Mirabella Seattle 116 Fairview Avenue N · Mirabella Seattle 116 Fairview Avenue N Seattle, WA...

November 8, 2017

AdministratorMirabella Seattle116 Fairview Avenue NSeattle, WA 98109

Dear Administrator:

The Department of Social and Health Services (DSHS), Residential Care Services isaccepting your Plan of Correction (POC) dated September 29, 2017 as evidence that thecited Health deficiencies are, in fact, corrected effective October 30, 2017.

The Washington State Patrol, Office of the State Fire Marshal (OSFM) has verified that thedeficiency(ies) cited on the LSC Survey have been corrected effective October 13, 2017.

Based on these dates of correction, we find your facility is in compliance effective October30, 2017. DSHS will take no enforcement action and your certification for Medicare and/orMedicaid participation will continue.

If you have any questions, please contact me at (253) 234-6044.

Sincerely,

Loretta Maestas, MSN, RN Field Manager - Region 2 , Unit F Residential Care Services

cc: Region/Unit File OSFM Chief Deputy State Fire Marshal

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 03/13/2018FORM APPROVED

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

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STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

116 FAIRVIEW AVENUE NMIRABELLA SEATTLE

SEATTLE, WA 98109

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

This report is the result of an unannounced Off-Hours Quality Indicator Survey conducted at Mirabella Health Center on 09/10/17, 09/11/17, 09/12/17, 09,/13/17, 09/14/17 and 09/15/17. The survey included a Federal Off-hours survey conducted on Sunday, 09/10/17. A sample of 22 residents was selected from a census of 35. The sample included 22 current residents.

The survey was conducted by:

Molly Scott, RN, B.S.N.Susan Abrisz, MSW Christine Odachowski, RN, B.S.N.Robin Windhausen, R. D, M.S.

The survey team is from:

Department of Social & Health ServicesAging & Long Term Support Services AdministrationResidential Care Services, Region 2, Unit F20425 72nd Avenue South, Suite 400Kent, Washington 98032-2388Telephone: (253) 234-6000Fax: (253) 395-5070

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

09/29/2017Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete X09111Event ID: Facility ID: WA40950 If continuation sheet Page 1 of 42

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F 176 Continued From page 2 F 176had informed his nurse that he took one he stated "I did not this time."

On 09/15/17 at 8:00 a.m., the Resident Care Manager (RCM-Staff D) acknowledged that residents with medications at bedside should have self-medication assessments. Staff D stated she believed Resident #48 did have a self-medication assessment for some of his medications. Upon review of the assessment, however, the was not one of the medications included.

At 8:15 a.m., Staff D identified that the had not been one of the medications

assessed for this resident. When asked if she knew the resident had at his bedside, Staff D replied "No" and indicated a self-medication assessment needed to be in place to ensure safe administration of the

Additionally, staff were unaware of when the resident took this medication, so could not monitor if he needed further treatment. Staff D was informed of this and acknowledged a system needed to be in place for staff to be aware of when the resident took the

Reference: WAC 388-97-0440.

F 241SS=D

DIGNITY AND RESPECT OF INDIVIDUALITYCFR(s): 483.10(a)(1)

(a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident.

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F 241 Continued From page 3 F 241This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure care and services were provided in a manner that enhanced dignity for 3 of 22 sample residents (# 5, 18, and 28). Failure to ensure caregivers responded to a resident's request for assistance with toileting and ensure residents were provided timely assistance with dining and responded to call lights in a timely manner had the potential to negatively impact a resident's sense of well-being and dignity.

Findings include:

DIGNITY DURING DININGOn 09/10/17 Resident #5 was observed seated in the dining room with a Private Duty Attendant (PDA), seated beside her. At 11:51 a.m., Resident #5 was overheard telling the PDA, "I have to go to the bathroom", the PDA responded to the resident request and stated "after lunch." The resident responded in a loud voice "I can't do that." The Food Service Manager (Staff G) approached the table and the resident was overheard to say "I can't get my chair out, could you please help me?" The PDA responded to the request and told the resident "lunch is coming." The resident stated "I don't want any then." Staff G, was again asked, "Can you get me up?"

At 12:06 p.m., the Director of Nursing Services (Staff B) was alerted to Resident # 5's repeated requests for assistance to use the bathroom and the responses of the PDA. When Staff B approached the table, Resident #5, stated "I need someone to get me up". Staff B reassured

F 2411. The Private Duty Aid (PDA) for resident # 5 was educated on providing dignified care and responding to the resident s needs. Resident # 18 will have fluids offered in a timely manner. The call lights for residents # 28 and 98 will be answered and needs met within a reasonable amount of time.2. All residents with PDAs will be reviewed to ensure that care is provided by the PDA in a dignified manner or that communication occurs with facility staff.3. PDAs will be educated by the facility SDD on dignity and communication. All staff will be educated by the DNS or SDD on answering call lights timely.4. DNS or designee will ensure compliance by conducting audits weekly on call light wait times. Dining room will be monitored daily to ensure all residents are offered fluids, and that resident needs are met in a dignified manner. Findings if any will be reviewed and evaluated monthly as part of the facility s QAPI process


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F 241 Continued From page 4 F 241the resident someone would help her. The PDA stated "we have a schedule" and advised her the resident would be "toileted after lunch." Staff B then left the dining room to locate a staff member to assist the resident with toileting. The PDA continued the conversation with Resident #5 and was heard to tell the resident "we will miss lunch" for a "diaper change" in a loud voice in the dining room. The PDA then stated in a loud emphatic manner "you want to go to toilet? You have to choose eat lunch or go the bathroom" and was overheard making a reference to a "diaper change," in a loud voice. At 12:13 p.m., the Resident Care Manager, Staff D, assisted the resident and the PDA back to her room for the care she repeatedly requested.

On 09/10/17 at 11:56 a.m., Resident #18 was observed seated in the dining room in her wheelchair. Staff G approached the resident while passing beverages in the dining room. Staff G was overheard telling Resident #18, "someone would be here to assist her with the meal, soon". The resident, who was dependent on staff for eating, was not offered any beverages.

At approximately 12:25 p.m., Resident # 18 remained seated at the table, however no food or fluids had been served to her, and no staff were present at the table to assist her with the meal. Over the next 15 minutes, Resident #18 was noted to intermittently groan or moan, as she waited. At 12:40 p.m., her lunch tray was served, and with in several minutes a Nursing Assistant entered the dining room and began assisting the resident with the meal. Resident #18 waited approximately 40 minutes in the dining room to receive assistance with her lunch.


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F 241 Continued From page 5 F 241

DELAYED RESPONSE TO CALL LIGHTSOn 09/10/17 at 10:13 a.m., Resident # 28's call light was observed sounding, the display panel at the nurses station showed the call light had been on for 20 minutes. At 10:23 a.m.,the display panel documented the call light had been sounding for 28 minutes.

Resident #28 was observed seated in a wheelchair in the room and a family member was present. The call light was still on, when asked about the call light, the family member said a Nurse had responded to the call light earlier and advised them a Nursing Assistant would be there soon to take care of the resident. The family member stated it was hard to get the light answered sometimes, especially around meal times when staff are busy. It was 10:41 a.m., when a NA entered the room to provide care requested by Resident #28. The resident waited approximately 41 minutes, before the resident received the assistance s/he had requested.

On 09/13/17 between 2:02 p.m. and 2 15 p.m. a series of call lights for several resident rooms were observed signaling on the call light monitor at the South East nurse's station. At 2:02 p.m., the call light for the resident in room 251 showed it had been ringing for eleven minutes. The call light continued to signal for the next eight minutes, until 2:10 p.m., or a total waiting time of 19 minutes. Also at 2:02 p.m., a call light in room 265 showed it had been ringing for assistance since seven minutes. The call light continued to ring until answered at 2:15 p.m., a period of twenty minutes.


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F 241 Continued From page 6 F 241On 09/15/17 between 7:33 a.m. and 7:53 a.m., a call light was observed ringing for room (Resident #98). During this 20 minute period, one staff nurse was observed in the hallway passing medications and a second nurse (Staff E) was observed to enter two utility rooms, then the nurses' station, without checking on the resident. At 8:00 a.m., a family member visiting Resident #98 said the resident had been waiting for help when family arrived, and that this resident had voiced similar concerns about a lack of prompt response by staff to his call light previously.

In a previous interview on 09/11/17 at 2:25 p.m., Resident #98 stated just a few days prior he had been left in the bathroom by an aide and instructed to pull the call light cord when he was done. Upon pulling the cord, however, it came out of the wall. The resident stated he waited on the toilet for at least 15 minutes and then decided to transfer himself to his wheelchair.

Similar findings were reported by Resident #40 who, in an interview on 09/12/17 at 10:33 a.m., stated recently she had been left on the toilet twice and instructed to pull the call light cord when she needed assistance. She reported having to wait several minutes for assistance after pulling the cord. Resident #40 stated she had to wait up to 45 minutes for help in the past.

On 9/15/17 at 10:35 a.m., the Director of Nursing Services (DNS, Staff B) was interviewed about the facility's policies and practice regarding response to call lights. She stated she generally expected staff to respond to a resident's call light (or other request for assistance) within ten minutes. She said information from the call light


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F 241 Continued From page 7 F 241monitoring system was reviewed as part of the facility's Quality Assurance (QA) system or if a grievance about call lights was filed by a resident or family. When told over half of the seventeen residents interviewed during Stage I reported they had experienced long waits to get their call lights answered and assistance from staff, Staff B described that staffing was based on the census, acuity of residents and the budget. She also stated she was aware of reported problems with call light response by staff at meal times, during change of shift and at bed time.

Refer also in this report to F353 Sufficient Staffing.

Reference: WAC 388-97-1080(1) and (4) .F 279SS=D

DEVELOP COMPREHENSIVE CARE PLANSCFR(s): 483.20(d);483.21(b)(1)

483.20(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan.

483.21(b) Comprehensive Care Plans

(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental

F 279 10/30/17


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F 279 Continued From page 8 F 279and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -

(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).

(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.

(iv)In consultation with the resident and the resident’s representative (s)-

(A) The resident’s goals for admission and desired outcomes.

(B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this


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F 279 Continued From page 9 F 279section.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure resident care plans were accurate and revised when indicated to address current resident care needs, for three (#s 19, 11 and 6) of the 22 residents whose care plans were reviewed in Stage 2. Failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff related to mental health issues, discharge planning, preferences regarding a private caregiver and a hearing device, placed residents at risk to receive less than adequate care.

Findings include:

RESIDENT #19Resident #19 was admitted on /17, after surgical repair of a . The resident was admitted for skilled nursing care and skilled therapies. During her stay, on 08/24/17, Resident #19 expressed feelings of distress, including

, to a Physician's Assistant. Staff did place the resident on alert monitoring after this incident, and started treatment to address her distress.

Review of Resident #19's care plan (CP), dated 08/25/17, revealed the CP was not revised after that time to identify this significant change, or develop goals or interventions to clarify how staff would work with the resident to address changes in her mood. Additionally, the CP also did not address goals and interventions related to discharge planning, even though the resident's

F 2791. Resident # 19 has been discharged home. The Care plan for resident # 11 was amended to include the duties of the PDA. The Care plan for resident # 6 was amended to reflect the current need for the .2. All care plans will be reviewed to identify any other resident at risk for inaccurate information and guidance to staff.3. Staff responsible for writing and reviewing residents care plans, including staff C and D, will be re- educated by the DNS on the need for accuracy. Staff, including staff L and M, will be re- educated by the SDD on following the established plan of care for each resident4. DNS or designee will ensure compliance by randomly reviewing care plans per the MDS calendar, upon admission and with the initiation of a new PDA. Findings if any will be reviewed and evaluated monthly part of the facility s QAPI process.


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F 279 Continued From page 11 F 279caregiver comes in at 8:00 a.m. and helps her get dressed. Then they (the PDA) come back to help her get ready for dinner and take her to activities. Whatever she needs in between we (the facility) provide the care. It is their (family/resident's) request that the private caregiver help her in the morning to get dressed." Staff D indicated that is why the facility staff might have asked where the resident's PDA was. Staff D was then asked if these preferences with the PDA were in the CP. After review, Staff D stated that they were not and acknowledged the CP needed to be updated.

RESIDENT #6Resident #6 was admitted to the facility in 2016 with multiple diagnoses including

The most recent full MDS assessment, dated 03/01/17, documented the resident had a hearing impairment and used a hearing device.

On 09/10/17 at 9:40 a.m., during the initial tour of the facility, Resident #6 was observed in bed wearing a pair of head phones that were attached to a The Private Duty Attendant (PDA) stated the headphones and was a hearing device the resident used.

The CP dated 10/18/16 identified communication problems. The directives included the following; "teach caregivers the use and care of hearing aid(s)" and noted the resident had bilateral hearing aids."

Although the CP noted the use of an assistive device for hearing, it was not utilized during observations on site on 09/11, 09/12, 09/13, and 09/14/17. During observations of the resident in


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F 282 Continued From page 13 F 282as outlined by the comprehensive care plan, must-

(ii) Be provided by qualified persons in accordance with each resident's written plan of care.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to consistently implement Care Plan directives for 2 of 25 residents (#18, #6) included in stage II. Failure to follow guidelines for positioning and ensure care plan interventions for the use of a hearing device was consistently implemented placed these residents at risk for health complications associated with unmet care needs.

RESIDENT #18 Resident #18 was admitted in 2011 with multiple diagnoses, including . The most recent annual Minimum Data Set (MDS) assessment, dated 03/10/17, documented the resident had a significant change in condition, and was on oxygen therapy. The assessment also indicated the resident needed extensive assistance with eating and had an altered texture diet.

Resident #18's current care plan identified the resident to be at risk for aspiration / swallowing. The care directives stated the resident should remain in an upright position for 45 minutes to an hour after meals.

On 09/11/17, Resident #18 was observed seated in a wheelchair in the room, in a reclined position, at approximately a 45 degree angle. At 8:22 a.m.

F 2821. The care plan for resident # 18 was reviewed and amended to accurately reflect positioning during and after meals. The reclining chair for resident # 18 has been repaired. Resident # 6 will have the

available as stated in the plan of care.2. Residents requiring specific positioning assistance were reviewed and no other residents were identified. Residents with assistive hearing devices were reviewed for proper placement and availability per the individual plan of care.3. Staff, including staff J, K, L, and M, will be educated by the SDD on the procedure for obtaining repairs for chairs not functioning properly. Staff will be re-educated by SDD on following the residents plan of care.4. DNS or designee will ensure compliance through observation of residents positioning and assistive hearing devices as part of the daily rounds. Findings if any, will be reviewed and evaluated monthly times 1 month and then quarterly as part of the facility s QAPI process.


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F 282 Continued From page 14 F 282a Certified Nursing Assistant (CNA) moved the resident to the dining room, while the wheelchair remained in a reclined position.

Between 8:22 a.m. and 8:43 a.m., Resident #18 was observed in the main dining room being fed by a CNA. The resident's wheelchair was in a reclined position (45 degree angle). Staff J, the CNA assisting the resident with the meal, was asked about the positioning. Staff J reported the wheelchair "was stuck" in the reclined position. When asked if it was safe to feed the resident in a reclined position, Staff J commented the resident "seems to be doing okay". When asked what the resident's care plan directives said about positioning, Staff J said, "I have to look".

At 8:54 a.m., the resident was assisted back to her room. The wheelchair remained in a reclined position at a 45 degree angle. At 10:25 a.m., Resident #18 was observed to remain in the same position in the wheelchair.

On 09/12/17 at 1:11 p.m., Staff K, a CNA was observed exiting the resident's room. Resident #18 was in bed, with head of the bed raised at an angle of approximately 25 to 35 degrees, rather than upright. Staff K said Resident #18 had just returned to the room after lunch. When asked how long the resident had been in the room after the meal, Staff K said "five minutes."

On 09/13/17, Resident #18 was observed in the dining room being fed by Staff L, a CNA. The resident's wheelchair was in an upright position. The meal was served to Resident #18 at 12:35 p.m.. At 12:50 p.m., Resident #18 had finished the meal and Staff L assisted with the last of the


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F 282 Continued From page 15 F 282fluids offered with the meal. At 12:55 p.m., Staff L moved Resident #18 in her wheelchair back to the room. When asked, Staff L reported the resident was going to be transferred back to bed. The resident was then transferred back to bed by Staff L and Staff K, using a mechanical lift. After the transfer, the staff provided incontinence care, the resident was observed to lie flat in bed while staff assisted the resident. It was also noted the resident had a deep gurgle with coughing. Prior to leaving the room, one of the staff members elevated the head of Resident #18's bed to approximately 30 to 40 degrees.

On 9/15/17 at 9:00 a.m. during an interview, Staff D said she was aware the wheelchair was stuck in a reclined position. She said the maintenance staff looked and the wheelchair and had done some repairs. According to Staff D, the staff should be following the guidelines for positioning during and after meals.

Not ensuring the care plan directive to leave resident upright for 45 minutes to an hour after the meals, placed Resident #18 at risk for aspiration.

RESIDENT #6Resident #6 was admitted to the facility in 2016 with multiple diagnoses including a

The most recent annual MDS assessment, dated 03/01/17, documented the resident had a hearing impairment and used a hearing device.

On 09/10/17 during the initial tour of the facility, Resident #6 was observed in bed wearing a pair of head phones that were attached to a A


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F 282 Continued From page 17 F 282.

F 309SS=D

PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGCFR(s): 483.24, 483.25(k)(l)

483.24 Quality of lifeQuality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.

483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following:

(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.

(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered

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F 309 Continued From page 21 F 309edema..." and indicated she would look for additional information.

At this time, Staff D was also asked about the postural BP values. After review, Staff D stated "That is all the same" and stated she would check on this as well. Staff D added that the resident was able to stand, so there was no reason why staff could not perform this task in its entirety

On 09/15/17 at 7:15 a.m., Staff D stated she spoke to one of the nurses who put in postural BPs on one of the dates and that the nurse claimed the values were all the same. When asked what the likelihood was that the resident had the same BP and pulse lying, sitting and standing for the last two and a half months, Staff D did not have a response.

At 7:38 a.m., Staff D stated an edema assessment had been completed on the resident the day before and that the physician had changed the diagnosis for the order from " to . Staff D acknowledged monitoring prior to this had not taken place.

The failure of the facility to assess this resident's edema as well as analyze the data being collected (postural BPs), did not ensure this resident had adequate monitoring and prevented staff from knowing about a potential change or decline in her condition.

Reference: WAC 388-97-1060(1).

F 312 ADL CARE PROVIDED FOR DEPENDENT F 312 10/30/17


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F 312 Continued From page 22 F 312SS=E RESIDENTS

CFR(s): 483.24(a)(2)

(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide or assist with Activities of Daily Living (ADLs), related to nail care for two (#s 5 and 13) of three residents reviewed for ADLs. These failures placed the residents at risk for poor hygiene, unsightly nails and embarrassment.

Findings include:

RESIDENT #5Resident #5 admitted to the facility on /13 with multiple diagnoses which included

. According to the most recent quarterly Minimum Data Set (MDS-an assessment tool) dated 08/09/17, this resident was cognitively intact and was assessed to require at least extensive assistance with most of her ADLs, to include personal hygiene.

On 09/11/17 at 9:30 a.m., the resident's fingernails were observed to be so long some of them were curling over. Some were jagged and chipped nail polish was also observed. When asked about her nail length the resident stated "They are much too long."

Review of the resident's ADL care plan, with a goal date of 11/10/17, revealed the resident had

F 3121. Residents # 5 and 13 received nail care as allowed.2. All residents are observed for needed nail care during showers/bathing. No other residents were identified in need of nail care.3. The policy and procedure for nail care was reviewed and revised as needed. The Staff will be re-educated by the DSD on the P & P. Staff will be re-educated by the DSD on documentation of resident refusal of care.4. DNS or designee will ensure compliance by observing resident nails during daily rounds. Findings if any will be reviewed and evaluated monthly times 1 month and then quarterly as part of the facility s QAPI process.


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F 312 Continued From page 23 F 312"impaired mobility" and "Requires staff to provide extensive to total assist with all adl's [sic] and mobility."

On 09/14/17 at 8:27 a.m., one of the nurse aides (Staff H) was asked about resident nail care. Staff H stated nail care was usually provided on the residents' shower days.

According to the bathing documentation, Resident #5 had been bathed on 09/10/17 and 09/14/17. On 09/14/17 at 12:20 p.m., the resident's fingernails were still observed to be long and some were jagged.

On 09/15/17 at 11:12 a.m., the Resident Care Manager (RCM-Staff C) was present when the resident's fingernails were observed again. Staff C stated "Yes those are long...and need to be filed..." Resident #5 again stated she would like her fingernails shorter.

RESIDENT #13Similar findings were identified for Resident #13 who admitted to the facility on 16. According to the most recent annual MDS dated 08/10/17, this resident was cognitively intact and was assessed to require supervision and limited assistance with most of her ADLs.

On 09/11/17 at 1:33 p.m., Resident #13's fingernails were observed to be long. Review of the ADL care plan dated 08/22/16 revealed staff were to "Provide cues and assist with ADLs..." According to the care guide, last updated 09/13/17, this resident usually had daily showers.

On 09/15/17 at 7:08 a.m., Resident #13 was


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F 312 Continued From page 24 F 312asked about her fingernails and she stated "I don't like them this long...I can work with my left hand but my right hand is hard. I would like them manicured."

On 09/15/17 at 7:30 a.m., the other RCM (Staff D) was present to observe the resident's fingernails. When asked about them, Staff D stated "They are long."

Reference: WAC 388-97-1060(2)(c).

F 329SS=D

DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGSCFR(s): 483.45(d)(e)(1)-(2)

483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--

(1) In excessive dose (including duplicate drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use; or

(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

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F 329 Continued From page 27 F 329behaviors/ symptoms and document per facility protocol; Combativeness /Aggressiveness toward care giving efforts". There was no mention of the resident being monitored for even though this was the stated rationale for the use of the medication.

Review of notes from a care conference on 06/15/17, attended by facility staff and the resident's guardian, included a brief statement that the resident's medications were reviewed and that he might have been experiencing sedation. There was no information to show if or when the resident experienced any

or the extent to which they were a factor in Resident 39's behavior. On 06/19/17, the resident's physician did prescribe a lower dose of the from 100 to 50 mg.

On 07/13/17, in a "Behavioral/ Pharmacological" review for Resident #39, facility staff briefly concluded the resident's "Behavior status" was "stable" but did not provide any factual data to support this decision. In a concluding "Behavior summary," staff briefly documented the recent reduction in the for Resident #39 was "successful," but again did not address the extent to which he was experiencing any type of

behavior, or was either resisting or cooperative with care. A final section of this assessment form, which directed staff to "Describe Effectiveness of Interventions Related to Target Behaviors", was left blank.

Further review of Resident #39's medical record for August and September 2017 revealed no documentation by licensed nursing staff in the Medication Administration Record (MAR) or the


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F 329 Continued From page 28 F 329Treatment Administration Record (TAR) for either month regarding which TBs were being monitored by staff, or which possible ASEs were being monitored for this resident.

Review of nursing progress notes by licensed nursing staff in recent weeks frequently described Resident #39 as, "alert and combative" during their shift, but did not identify the frequency of Resident #39's behaviors, or any pattern of precipitating events. There was also no information found regarding either expressed by the resident, or any behaviors indicating he was having There were intermittent notations that the resident was having no side effects from the medications. Current literature for does list "agitation" as a potential side effect, but the available data for this resident did not show staff had monitored for this.

On 09/14/17 at 10:40 a.m., a Resident Care Manager (RCM- Staff C) was asked where staff were monitoring TBs for residents. Staff C replied if the resident wasn't on alert charting for a behavioral issue, the information regarding monitoring would be listed on a "care guide" with a summary of each residents' care needs for staff to reference. Review of the care guide for Resident #39, last updated 09/13/17, found no mention of monitoring for behavioral symptoms or potential ASEs of his current medications.

The facility's current policy was reviewed regarding identifying and monitoring the effects of

medications on residents. While the current policy (dated March 2017) included


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F 329 Continued From page 29 F 329directives to staff about the need to identify and monitor target behaviors, the policy lacked specific procedural guidelines for facility staff (including that residents be "adequately monitored"). Additionally, the policy did not address specific procedural elements for documenting information in a systemic manner that would allow staff or physicians to analyze behavioral information in an objective manner to determine if a medication was having the intended effect on the TBs, or the extent to which specific ASEs were noted.

On 09/15/17 at 10:25 a.m., the current policy was discussed with the Director of Nursing Service (DNS- Staff B). The lack of a specific procedure that could be consistently utilized by staff to monitor for TBs and ASEs was addressed. Staff B acknowledged staff had been directed by prior staff to write this information in a progress note. Documenting TBs and ASEs in this manner did not allow analysis for trends in a resident's response to a medication (e.g. a decline in

combativeness, or an increase in desired behaviors).

Failure by the facility to gather information about this resident's behaviors and /or ASE's in a manner which allowed staff to analyze factors affecting behavioral symptoms, did not ensure adequate monitoring or awareness of an improvement or decline in his condition.

RESIDENT #6Resident #6 admitted to the facility in 2016 with multiple medical diagnoses including a The last annual MDS assessment, dated 03/01/17, did not identify any behavioral issues.


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F 329 Continued From page 31 F 329medication was prescribed. According to Staff M, if the Resident was stable for seven days on the new medication, the alert was removed.

On 09/14/17 at 10:20 a.m., the Resident Care Manager (Staff D) was interviewed about Resident #6 and the administration of on a prn basis. Staff D explained staff should document a description of behaviors and identify what NDIs were attempted.

Further review of the clinical record found no description of the behaviors displayed by the resident when agitated. There was no information about potential ASEs related to the use of the medication and there were no directives identifying NDIs to de-escalate the resident's agitation.

On 09/15/17 at 10:30 a.m., Staff D, reviewed the clinical record, but could not find any additional information concerning the administration of the medication. She verified no additional information was found for the administration of the medication on the three dates described above. Failure to attempt NDIs prior to administration did not provide adequate indication for use of the prn

Reference: WAC 388-97-1060(3)(k)(i).

F 353SS=E

SUFFICIENT 24-HR NURSING STAFF PER CARE PLANSCFR(s): 483.35(a)(1)-(4)

483.35 Nursing Services

The facility must have sufficient nursing staff with

F 353 10/30/17


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F 353 Continued From page 32 F 353the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)]

(a) Sufficient Staff. (a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph (e) of this section, licensed nurses; and

(ii) Other nursing personnel, including but not limited to nurse aides.

(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.


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F 353 Continued From page 33 F 353(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by Resident #s 43, 9, 89, 13, 11, 54, 98, 17, 40, 49, 7 and one anonymous resident, twelve of seventeen Stage I residents interviewed. Additionally, during interviews with family members of residents who could not be interviewed, three of the three family members (for Resident #s 12, 28 and 96) each expressed concerns about insufficient staffing and long waits for care.

Observations during survey revealed a lack of sufficient and well trained caregivers to ensure residents received assistance with toileting (Resident #5) or dining (Resident #18) and a lack of prompt call light response (Residents #28, 98 and , in accordance with established clinical standards and preferences, placing residents at risk for injury, emotional distress and a decreased quality of life.

Findings include:

Refer to:CFR 483. 15(a) , F 241 DignityCFR 483.25(a)(3), F-312, Dependent Resident Receives Care

STAGE I INTERVIEWSDuring Stage I interviews, twelve of seventeen

F 3531. Residents #9, 17 and 96 no longer reside in the facility. Residents # 43, 89, 13, 11, 54, 49, 7, 12 and 96 will have their needs met in a reasonable amount of time. For residents # 5, 28, and 98 see F 241.2. All residents are at risk for what is perceived as a long wait time and having their needs met.3. Staffing patterns have been reviewed, to determine if shifts might be staggered to provide more staff during the busier times of day. Call light wait times will be reviewed and analyzed for patterns. The addition of 1 NAC will be initiated October 1st. A plan will be developed to assist with replacing staff that have called off, and hiring staff for open positions. Staff responsible for scheduling and replacing staff will be educated by the DNS on the plan.4. DNS or Designee will ensure compliance by reviewing staffing patterns daily, determining staffing needs weekly and communicating needs with the facility Administration. Findings if any will be reviewed and evaluated monthly as part of the facility s QAPI process.


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F 353 Continued From page 34 F 353residents answered "No" when asked "Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time?" On 06/02/17 at 10:02 a.m., Resident #43 said, "No", then commented "staffing is off and on", but did not elaborate on the effects of having to wait. When interviewed on 09/11/17 at 9:26 a.m., Resident #9 stated there was not enough staff to provide assistance, but also did not elaborate.

On 09/11/17 at 9:16 a.m., Resident #89 stated there was not enough staff and said he "occasionally" had to wait too long for help from staff. Similar concerns were expressed by Resident #13 when interviewed on 09/11/17 at 1:26 p.m., when she also endorsed a lack of sufficient staff , commenting it could take 15 to 20 minutes before staff answered her call light.

On 09/11/17 at 1:50 p.m.., Resident #11 replied, "No, sometimes it takes a long time... sometimes up to 40 minutes; [to have staff answer her call light]. They say, 'I'll be back'... then they don't come back...that's what I hate the most."

During an interview with Resident #54 on 09/11/17 at 9:13 a.m., the resident said the facility did not have sufficient staff "most of the time" and gave an example of the facility needing to call upon additional staff to serve meal trays.

On 09/11/17 at 2:25 p.m., Resident #98 described waiting in the bathroom for assistance for 15 minutes and then had to transfer himself without help from staff. During a second encounter on 09/15/17 between 7:33 a.m. and 7:53 a.m. the call light was observed ringing in


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F 353 Continued From page 35 F 353Resident #98's room. A family member of Resident #98 talked about a recent problem during the first week in September 2017, when staff had not responded promptly to the call light, as previously described in F241.

On 09/11/17 at 1:40 p.m. Resident #17 responded, "No, sometimes you have to wait up to an hour for help" (in response to her call light). She described an "average" waiting time of 15 minutes, then commented again that the facility had been short of staff the previous day, on 09/10/17.

On 09/12/17 at 10:33 a.m., Resident #40 said there were not enough staff, and commented sometimes she had to wait a long time, and there were problems at night getting help. She said at times she had to wait as long as 45 minutes. She then described an instance of being toileted by an NAC who helped her to the toilet then told her to put on the light when she was ready to go back to bed. He then told her the resident he was going on break. According to Resident #40, there had been two instances since early September 2017 of staff helping her to the toilet, then not returning back to help her. She concluded by saying, "You can ask for something and they will basically say it's not their job...you never hear anything back."

During an interview on 09/10/17 at 1:01 p.m., Resident #49 also identified a lack of sufficient staff, stating the effects of waiting for help from staff was noticeable at "peak times" such as during meals and at bed time. Resident #7 also said there was not sufficient


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F 353 Continued From page 36 F 353staff available to help when needed, commenting "Sometimes staffing can be a little iffy," when interviewed on 09/11/17 at 1:26 p.m.

A twelfth resident, who requested his/ her responses to remain anonymous, replied to this question about staffing saying there were not enough staff and described seeing staff as "hard working but always rushed" when they helped him/ her, often getting paged multiple times to help other residents while providing care.

FAMILY INTERVIEWSIn addition to the above residents, three of three family members chosen randomly for interviews each identified concerns about insufficient staff on duty and it's impact on resident care.

Resident #12's family member was interviewed on 09/11/17 at 1:45 p.m. When asked about staffing, he replied there was not enough staff, with long waits for care, most recently a few weeks ago. He described the staff as ".. super... they work hard; there just aren't enough of them. They have a good attitude in spite of the work load". However, when asked how his concerns about staffing affected him, the family member said he felt he had to come feed the resident daily or she wouldn't get the help she needed, due to a limited number of staff and many residents needing help along with the resident's inability to speak up for herself. The family member also voiced an awareness of staff working "short" (not as many staff on duty as scheduled), as well as staff being asked to work double shifts. He described a perception of staff appearing "stressed" and described time for nurses to provide supervision to NACs as


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F 353 Continued From page 37 F 353"limited".

Similar concerns were voiced by another family member who spent time most days with Resident #28. He replied sufficient staffing was "an issue during meal times and at shift change." He stated waits for assistance for Resident #28 ranged from 10 to 30 minutes in recent weeks. Interview with Resident #96's family on 09/11/17 at 10:00 a.m., yielded similar concerns about a lack of staff to attend to this dependent resident, including at times feeling it was necessary to hire a private care giver when the family was not available.

EXTENDED WAITS FOR ASSISTANCEAs previously documented in F 241, observations on 09/10/17 showed Resident #5 waited in the main dining room to be assisted with toileting from 11:51 a.m. until 12:13 p.m. On that same day, Resident #18 remained seated in the dining room waiting for an hour to be assisted with lunch, as observed from 11:56 a.m. until 12:45 p.m. These residents were dependent on staff for care.

Observation on 09/13/17 between 2:02 p.m. and 2:25 p.m., revealed additional instances of resident call lights ringing for extended periods of time (19 and 20 minutes), as described in F241, Dignity.

On 09/15/17 at 10:40 a.m., the Director of Nursing Services (DNS, Staff B) was interviewed about the facility's staffing. Staff B was told over half of the seventeen residents interviewed during Stage I, and three of three families had


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F 353 Continued From page 38 F 353responded negatively to questions about adequate facility staffing to prevent long waits for assistance, including long waits for call light response. When asked how the facility determined how to provide sufficient staff, she said daily staffing was based on the census, acuity of current residents and the budget. Staff B also stated that the usual staffing for day and evening shift was five NACs on each shift, and three NACs on duty during night shift. When it was noted that there were only three NACs on duty during day shift on 09/10/17, she said this was because they were unable to replace staff who called in sick. She also stated she was aware of reported problems with call light response by staff at meal times, during change of shift, and at bed time, and was still working to create a system that addressed these staffing issues.

Reference: (WAC) 388-97-1080(1).

F 363SS=D

MENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWEDCFR(s): 483.60(c)(1)-(7)

(c) Menus and nutritional adequacy.

Menus must-

(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

(c)(2) Be prepared in advance;

(c)(3) Be followed;

(c)(4) Reflect, based on a facility’s reasonable

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F 363 Continued From page 39 F 363efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

(c)(5) Be updated periodically;

(c)(6) Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

(c)(7) Nothing in this paragraph should be construed to limit the resident’s right to make personal dietary choices.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow resident menus during meal service for Resident #s 11, 34, 28, 17 and 98, five of 35 residents. Observations during a lunch meal service revealed staff did not consistently serve resident meals in accordance with written menus. Failure to follow menus placed residents at risk for unmet nutritional goals.

Findings include:

On 09/13/17, the noon meal service for Health Center residents was observed from 11:45 am until 12:52 p.m. Three staff were involved in serving the meal, and the Dietary Manager (Staff G) was present at various times during the meal service.

At 11:52 a.m., staff began serving trays for residents who ate in their rooms on the Southwest unit. A tray served for Resident #11 did not include a salad with the meal, even

F 3631. Resident # 17 was discharged home. Residents # 11, 34, 28, and 98 were served the correct meal.2. All residents are at risk for receiving meals not in accordance with their written menus. No other residents were identified during observation of tray preparation.3. The Staff preparing the meals including staff F have been re-educated by the Dining Services Manager on the need for providing the meal as written on the menu/meal tickets. 4. Dining Services Manager or designee will watch tray service 2-3 times per week to ensure all trays are completed in accordance with the written menus. Findings if any will be reviewed and evaluated monthly times 1 month and then quarterly as part of the facility s QAPI process.5. Administrator will ensure compliance.


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F 363 Continued From page 40 F 363though this was on her written menu. At 12:03 p.m., a meal served for Resident #34 included a regular-sized portion of rice with the entree, even though her menu card said the resident wanted only half of the regular portion of the starch at meals.

At 12:31 p.m. the menu card for Resident #28 specified that her meal was to be served on an adaptive "scoop plate". The server (Staff F) was alerted to this notation by another dietary aide, but staff F responded "We'll do that later" and finished serving Resident #28's meal on a regular plate.

At 12:35 p.m. Resident #17 was served a whole tuna salad sandwich as her entree. Review of her menu card revealed the resident had requested small portions. When Staff G was asked to clarify the portion size to be served for this resident, he replied, "It should be half".

For Resident #98, the menu card specified he was to be served "extra sauce" with his entree. As Staff F was observed serving his meal, she put a two-ounce ladle of sauce over the resident's meat. This was the same amount being served to residents on a regular diet, who did not require extra sauce or gravy. When asked to compare the menu card with what was served, Staff F did not see this omission until pointed out by the surveyor. During observations of the meal service, each error or omission was discussed with staff so residents were then served the planned meal.

On 09/13/17 at 1:25 p.m., Staff G was interviewed about the meal service. The errors


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F 363 Continued From page 41 F 363made by staff described above were summarized. Staff G explained another staff was responsible for reviewing a resident's meal once served, but also acknowledged that several observed errors were, in part, related to Staff F not reading menu cards, and in one instance, disregarding an error that was pointed out by another staff.

Reference: WAC 388-97-1180(1).


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State of Washington

WA40950 09/15/2017C

NAME OF PROVIDER OR SUPPLIER

MIRABELLA SEATTLE

STREET ADDRESS, CITY, STATE, ZIP CODE

116 FAIRVIEW AVENUE NSEATTLE, WA 98109



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L 000 WAC - Initial Comments

Note: According to RCW 18.51.060, the Department is authorized to deny, suspend or revoke a license and/or assess monetary fines for deficiencies cited in this report.

.

L 000

This report is the result of an unannounced Off-Hours Washington State Licensing Survey conducted at Mirabella Health Center on 09/10/17, 09/11/17, 09/12/17, 09,/13/17, 09/14/17, and 09/15/17. The survey included a Federal Off-hours survey conducted on Sunday, 09/10/17. A sample of 22 residents was selected from a census of 35. The sample included 22 current residents.

The survey was conducted by:

Molly Scott, RN, B.S.N.Susan Abrisz, MSW Christine Odachowski, RN, B.S.N.Robin Windhausen, R. D, M.S.

The survey team is from:

Department of Social & Health ServicesAging & Long Term Support Services AdministrationResidential Care Services, Region 2, Unit F20425 72nd Avenue South, Suite 400Kent, Washington 98032-2388Telephone: (253) 234-6000Fax: (253) 395-5070

State Form 2567LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

09/29/17Electronically Signed

If continuation sheet 1 of 36899STATE FORM X09111

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L1440Continued From page 1 L1440

L1440 WAC 388-97-1440 Tuberculosis—No Testing

The nursing home is not required to have a person tested for tuberculosis if the person has:(1) A documented history of a previous positive skin test results;(2) A documented history of a previous positive blood test; or(3) Documented evidence of:(a) Adequate therapy for active disease; or(b) Completion of treatment for latent tuberculosis infection preventive therapy.

This Washington Administrative Code is not met as evidenced by:

L1440 10/30/17

Based on interview and record review, the facility failed to ensure two of five employees reviewed for TB (tuberculosis) testing provided required documentation of a previous positive skin or blood test, prior to withholding required testing for TB for new employees.

Findings include:

On 09/14/17 at 09:30 a.m., a sample of records for five recently hired staff were reviewed for compliance with current TB screening regulations. Two of these five staff lacked documentation in their files to prove they had been previously tested for TB exposure, and that test was positive for such exposure. Data for Staff H showed after she was hired on 05/10/17, she had not received any testing for TB, and had no proof of a previous positive Mantoux TB test on record.

Similar findings were present for Staff I, who was hired on 07/05/17, and had provided a prior negative chest X-ray, but no other evidence

L 1440

1. Staff H and I have been asked to provide documented proof of prior positive reactions to TB testing or documentation of prior treatment of active or latent TB.2. Documentation of a positive skin test or blood test result will be obtained prior to accepting an XRay in lieu of testing.3. Policy and Procedure for TB testing was reviewed and rewritten as needed Staff E has been made aware of the requirement stated in WAC 388-97-1440 by the DNS.4. HR will review/audit all HC employee files for compliance findings if any will be reviewed and evaluated monthly as part of the facility s QAPI processAdministrator will ensure compliance.

State Form 2567If continuation sheet 2 of 36899STATE FORM X09111

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L1440Continued From page 2 L1440

which proved she had had a positive reaction to a previous Mantoux TB test. This requirement and a clear definition of proof of a positive Mantoux test was not identified in the facility's current Policy and Procedure, dated August, 2017.

At 10:10 a.m., this was discussed with the Assistant DNS (Staff E), who said she was not aware that having evidence of a negative chest x-ray was not sufficient evidence of a prior positive Mantoux TB test, and was not aware of this requirement for staff TB testing.

State Form 2567If continuation sheet 3 of 36899STATE FORM X09111

Mirabella Seattle 116 Fairview Avenue N · Mirabella Seattle 116 Fairview Avenue N Seattle, WA...

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