xs DATE SURVEY JAND PLAN OF CORRECTION IDENTIFICATION NUMER: ‘couuereD A supe yan. li} 505326 0470372009 [NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CY, STATE, IP CODE rer £835 MADISON AVENUE NORTH Seacrest : BAINBRIDGE ISLAND, WA 98110 am ‘SUNMARY STATEMENT OF DEFICIENOIES > ‘PROVIDER'S PLAN OF CORRECTION =, Fron | (EACH DEFICIENGY MUST BE PRECEDED BY FULL PRER (EACH CORRECTIVE ACTION SHOULD Be | cowbuznow “TAG. | REGULATORY OR LSC IDENTIFYING INFORMATION) Tae (OROSE-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) F 323 | Continued From page 16 F323 was the nursing assistant caring for the resident. : Staff A left Resident #78's hallway to find Staff U. ‘At 4:38 p.m., twenty minutes later, Staff U went into the Resident #78's room. Resident #78 wes stil siting on his bed. Staff U indicated the resident never wore clothes to sleep in and Resident #78 had not wanted to get up earller in the day. Staff U indicated she did not know ‘where the alarm was, she indicated Resident #78 {wore the alarm attached to clothes and the |.__ See ‘wheelchair on 4/1/08. Afier Staff U assisted Resident #78's to get dressed and transferred him to his wheelchair, she found the alarm on Resident #78's bedside table. Staff U attached . the alarm to Resident #78's shirt and to the wheelchair, ‘On 4/9/08, Staff G was asked what the night staff attached Resident #78's alarm to, since he slept ‘without clothes on. Staff G indicated she did not know and later in the day Staff G determined Resident #78 needed a bed alarm. The bed alarm was placed on the resident's bed, the bed alarm does not attach to the resident’ clothes. The bed alarm sounds when a resident moves in bed. When the resident was up in his wheelchair, he | would continue to have an alarm attached to his | clothes. ‘The facility failed to supervise the Resident #78 | when Staff A did not immediately assist him to his wheelchair after being alerted by the housekeeping staff that he could fal. The facility | failed to provide the resident with an assistive | device (bed alarm) to use when he was in bed. F 364 | 483.35(d)(1)(2) FOOD F 364 SSE FoR GuS 557 0 Pros Veen Oeste Erecb-FROTIY FaeRD WARS TF contnuaton shea Page 16o721PRINTED: 04/10/2000 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES. ‘OMB NO. 0898-0391 STATEMENT OF OEFIGENCES |x) PROVDERGUFPUERCUR oa) MUCTPLE CONSTRUCTION ets oxre sve aipuwarcoraecrion |” ENTRIOATON NUMBER: Conte JA eunows Ge) 508325 pean 4/03/2008, ‘NA OF PROVIDER OR BUPPLER STREET ADDRESS, GT¥, STATE 21 CODE {35 MADISON AVENUE NORTH Pe eeeaeteee eee reeeeaner ce BAINBRIDGE ISLAND, WA 98110 op SUMMARY STATEMENT OF ERIENOES o PROVES PLAN OF CORRECTION @ S25. | gacibencenor must eeprecebe oy FUL, patmx | _ @AGTCORRECINEATONSHOUD a2 | coutren TAG’ | REGULATORY Of (SC DENTIPVNG INFORMATION) The, | CROSERERENENGED TO RieAPPnOFMATE | ONE GEREN F 864] Gontinued From page 16 F 364 fe Each resident receives and the facilly provides : food prepared by methods that conserve nultiive value, flavor, and appearance; and food that is F364 Food 4/44 palatable, attractive, and at the proper ‘temperature. This REQUIREMENT is not met as evidenced by: Based on observation and interview the facility Jolled fo ensure tht food was palatable and. ‘served at the proper temperature. In the data meals in their room, complained of hot foods at palatable temperatures resulted in residents potentially affect the residents food intake and nutritional status, Findings include: During observation of the breakfast meal on ‘ested on the kitchen steamtable. Although the | held outside hazardous tempurature zones (below 41 degrees or above 140 degrees ‘on the test trays at the point of delivery were found below 140 dF. ‘On 4/1/08, at 7:35 a.m., the breakfast meal gathering stage of the survey, 11.of 15 residents located in all three hallways, who received their being served to them cold. Failure to serve meals } | expressing dissatisfaction with the food and could 4/1109, the tempuratures of the food items were ‘tempuratures of the foods on the steamtable were Fahrenheit (dF), the tempuratures of food items service from the kitchen fo those residents who received their meals in their rooms was observed. | Meal test trays were requested for 2 of the 3 hall carts, Items for both mechanical and reguler diets were obtained. Steamtabie temperatures were all Individual Residents In this citation, ‘a8 possible. hall tray service. Ongoing Monitorins ‘There were no individual residents named Residents in Similar Situations |_Aldes willbe inserviced on the necessity _| 10 keep hall cart doors closed between tray passes and to pass trays as quickly Measures toPreventReoccurrence | A pelist food warming system will be ordered and implemented in the facility for Test trays will be checked at least weekly ‘for appropriate temperature. Temps will be tracked and trended and reviewed by FORM CUS. 2567(C2.95 Provou Versions Obslele Even i: FROTH® the QA Committee. Individual to Ensure Compliance ‘The Administrator or designee will monitor for compliance Feely 0 WAzaS00 if continuation sheet Page 17 of 24DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2009 FORM APPROVED STATEMENT OF DERGIENGIES |i) PROVIPERIGUPRLIERICLA pe MULTIPLE CONSTRUCTION AND PUAN OF CORRECTION IDENTIFICATION NUMBER. [A euUDING i 305325 B.wane, 'NaMté OF PROVDER OR SUPPLIER STREET ADDRESS, OT, STATE ZIPCODE ‘885 MADISON AVENUE NORTH [TH & REHAB eee fae BAINBRIDGE ISLAND, WA 98110 eae ‘nWARY STATENENT OF DEAGIENGIES 3 'PROVBERS PLAN OF CORRECTION Ror | (each Deh Glenr must se PRECEDED BY FULL PRERR GAGHOORRECTIVG ACTION SHOUD BE | coultron Tae” | REGULATORY On 96 IDENTRYING INFORMATION) Tae | cHOSenEPeneNGnD forMeAPRonriare | “aT DERCIENCY) F 364 | Continued From page 17 F 364] F444 SSE above 178 dF of meats (ground), hot cereal, eggs, blueberry syrup for pancakes, and both mechanical/pureed items. ‘The first cart was for South hall. The kitchen prepared trays for the cart beganning at 7:40 a.m. and delivered the cart to the hallway at 7:48 a.m, Staff served the last resident at 8:10 a.m. At that time, the food temperatures of the test tray were taken. A full scoop of mechanical meat with gravy ‘was.424.dF, a full scoop of scrambled eggs. was. 124.6 dF and the pancake with blueberry sauce was 112 dF. ‘The third cart was for North hall. The kitchen prepared trays for the cart at 7:49 a.m. and delivered the car to the hallway at 7:57 am. Staff ‘served the last resident at 8:03 a.m. At that time, the food temperatures of the test tray were taken. ‘Aull scoop of mechanical meat and gravy was 114.9 dF, a 1/2 bow of hot cereal wes 136.1 dF, and a pancake without blueberry syrup was 04.1 4F,, a regular slice of bacon was coo! to the touch | and was difficult to obtain an actual temperature. ‘Surveyor tasted all fools on both test trays and found to be warm to the palette and not hot. 483.65(b)(3) PREVENTING SPREAD OF INFECTION ‘The facility must require staff to wash thelr hands after each direct resident contact for which handwashing is indicated by accepted professional practice. ‘This REQUIREMENT is not met as evidenced by: F aad ‘FORM CNS 2587(0206) Prevous Vertona Obeclale Event OVFROTHA Fast: Wazs900 TF eontinuaton sheet Page 18 of 2DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/10/2009, " FORM APPROVED _CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO, 0938-039 [STATEMENT OF DEFICIENCIES |i) PROVIDERISUPPLERIOUA [pea wucTIPLE CONSTAUGTION foe) pare sunver [AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. uN i ‘505325 cee 04/03/2009 "Nate OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE 1835 MADISON AVENUE NORTH ISLAND HEALTH & REHAB CENTER : BAINBRIDGE ISLAND, WA 98710 : iD ‘SUMMARY STATEMENT OF DEFENCES @ PROVDERS PLAN OF CORREDTION. 2, Prem | (GACH DEPIGENGY MUST BE PRECEDED BY FULL PRE (EACH CORRECTIVE ACTION SHOULD BE | COMLETON aS. | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CHOSSREFERENGED TO THE APPROPRIATE | ONE DEFICIENCY F 444] Continued From page 18 F aaa Based on observations and interviews, the facility failed to ensure that staff followed established : hand hygiene practices when providing personal care for two Sampled Residents (# 4 and 8) and ‘F444 Preventing the Spread of 34/4 when assisting seven residents in the assisted — dining room. Staff falling to use appropriate | handwashing or gloving practices placed 9 Individual Realdents residents at risk of harm from facility acquired Residents #4 and #8 had no adverse infections. ‘effects from this practice. Findings includes... ~ ‘Residents in Simllar-Situations .. RESIDENT #4 Aides willbe inserviced on infection On 4/1/09 at 3:55 p.m. Staff M, an agency NAC, contro! procedures when providing } removed a urine soiled hand towe! from around Personal care to residents, Resident #4 "s leaking superpubic (a surgical ' ‘opening in the lower abdomen area directiy into Measures to Prevent Reoccurrence the bladder) catheter with gloved hands. Without Hand sanitizer dispensers will be installed removing her contaminated gloves, Staff M throughout the faclity, including in the replaced the towel around the catheter, covered dining rooms, ofaciiato ease of hand the towel and catheter site with the disposble | sanitization, brief; then, covered the resident with blankets. ‘She did not remove her gloves. Ongoing Monitoring Staff Mt lft the room to gather supplies for Education and Training Director will personal care. Using her contamianated gloves, ‘conduct audits of infection control Staff M touched the doorknob to open the techniques on varying shifts at least resident's room door. She touched the edge of quarterly. the door to partially close the door behind her. ‘She walked across the hall fo the linen closet ual to Ensure Compliance Without removing her gloves, Staff M touched the istrator or designee wil doorknob 1o open the door and hold the door in tortance cheery ‘open. She then reached into the room to obtain clean wash clothes from the linen cart with her other gloved hand. She took a roll of plastic trash | bags from her apron pocket and removed two bags with her gloved hands. Staff M returned to Resident #4 's room wearing the same gloves. | FORM CNS- 256710200) Prous Versione Obese Event OFROTHY Fain: wa23500 TFeontinuation sheet Page 19 of 21DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 04/10/2009 FORM APPROVED. OMB NO. 0938-0391 [etaTEWENT oF DEicieNcies — pt) PROVIDERISUPPLIEROUA JAND PLAN OF CORRECTION. IDENTIFICATION NUMBER: 505325 [oe MULTIPLE CONSTRUCTION lA guLDNG B. WING. [os bare suRveY ‘COMPLETED 04/03/2009 | NAME OF PROVIDER OR SUPPLIER ISLAND HEALTH & REHAB CENTER ‘STREET ADDRESS, CTY, {896 MADISON AVENUE NORTH BAINBRIDGE ISLAND, WA 98110 STATE, ZIP CODE 40 “SUMMARY STATEMENT OF DEFCIENGES re | (EACH DEFICIENCY MUST a PRECEDED BY FULL TAS REGULATORY OR LSC IDENTIFYING INFORMATION) ry PROVIDERS PLAN OF CORRECTION 2. PREFIX (EACH CORRECTNE ACTION SHOULD BE | cowivon Tas (OROSS-REFERENGED TO THE APPROPRIATE DEFICIENCY) i F 444 | Continued From page 19 Only after the surveyor pointed out she was wearing the same gloves she used to handle the resident's soiled towel did Staff M change her gloves. StaffM then proceeded to use peri-wash to wipe down surfaces she touched with her contaminated gioves. RESIDENT #8 (On'4/1/09 at 11:00 a.m. Staff |, a NAC, put two | pairs. of gloves on each hand before providing Using her left hand to cleanse labia and vulva, Staff | removed and discarded the top left hand glove. She continued with providing perineal ‘care. Then removed and discarded the top right ~ [hand glove. Staff! continued providing care two gloves, When asked on 4/109, how many pairs of gloves she started care with, Staff t said she "! always start with two pair." Staff then asked, "Was that wrong? * ASSISTED DINING ‘On 3/80/09 during the lunch time meal, seven residents were in the assisted dining room. The dining room did not have a sink. No alternative cleansing source, such as alcohol based hand sanitizer, was observed in the room. Staff opened a cabinet in the dining room to get clothing protectors. No hand washing sanitizer was in the cabinet. At least three staff members assisted residents with eating. The staff did not use soap and water or alcohol based hand rub between resident assisting residents to eat their meals. On 4/9/09 at 11:20 am., Staff G (Director of perineal (genital area) care for Resident #8. After alternately removing and discarding the remaining F aq) FORM CNS 256710290) Provo Versions Obslote ‘Event O:FROTHY Fash 1D WABERCO ‘Weontination coat Page 20 ofDEPARTMENT OF HEALTH AND HUMAN SERVICES. PRINTED: 04/10/2008 Nursing) said that for staff working in the assisted ining room the expectation was that they would wash their hands with alcohol based hand sanitizet between residents or use soap and water atthe sink in the occupational therapy room, located immediately adjacent to the assisted dining room. Staff G said that double gloving was not an acceptable practice end was Tot taught by the facility. FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0304 STATENENT OF DeFiciences — [xt) PROVIDERSUPPLIERICLIA [pa) MUCTIPLE CONSTRUCTION ox DATE SURVEY JANOPLAN OF CORRECTION, IDENTIFICATION NUMER COMPLETED A stone { 805325 ene 04/03/2009 | Nawé OF PROVIDER OR SUPPLER ‘STREET ADDRESS, CITY, STATE, ZIP CODE '835 MADISON AVENUE NORTH D ‘CENTER eae ee een BAINBRIDGE ISLAND, WA 98110 0 ‘UNIUARY STATEMENT OF DEAIGIENGIES a "PROVIDERS PLAN GF CORRECTION a, ‘Feax | (GACH DEGieNcY MUST 6: PRECEDED BY FULL Pern (GACH CORRECTIVE ACTION SHOULD Be | cownttron TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TA6 CROSS-REFERENCED 10 THE APPROPRIATE «| SATE DEFICIENCY F 444 | Continued From page 20 Fade FORO OMS 2587102 90) Previous Varn Obsat9 Eve IDFROTH® Facity B:WAzS00 continuation shest Page 21 of