PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 This Statement of Deficiencies was revised 4/4/2020 to correct dates, sources of record review and interviews about facility document information, and this supersedes all previous versions of the 3/16/2020 Statement of Deficiencies. The following reflects the findings of a focused complaint investigation survey associated with a Respiratory Illness outbreak occurring within the facility. The survey dates are from 03/06/2020 to 03/16/2020. On 03/06/2020, the facility was asked to provide a census from February 1, 2020. The facility provided a census of 120 residents. As of 03/8/2020, based upon the facility hospitalization tracking form, 54 residents were transferred to the hospital with respiratory like symptoms, 19 residents tested positive for Coronavirus disease (COVID-19) with several pending lab results and, 14 residents expired (#118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, #131). The total sample size was 54 and three unsampled residents (R200, 201 and 202). On 03/13/2020 near 3:45PM the Executive Director, and several other facility staff, were informed telephonically of three immediate jeopardy situations related to: - failure to have emergency physician services available 24 hours per day or to have an alternate emergency plan when the primary care physician, who also is the Medical Director, are unavailable to assist with a high volume of residents during a crisis situation (Refer to F0713). - failure to have an infection control surveillance LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Electronically 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 Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 1 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 000 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 program which analyzes and takes all actions to mitigate and reports timely to the Department of Health (Refer to F0880). - failure to provide quality care and services for residents during a respiratory outbreak (Refer to F0684). F 684 Quality of Care SS=L CFR(s): 483.25 F 684 § 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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have a system in place that ensured timely action related to an identified respiratory outbreak within the facility. This failure created an environment in the facility in February and March 2020 which resulted in multiple residents experiencing inadequate provision of care and services. Multiple residents experienced acute changes in condition such as respiratory distress, changes in vital signs, hospital transfers and in some cases, death during this outbreak. On 03/06/2020, the facility was asked to provide a census from February 1, 2020. The facility provided a census of 120 residents. As of 03/8/2020, based upon the facility hospitalization tracking form, 54 residents were transferred to the hospital with respiratory like symptoms, 19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 2 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 residents tested positive for Coronavirus disease (COVID-19) with several pending lab results and, 14 residents expired (#118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, #131). The total sample size was 54. There was no evidence the facility recognized all possible systemic risks and concerns related to this known outbreak, and the facility did not anticipate the need to develop contingency plans to address how the outbreak may affect their ability to provide consistent provision of quality care and services, such as in terms of infection control, sufficient medical provider and staff coverage, resident assessment and monitoring, and care. The facility failed to promptly act on and intervene to ensure timely notification of public health authorities and seek assistance from infection control expert(s), and ensure the availability of emergency physician services 24 hours a day during the outbreak crisis. In addition, there was no documented evidence of adequate and consistent resident evaluations, monitoring or consistent provision of quality care & services when there was a known outbreak in the facility. This contributed to the acutely ill residents needing to be emergently transferred out from the facility, and deaths of residents, which constitutes immediate jeopardy. Also Refer to F-Tag 880 Infection Control; and F-713 Availability of Physician Services for Emergency Care Findings include: During an interview on 03/07/2020 at 12:35 PM with the Infection Preventionist (IP) Nurse, she acknowledged having concerns and seeing a cluster with respiratory infections occurring in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 3 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 facility on approximately 02/12/2020 and had a discussion with Medical Provider 1 (MP1). The IP Nurse stated, "I did not consider calling the Department of Health because it was Flu season and the residents at the facility commonly have Pneumonia. The residents were being treated with antibiotics by the medical providers and being tested for Rapid Flu." She further confirmed all Rapid Flu Test were negative. During further interview, she denied being instructed or directed by anyone to contact the Department of Health prior to 02/26/2020. She also confirmed having concerns about the respiratory infections, but did not considered reviewing the facility policy in regard to outbreaks. Review of facility policy on 03/08/2020 titled "Infection Prevention and Control Program (IPCP) and Plan - Outbreak Control and Management" last revised on 03/04/2020, revealed, "If an outbreak is identified, the facility must: Take the appropriate steps to diagnose and manage cases, implement appropriate precautions, and prevent further transmission of the disease as well as documentation of follow-up activities in response; and comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks." During an interview on 03/08/2020 at 3:15 PM the Executive Director (ED) validated that MP2 was the primary care provider of greater than 90% of the facility residents and that he was also the Medical Director for the facility. The Executive Director confirmed that she was not informed of any respiratory infections concerns within the facility until 02/26/2020. She further explained that on 02/26/2020 the MP1, MP2 and IP Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 4 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 discussed calling the Department of Health, which was done by the IP Nurse. The ED clarified that the Hospitalization Tracking Form was being updated daily by the facility when they recieve the updates from the hospital. On 03/08/2020 near 3:00 PM during the interview with Medical Provider 1 (MP1) she acknowledged seeing an unusual occurrence of a respiratory illness occurring within the facility starting near 02/19/2020. On or near that date (02/19/2020) three additional facility residents had pneumonia, cough and fever. By or near 02/23/2020, six more residents were having respiratory illness symptoms. Based on the February 2020 admission list requested of the facility, there were 27 new admissions. During further interview on 03/11/2020 near 2:00 PM with MP1, it was revealed that on 02/26/2020 during a collaborative discussion with the Medical Provider 2 (MP2), the IP Nurse and Leadership, the facility finally decided that the Department of Health needed to be notified on 2/26/2020. In addition, it was revealed that COVID-19 testing was initiated on 02/26/2020 and facility admissions were stopped. On 02/28/2020 near 11:30 PM, the facility was informed the test results were positive for COVID-19. On 03/08/2020 at 3:15 PM during an interview with Medical Provider 2 (MP2) it was validated that he was the primary care provider for greater than ninety percent of the residents at the facility and that he was also the Medical Director. He concurred with all the interview comments shared by MP1. He further validated there was an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 5 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 atypical respiratory illness occurring within the facility, that he was in agreement with the notification to the Department of Health on 2/26/20, and the last time he was on site was 03/02/2020. On 03/11/2020 at 8:05 AM the Executive Director (EX Director) and Administrative Staff 1 (ADM STAFF 1) were interviewed, they validated that prior to 03/11/2020, the facility did not have an alternate emergency plan when the Medical Director who is also the primary physician was not available to assist with medical evaluations and decision making during the facility emergency. They also validated that they currently did not have an alternate emergency plan (See F-Tag 713). They also revealed that MP1 was also currently available for consultation by phone, but now not available to come into the facility to evaluate their residents. In addition, ADM STAFF 1 indicated that they could not manage their normal processes without leaning on the CDC and Department of Health (who the facility did not notify of the outbreak until 02/26/2020). She also stated, "We lost lots of staff quickly, greater than 30." There was no evidence the facility recognized all possible systemic risks and concerns related to this known outbreak. The facility did not anticipate the need to develop a contingency plan to address how the outbreak may affect their ability to provide consistent provision of quality of care and services, such as in terms of infection control, adequate medical provider and staff coverage, resident assessment and monitoring, and care. By not acting timely and implementing a facility plan created an environment that placed new FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 6 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 admissions and other residents at risk for harm and death. For example, the facility continued to admit residents into the facility with a known outbreak during February 2020, placing these residents at risk for infection and death. During a record review on 03/8/2020 of the infection control surveillance program, the records reflected that from 02/03/2020 to 02/23/2020 fourteen Facility Acquired Infections of Pneumonia and Lower Respiratory cases occurred at the facility. The Department of Health, State and Local authorities were not notified until 02/26/2020. In addition the facility Hospitalization Tracking Form ("Transfer since 2/19") reflected that 54 residents had changes in condition (such as changes in vital signs, mental status changes, agitation, respiratory distress) and 54 residents were sent to multiple hospitals, 19 residents were tested positive for COVID-19 and 14 residents died. The Hospitalization Tracking Form did not reflect the date or location of COVID-19 testing. On 03/08/2020 at 3:15 PM, the Executive Director clarified that the Hospitalization Tracking Form was being updated daily by the facility when they received the updates from the hospital. Continued record review on 3/10/20 of the Hospitalization Tracking Form and Electronic Health Record revealed: 1). Resident #118 admitted to the facility on 02/12/2020 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Cancer of Bladder, Chronic kidney disease. The resident was transferred to the hospital on 02/18/2020 with shortness of breath. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired on 2/26/20. The last medical provider FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 7 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 evaluation was dated 2/13/20. Record review also showed inconsistent care and monitoring by staff. 2) Resident # 122 admitted to facility on 2/11/20 with diagnoses of kidney failure, Atrial Fibrillation (A-Fib), Cerebral Infarct, Pleural Effusion. The Resident was transferred to the hospital on 2/26/20 with Pleural effusion. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19, and expired on 3/1/20. The last medical provider evaluation was dated -02/20/2020. Record review also showed inconsistent care and monitoring by staff. 3) Resident #125 admitted to facility on 02/19/2020 diagnoses of CHF, Pneumonia (PNA), and COPD. Resident was transferred to the hospital on 02/27/2020 with respiratory distress. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired on 03/04/2020. The last medical provider evaluation was dated 2/25/20. Record review also showed inconsistent care and monitoring by staff. 4) Resident #129 admitted to facility on 02/24/2020 with diagnoses of CHF and PNA. Resident was transferred to the hospital on 03/02/2020 with abnormal vital signs. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired on 3/3/20. There was no indication of medical provider evaluation documentation immediately prior to transfer. Record review also showed inconsistent care and monitoring by staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 8 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 The facility records review reflected that between 02/19/2020 to 03/08/2020, fourteen residents died at the hospital and several residents died in the facility. In addition, 54 residents were transferred to multiple hospitals with respiratory symptoms. Per interview with MP2 on 03/10/2020 at 2:30 PM, MP2 was available telephonically for guidance and direction, however he was not available to MP1 to assist with the medical evaluations and decision-making for the high volume of residents requiring assessment between 03/03/2020 to 03/05/2020. Between the aforementioned dates, there was a need for 25 residents to be assessed. Per interview on 03/10/2020 at 2:00 PM, MP1 acknowledged that sometimes during that time period, she made medical decisions, then later informed MP2 regarding her decisions. MP1 also verbalized with all the multiple evaluations, treatment decisions, and transfers of residents to the hospitals, she was not able to keep up with all the associated documentation and communications. MP1 stated that she did not have a physician onsite with her "until Thursday evening [03/05/2020]." Review of the most current available MP1 onsite visit notes were dated 02/27/2020. The facility records between 02/19/2020 to 03/08/2020, did not reflect consistent clinical evidence of physician and/or extender evaluations, interventions, or a clear medical plan of action. In addition the facility Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20. On 03/08/2020 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 9 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 9 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 3:15 PM, the Executive Director clarified that the Hospitalization Tracking Form was being updated daily by the facility when they received the updates from the hospital. In addition, review of resident records reflected inconsistent evidence of vital signs, oxygen saturation levels, and other monitoring and care documentation by nursing and direct care staff as follows: 1) Resident #119 admitted to facility on 01/29/2020 with diagnoses of Encephalopathy, Neoplasm Cancer, Hypertension (HTN), Asthma, and Malnutrition. The resident was transferred to the hospital on 02/24/2020 with weakness and confusion. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19, and expired. The last medical provider evaluation was dated 02/18/2020. Record review also showed inconsistent care and monitoring by staff. 2) Resident #120 admitted to facility on 4/29/17 with diagnosis of Pneumonia, Diabetes (DM), HTN, Heart Failure, and Anemia. The resident was transferred to the hospital on 02/24/2020 with respiratory distress. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired. The last medical provider evaluation was dated -02/19/2020. Record review showed inconsistent care and monitoring by staff. 3) Resident # 121 admitted to facility on 12/12/19 with diagnosis of subarachnoid hemorrhage, and Acute Respiratory Failure. The resident was transferred to the hospital on 02/24/2020 with an elevated temperature. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 10 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 10 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 that later the resident tested positive for COVID-19 and expired 02/24/2020 . Record review also showed inconsistent care and monitoring by staff. 4) Resident #123 admitted to facility on 11/18/19 with diagnoses of Dysphagia, Epilepsy, Congested Heart Failure (CHF), and DM. The facility infection control report for January 2020 identified that the resident acquired a respiratory infection Pneumonia (PNA). The resident was transferred to the hospital on 02/27/2020 with an increased respiratory rate. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired on 3/5/20. The last medical provider evaluation was dated 02/20/2020. Record review also showed inconsistent care and monitoring by staff. 5) Resident #124 admitted to facility on 05/20/19 with diagnoses of COPD (chronic pulmonary disease), Acute Respiratory Failure, DM, CHF, and Atrial-fibrillation. The resident was transferred to the hospital on 02/27/2020 with shortness of breath. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired on 03/01/2020. Record review also showed inconsistent care and monitoring by staff. 6) Resident #127 admitted to facility on 01/19/2020 with diagnoses of COPD, CHF, and PNA. Resident #127 was transferred to the hospital on 02/28/2020 with respiratory distress. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19, and expired on 03/01/2020. The last medical provider evaluation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 11 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 was dated 02/27/2020. Record review showed inconsistent care and monitoring by staff. 7) Resident #128 admitted to facility on 11/01/2019 with diagnoses of CHF, and Respiratory Failure. The resident was transferred to the hospital on 03/02/2020 with increased pulse and decreased oxygen saturation level. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested for COVID-19, and expired on 03/02/2020. The last medical provider evaluation was dated 0-2/25/2020. Record review also showed inconsistent care and monitoring by staff. 8) Resident #130 admitted to facility on 06/4/2015 with diagnosis of Heart Failure, pneumonia. The resident was transferred to the hospital on 03/02/2020 with difficulty breathing and decreased oxygen saturation level. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested for COVID-19 pending results, and expired on 03/05/2020. The last medical provider evaluation was dated 02/26/2020. Record review also showed inconsistent care and monitoring by staff. 9) Resident #131 admitted to facility on 09/11/2019 with diagnoses of Urinary Tract Infection, and Pneumonia. The Resident was transferred to the hospital on 03/04/2020 with elevated temperature, diaphoretic, and wheezing. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated resident expired on 03/04/20. The last medical provider evaluation was dated 02/28/2020. Record review also showed inconsistent care and monitoring by staff. 10) Resident #126 admitted to the facility on 1/28/2020 with diagnosis of CHF, Diabetes (DM) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 12 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 and Atrial Fibrillation (A fib). Resident was transferred to the hospital on 2/28/20 with increased confusion. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19, and expired on 2/29/20. During interviews on 03/11/2020 at 8:05 AM with EX Director, ADM STFF 2, and ADM STFF 1, they stated that MP1 was still in the process of writing her resident evaluation notes from late February and early March 2020. They stated that during that time, "it was very chaotic" and no written medical provider evaluations would be available because there had been too many residents becoming acutely ill, "We were triaging residents as the residents were crashing, so there wasn't going to be a lot of documentation." In summary, the facility did not have effective systems in place that ensured timely actions related to an identified respiratory outbreak within the facility. The facility did not timely notify the appropriate health care authorities of the respiratory illness outbreak until February 26, 2020. In addition, the facility did not timely act to develop contingency plan(s) to address and provide emergent physician services (to assist MP1), and ensure the availability of an adequate amount of staff and other care and services to meet the increased needs of the residents during the outbreak. The facility did not effectuate consistent infection control procedures, lacked clinical evidence of physician and/or physician extender evaluations, interventions or a clear medical plan of action, and did not show evidence of consistent quality care and services in accordance to professional standards of practice. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 13 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 684 Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 684 This inaction lead to a systemic failure in terms of providing the necessary resources to effectively manage the respiratory outbreak and deliver optimal quality of care and services to these residents. On 03/13/2020 near 3:45 PM, the Executive Director was informed of an Immediate Jeopardy situation related to failure to provide quality care and services for residents during a respiratory outbreak which began on 03/03/2020. Lack of timely action related to implementation of infection control procedures, a lack of a plan for provision of emergent MD services and other services to meet the increased needs of the acutely ill residents, and lack of clinical evidence of physician and/or extender evaluations & interventions with a clear medical plan of action contributed to a failure to provide the necessary resources to effectively manage the respiratory outbreak and deliver optimal quality of care and services to these residents. F 713 Physician for Emergency Care Available 24 hrs SS=L CFR(s): 483.30(d) F 713 §483.30(d) Availability of physicians for emergency care The facility must provide or arrange for the provision of physician services 24 hours a day, in case of emergency. This REQUIREMENT is not met as evidenced by: Based on interview and document review the facility failed to arrange for the provision of physician services 24 hours a day in case of emergency. Failure to ensure emergency physician services are available during an urgent, emergent or crisis situation can potentially put all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 14 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 713 Continued From page 14 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 713 the residents at risk for harm. Findings include: On 03/08/2020 near 3:00 PM during the interview with Medical Provider 1 (MP1) it was stated she had noted an unusual occurrence of a respiratory illness occurring within the facility stating near 02/19/2020. On or near that date (02/19/2020) three additional residents of the facility had pneumonia, cough and fever. She further indicated Medical Provider2 ((MP2), the supervisor of MP1), and the Infection Preventionist (IP) Nurse were informed of her suspicions. It was conveyed she communication with professional colleagues regarding any atypical (not normal) illnesses that they may be seeing or treating in the community; no atypical illnesses had been identified. By or near 02/23/2020 six more residents developed respiratory illness symptoms. MP1 indicated she had been consulting with MP2 on a case by case basis regarding residents that may be having issues or concerns. During further interview on 03/11/2020 it was revealed that on 02/26/2020 during a collaborative discussion with the MP2 and the IP Nurse it was determined that the Department of Health needed to be notified of the atypical respiratory illness in the facility. On 02/26/2020 Coronavirus Disease 2019 (COVID19) testing was initiated. On 2/28/2020 near 11:30 PM the facility was informed the test results were positive for COVID19. On 03/08/2020 at 2:30 PM during an interview with Medical Provider 2 it was validated that he was the primary care provider for greater than nighty percent of the residents at the facility and that he was also the Medical Director. He FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 15 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 713 Continued From page 15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 713 concurred with all the interview comments shared by MP1. He further validated there was an atypical respiratory illness occurring within the facility, that he was in agreement with the notification to the Department of Health and the last time he was on site was 03/02/2020. The facility records reflect between 02/19/2020 to 03/08/2020 fourteen residents died at the hospital and several resident died in the facility. In addition 54 residents were transferred to multiple hospitals with respiratory symptoms. Recall Medical Provider 1 is supervised by MP2 who is also the Medical Director of the facility. MP2 was last physically present at the facility on 03/02/2020. MP2 was available telephonically for guidance and direction however he was not available to MP1 to assist with the medical evaluations and decision making for the high volume of residents requiring assessment 3/3/2020 to 3/5/2020. Between the aforementioned dates there was a need for 25 residents to be assessed. The MP1 acknowledged sometimes, during that time period, she made medical decisions then later informed MP2 regarding her decisions. MP1 also verbalized with all the multiple assessments, treatment decisions, and transfers of residents to the hospitals she was not able to keep up with all the associated documentation and communications. Record review of the facility contract between the Medical Director who is also MP2, indicates the Medical Director will "Coordinate with the Executive Director and with attending physicians to assure the twenty-four (24) hour per day availability of physician's services when a resident's attending physician is unavailable." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 16 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 713 Continued From page 16 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 713 Further document review of the facility policy titled Physician Services dated 09/23/2008 under the section titled Emergency Care, page 5, it states "In the event that an emergency occurs, and the resident's attending physician is not available, the alternate physician is contacted." Under the section that addresses Progress Notes the same policy states "Once initial assessment has been done, progress notes by the attending physician are maintained for each resident and reflect the condition of the resident, his or her response to treatment, and any new treatments deemed necessary. Progress notes are legible and provide needed information regarding the resident's current status to enable safe, effective continuing care and regulatory compliance. Progress notes are recorded whenever the physician sees the resident and/or whenever changes occur in the resident's condition ...." On 03/08/2020 3:15 PM the Executive Director was initially interviewed. She validated MP2 was the primary care provider of greater than 90% of the facility residents and that he was also the Medical Director for the facility. On 03/11/2020 she was further interviewed, on that date she validated that prior to 3/11/2020 the facility did not have, and currently does not have, an alternate emergency plan when the Medical Director who is also the primary physician was not available to assist with medical evaluations and decision making during the facility emergency. During that same interview it was revealed that MP1 was now also available for consultation by phone but NOT available to physically to come into the facility to physically evaluate their residents. During an interview of the Executive Director on 03/14/2020 near 1:00 PM, Administrative Staff 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 17 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 713 Continued From page 17 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 713 and Interim Administrative Staff 2 commented that the facility staff were not operating under normal circumstances. She further stated the medical providers were addressing the primary concerns of the residents and acknowledged that medical record documentation is being completed as the facility stabilizes. On 03/13/2020 near 3:45 PM the Executive Director was informed of an immediate jeopardy situation related to failure to have emergency physician services available 24 hours per day or to have an alternate emergency plan which began on 03/03/2020. MP2 is the Medical Director and is also the primary physician, and/or his physician extender (MP1), are only available telephonically. In short, the documentation reflects that when residents had changes in condition, multiple residents were sent to multiple hospitals and multiple residents died without sufficient medical evaluation. The interviews and record review reflects there was no facility plan in place prior to 03/11/2020 to ensure emergency physician services were available 24 hours per day. F 837 Governing Body SS=F CFR(s): 483.70(d)(1)(2) F 837 §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 18 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 837 Continued From page 18 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 837 required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility Governing Body failed to ensure that they had a Quality Assurance and Performance Improvement (QAPI) program that was operationalized for 2019. This failure is evident by the lack of adequate QAPI committee meeting minutes for 2019 which would demonstrate active Medical Director participation and attendance per facility policy. Failure to have a fully function governing body may lead to substandard qaulity of care concerns for all the residents in the facility. Findings Include: During an interview on 3/18/2020 at 9:35 AM with the newly appointed Executive Director (ED) she acknowledged the Medical Director was not in attendance in the 01/27/2020 and 02/19/2020 QAPI meetings. She validated the Infection Preventionist (IP) Nurse did not discussed the infection control surveillance report during the QAPI meeting on 01/27/2020. She further explained that the IP Nurse was not in attendance for the 02/19/2020 meeting and the Facility Acquired infections of Pneumonia and lower respiratory infections were not discussed. The Executive Director stated, "When I started in January 2020, it was identified that the facility had not been holding regular QAPI meetings. As a result I planned on having a monthly QAPI meeting for next three months". The Executive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 19 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 837 Continued From page 19 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 837 Director also stated, "Normally if there are concerns in infection control it would have been discussed in the QAPI meeting". During further discussion she confirmed not having all the evidence from the 2019 QAPI meeting minutes. Further documented evidence of all the Governing Body meeting minutes for 2019 were requested to ascertain communication between the former Executive Director and Governing Body from the facility and/or the corporate office. On 03/19/2020 documents received from the Executive Director via email states "The Governing body meetings include: meetings with the ED, Regional Vice President (RVP), and the regional team. She valided no minutes of these meetings are kept". On 03/25/2020 at 2:00 PM an interview was conducted with Adm. Staff 4 he confirmed being the Regional Vice President Representative for the Governing Body at Life Care Center of Kirkland and is the Chairperson representative for Governing Body. He validated not having a written agenda or meeting minutes for the Governing Body. He indicated the Governing Body communications are done verbally on the phone and/or via emails. The documents provided on 03/26/2020 were reviewed. One of the documents was the facility's Regional Team Visit Quality Assurance Performance Improvement Program conducted on 12/19/2019. The document reflected the facility is in non-compliance with the Medical Directors responsibility. The documents provided did not provide further explanatory evidence of how the Governing Body addressed the concerns identified on 12/19/2019 in regards to the Medical Director. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 20 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 837 Continued From page 20 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 837 On 03/15/2020 the facility policy titled "Quality Assessment and Assurance Committee Roles and Responsibilities revised on 02/20/2019" was reviewed and it reveals: "Under the section of Governance and Leadership: The governing body and/or executive leadership organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: -An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. -The QAPI program is sustained during transitions in leadership and staffing; -The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed; -The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to resident based on performance indicator data, and resident and staff input, and other information. -Corrective actions address gaps in systems, and are evaluated for effectiveness; and -Clear expectations are set around safety, quality, rights, choice, and respect. A facility must maintain a quality assessment and assurance committee consisting at a minimum of: -The director of nursing services; -The Medical Director or his or her designee; -At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and -The infection control and prevention officer. The quality assessment and assurance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 21 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 837 Continued From page 21 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 837 committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through ( e) of this section. The committee must: Develop and implement appropriate plans of action to correct identified quality deficiencies; and Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements". On 03/15/2020 the facility policy titled "Administrative General Policies; Administrative Policies and Procedures Manual; Medical Director revised on 06/21/2019 was reviewed and it reflects: 1)."The Medical Director shall enter into a written agreement with his/her facility and such agreement should outline the duties and responsibilities of both the medical director and the facility. A copy of the agreement will be maintained on file in the executive director's office. This written agreement will be reviewed annually by the medical director and executive director. 2).Medical Director responsibilities must include their participation in: -Administrative decisions including recommending, developing and approving facility policies related to residents care. Resident care includes the resident's physical, mental and psychosocial well-being; -Issues related to the coordination of medical care identified through the facilities Quality Assessment and Assurance (QAA) committee and other activities related to the coordination of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 22 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 837 Continued From page 22 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 837 care; -Organizing and coordinating physician services and services provided by other professionals as they relate to resident care; -Coordinating and planning for improvement of medical care in the facility; -Participate in the QAA committee or assign a designee to represent him/her; -Chairing the Medical Director Facility Oversight Committee; and -Designation of an alternate medical director with sufficient training and experience to perform the responsibilities if the medical director is unavailable. 3). In addition, the Medical Director responsibilities should include, but are not limited to: -Assisting in the development of educational programs for facility staff and other professionals -Working with the facility's clinical team to provide surveillance and develop policies to prevent the potential infection of residents". On 3/26/2020 reviewed the facility Regional Team Visit Quality Assurance Performance improvement program conducted on 12/19/2019 it reveals an 1). "The QAPI Committee meets monthly and meeting sign-in sheets includes the following disciplines: "Complaint" Executive Director Director of Nursing Medical Director Quality Assessment Performance Improvement Coordinator 2). QAPI Committee follows an agenda for conducting the meeting showing tracking and trending: "Compliant" 3). Documentation supports the Medical Director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 23 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 837 Continued From page 23 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 837 Oversight committee meets monthly after the QAPI committee: "NON-COMPLIANT" Comments: "NOT CURRENTLY IN PLACE". F 841 Responsibilities of Medical Director SS=F CFR(s): 483.70(h)(1)(2) F 841 §483.70(h) Medical director. §483.70(h)(1) The facility must designate a physician to serve as medical director. §483.70(h)(2) The medical director is responsible for(i) Implementation of resident care policies; and (ii) The coordination of medical care in the facility. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failure to have an active Medical Director participating in the Quality Assurance & Performance Improvement (QAPI) Program per policy. This failure could potentially impact quality of care for all residents. Findings included: During an interview on 3/18/2020 at 9:35 AM with the newly appointed Executive Director, she acknowledged the Medical Director was not in attendance at the 01/27/2020 or the 02/19/2020 QAPI meetings. A request was made for further documentation from the facility and/or corporate office regarding the Medical Director's participation and attendance in the QAPI committee meetings for 2019, however no further documentation was received. The limited amount of 2019 QAPI data that was made available does not support adequate evidence reflecting active involvement by the medical director. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 24 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 841 Continued From page 24 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 841 On 03/15/2020, the facility policy titled, "Quality Assessment and Assurance Committee Roles and Responsibilities revised on 02/20/2019" was reviewed and it revealed: 1).The QAA Committee meets at least quarterly and as needed, and evaluates issues and determines opportunities for improvement. These meetings will be documented on the QAA Minutes Form. 2).A facility must maintain a quality assessment and assurance committee consisting at a minimum of: -The director of nursing services; -The Medical Director or his or her designee; -At least three other members of the facility's staff, at least one of who must be -The administrator, owner, a board member or other individual in a leadership role; and -The infection control and prevention officer. 3).The Medical Director is an active member of the organization's quality committee and any team(s) that have specific responsibilities related to QAPI. Duties and responsibilities to the QAPI program include, but are not limited to, the following: -Attend QAA meetings and Medical Director Oversight Committee Meetings quarterly or by phone as available -Review minutes of the facility's QAA Committee meeting for items needing follow-up, medical consideration, further investigation or referral, as well as new policies or procedures -Present and discuss any reports or studies from outside agencies (such as the health department) -Note and review any trends or outstanding problems of the medical staff in general and assist and resolve concerns and issues between physicians, health care practitioners, and facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 25 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 841 Continued From page 25 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 841 staff -Discuss follow-up of previous performance improvement questions or issues -Recommend policy changes to other departments or to administration, where needed -Review facility practices to ensure compliance with acceptable standards to provide quality resident care -Assist in implementation of resident care procedure. On 03/25/2020 at 2:00 PM interview conducted with Adm. Staff 4 he confirmed being the Regional Vice President Representative for the Governing Body at Life Care Center of Kirkland and is the representative for Governing Body. He validated not having a written agenda or meeting minutes for the Governing Body. He indicated the Governing Body communications are done verbally on the phone and/or via emails. The documents provided on 03/26/2020 were reviewed. One of the documents was the facility's Regional Team Visit Quality Assurance Performance Improvement Program conducted on 12/19/2019. The document reflect the facility is in non-compliance with the Medical Directors responsibility. The documents provided did not provide further explanatory evidence of how the Governing Body addressed the concerns identified on 12/19/2019 in regards to the Medical Director. On 3/15/2020, the facility policy titled, "Medical Director Agreement" was reciweved and it revealed: ("Agreement") is by and between XXX MD, PLLC ("Director") and Life Care Center of Kirkland ("Faciliti'), will be effective as of the date fully executed by all parties hereto ("Effective Date"), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 26 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 841 Continued From page 26 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 841 and supersedes any prior agreement between the parties as to the subject matter herein: 1.5 Assist with implementation and participation in governance of written by-laws, rules and policies for Facility as necessary, including: Policies governing the medical, nursing, and other related health services provided in Facility 1.6 If there is an organized medical staff at Facility, to be a member hereof, and attend meetings and help ensure adherence to Facility by-laws, rules and policies. 1.7 Develop and participate in effective utilization review; the effect of which is to promote the most effective and efficient use of Services consistent with resident needs. 1.8 Remain available for consultation and participation in in-service programs at Facility 1.11 - Serve as a member of the: (i) Quality Assurance and Assessment (ii) Pharmacy; (iii) and Infection Control Committees at Facility. 1.12 Advise and participate in the development of Facility's safety and training programs, including Facility's in-service education training programs and advising or serving upon any related committees designated by Facility". On 03/15/2020, the facility policy titled, "Administrative General Policies; Administrative Policies and Procedures Manual; Medical Director," revised on 06/21/2019, was reviewed and it revealed: 1) "The medical director shall enter into a written agreement with his/her facility and such agreement should outline the duties and responsibilities of both the medical director and the facility. A copy of the agreement will be maintained on file in the executive director's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 27 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 841 Continued From page 27 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 841 office. This written agreement will be reviewed annually by the medical director and executive director. 2).Medical director responsibilities must include their participation in: -Administrative decisions including recommending, developing and approving facility policies related to residents care. Resident care includes the resident's physical, mental and psychosocial well-being; -Issues related to the coordination of medical care identified through the facility's Quality Assessment and Assurance (QAA) committee and other activities related to the coordination of care; -Organizing and coordinating physician services and services provided by other professionals as they relate to resident care; -Coordinating and planning for improvement of medical care in the facility; -Participate in the QAA committee or assign a designee to represent him/her; -Chairing the Medical Director Facility Oversight Committee; and -Designation of an alternate medical director with sufficient training and experience to perform the responsibilities if the medical director is unavailable. 3). In addition, the medical director responsibilities should include, but are not limited to: -Assisting in the development of educational programs for facility staff and other professionals -Working with the facility's clinical team to provide surveillance and develop policies to prevent the potential infection of residents". On 3/26/2020 reviewed the facility Regional Team Visit Quality Assurance Performance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 28 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 841 Continued From page 28 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 841 improvement program conducted on 12/19/2019 it reveals an 1)."The QAPI Committee meets monthly and meeting sign-in sheets includes the following disciplines: "Complaint" Executive Director Director of Nursing Medical Director Quality Assessment Performance Improvement Coordinator 2).QAPI Committee follows an agenda for conducting the meeting showing tracking and trending: "Compliant" 3). Documentation supports the Medical Director Oversight committee meets monthly after the QAPI committee: "NON-COMPLIANT" Comments: "NOT CURRENTLY IN PLACE" F 842 Resident Records - Identifiable Information SS=F CFR(s): 483.20(f)(5), 483.70(i)(1)-(5) F 842 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 29 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 842 Continued From page 29 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 842 (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 30 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 842 Continued From page 30 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 842 (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview and medical record review the facility failed to ensure it did not leave resident identifiable and medical information available to the public for residents (sample resident #134 and non-sample residents #200, #201 [x2] and #202). Failure to safeguard resident identifiable information could potentially lead to identity theft of personal and/or healthcare. Additionally, the facility failed to ensure the medical records were complete and accurately documented for several of the sampled residents [cross refer to finding at F684]. Of the 54 residents (residents 131, 136, 141, 152, 156, and 160) that were transferred out to the hospitals reflected a lack of medical assessments prior to the transfers. Failure to ensure the medical records are complete and accurately documented could potentially contribute to gaps in the continuity of care for all residents. Findings include: 1. On 03/06/2020 near 2:30 PM the initial tour of the facility occurred. The building can be described as some-what rectangular or square with 4 main corridors with resident rooms on each side. The halls are areas where residents, the public, staff and visitors could access/walk; medications carts were observed with multiple FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 31 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 842 Continued From page 31 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 842 papers and computers were on top of them. On 08/08/2020 near 2:00 PM care observations and interviews were completed. On top of 3 of the 4 medication carts there was a paper communication tool. The title of the tool was Life Care Kirkland Licensed Nurse Report. The documents were NOT secure and examples of information that anyone could see include: resident names, who the resident's physician is, possible laboratory data results or pending laboratory specimens to be collected, blood sugar results and any specific notes the nurses may collect on the residents. - On the top of the medication cart #3 there were 4 individual residents (#134, #200, #201[x2] and #202) Yellow Family Concern Forms. The forms were filled out and information contained on the form includes the name of the resident, the person being called, relationship, phone number and/or email of the person being called and the concern/comments in addition to any response or needed follow up; the forms were not secure. Facility LN3 acknowledged the information should not be left viewable to the public. -On top of the Cascade medication cart there was a 5 page Life Care Kirkland Licensed Nurse Report that had resident information facing upward that was unsecured and viewable by the public. - On top of the Baker Station medication cart there was a 5 page Life Care Kirkland Licensed Nurse Report that had resident information facing upward that was unsecure and viewable by the public and the computer was not secured; information on all residents was potentially accessible. Agency Licensed Nurse 3 acknowledged she did not lock the computer. - On top of the Glacier Station medication cart FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 32 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 842 Continued From page 32 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 842 there was a Life Care Kirkland Licensed Nurse Report that was unsecure and viewable by the public and the computer was not secured; information on ALL residents was potentially accessible. The facility LN1 was on the phone and his colleague, an Agency Nurse, was speaking with other coworkers down the hall. On 03/08/2020 near 4:30 PM during an interview with the Executive Director and ADM Staff 2 it was acknowledged the residents had a right privacy and that resident's information should be protected. On that same date the facility policy on release of patient information was requested. The policy titled Disclosure of Protected Health Information was provided. Within that document it indicates: -"The facility maintains the confidentiality of the resident's medical, financial and /or social information contained in the resident's records regardless of the form or storage method of the records." -"The resident is assured confidential treatment of his or her medical records ...." Within the policy addressing Safeguarding Electronic Health Information it states under Procedure: -"Computer screen placement should be reviewed periodically to ensure that unauthorized viewing is not easily possible." -"All users should be trained to log off their workstations every evening before leaving and when away from workstations." 2. Cross refer to findings at 684. Record review of some of the 54 residents (residents 131, 136, 141, 152, 156, and 160) that were transferred out to the hospitals reflected a lack of medical assessments prior to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 33 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 842 Continued From page 33 F 842 transfers. F 865 QAPI Prgm/Plan, Disclosure/Good Faith Attmpt SS=F CFR(s): 483.75(a)(2)(h)(i) F 865 (X5) COMPLETION DATE §483.75(a) Quality assurance and performance improvement (QAPI) program. §483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; §483.75(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. §483.75(i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to ensure it developed a plan that describes the process for conducting Quality Assurance and Performance Improvement/Quality Assurance Assessment (QAPI/QAA) activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement. QAPI/QAA activities are designed to improve the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. This failure was evident when the facility failed to provide evidence of all QAPI committee minutes for 2019 and evidence of the Medical Director attendance for 2019 and 2020. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 34 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 865 Continued From page 34 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 865 This failure has the potential to affect the quality of care for all the residents in the facility. Findings include: On 3/12/2020 reviewed the facility Quality Assurance & Performance Improvement (QAPI) monthly meeting minutes it revealed that the facility conducted a meeting on 01/27/2019 and the Infection Preventionist (IP) Nurse attended the meeting, but the Medical Director or representative was not in attendance. Additionally no infection control issues or concerns were discussed. On 02/19/2020 another QAPI meeting was conducted, the IP nurse nor the Medical Director or representative was not in attendance. Further review of the QAPI meeting agenda does not include any discussions of the Facility Acquired Infections related to the eight Pneumonia and Lower respiratory concerns. The facility provided documents from the Ad-Hoc QAPI meeting held on 1/27/2020. The documents received does not contain evidence that the facility had consistent or effective QAPI meetings for year (2019). The facility documented it began holding QAPI meetings monthly for three months. Further review of the 02/19/2020 monthly QAPI meeting minutes under the nursing section revealed: no reports of infection concerns at the facility. During an interview on 03/18/2020 at 9:35 AM with the newly appointed Executive Director she acknowledged the Medical Director was not in attendance in the 01/27/2020 or the 02/19/2020 QAPI meetings. She validated the Infection Preventionist (IP) Nurse did not discussed the infection control surveillance report during the QAPI meeting on 01/27/2020. She further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 35 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 865 Continued From page 35 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 865 explained that the IP Nurse was not in attendance for the 02/19/2020 meeting and the Facility Acquired infections of Pneumonia and lower respiratory infections were not discussed. The Executive Director stated, "When I started in January 2020, it was identified that the facility had not been holding regular QAPI meetings. As a result I planned to have a monthly QAPI meeting for next three months". The Executive Director also stated, "Normally if there are concerns in infection control it would have been discussed in the QAPI meeting". During further discussion she confirmed not having all the evidence from the 2019 QAPI meeting minutes. On 03/25/2020 at 2:00 PM interview conducted with Adm. Staff 4 he confirmed being the Regional Vice President Representative for the Governing Body at Life Care Center of Kirkland and is the representative for Governing Body. He validated not having a written agenda or meeting minutes for the Governing Body. He indicated the Governing Body communications are done verbally on the phone and/or via emails. The documents provided on 03/26/2020 were reviewed. One of the documents was the facility's Regional Team Visit Quality Assurance Performance Improvement Program conducted on 12/19/2019. The document reflect the facility is in non-compliance with the Medical Directors responsibility. The documents provided did not provide further explanatory evidence of how the Governing Body addressed the concerns identified on 12/19/2019 in regards to the Medical Director. On 3/15/2020 the facility policy titled "Quality Assessment and Assurance Committee Roles and Responsibilities revised on 02/20/2019" was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 36 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 865 Continued From page 36 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 865 reviewed and it revealed: Policy The Executive Director may delegate the necessary authority for actions and processes inherent in the QAPI program to the QAA Committee. In interest of coordinating all activities of QAA, the QAA Coordinator is appointed the chairperson of the committee. If any compliance issues are identified, they should be reported to the Executive Director and the compliance department. Procedure: 1).The facility will establish and maintain a quality assessment and assurance (QAA) committee consisting at a minimum of the following: -The Director of Nursing -The Medical Director or his/her designee -At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and -The Infection Preventionist 2).The QAA committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program. 3).The QAA committee must: -Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary -Develop and implement appropriate plans of action to correct identified quality deficiencies; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 37 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 865 Continued From page 37 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 865 -Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. 4).The QAA committee determines what performance indicators will be monitored and the schedule or frequency for monitoring this data. 5).The QAA committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the QAPI program. 6).The QAA committee must develop and implement corrective action, and monitor to ensure 7).The QAA Coordinator shall be responsible for the minutes of all regular and specially called meetings of the QAA Committee include, at a minimum, the following information. -The date and time the committee met -The names of committee members present -A list of topics reviewed/discussed -Whether a QAPI PIP is required -Department(s) responsible for the development of QAPI PIP -The time the meeting adjourned 8).The committee maintains documentation of its meetings, findings, and recommendations for a minimum of seven years. 10). Immediately following the QAA Committee Meeting the Medical Director Oversight Committee meets. On 3/26/2020 reviewed the facility Regional Team Visit Quality Assurance Performance improvement program conducted on 12/19/2019 it revealed: 1).The QAPI Committee meets monthly and meeting sign-in sheets includes the following disciplines: "Complaint" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 38 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 865 Continued From page 38 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 865 Executive Director Director of Nursing Medical Director Quality Assessment Performance Improvement Coordinator 2).QAPI Committee follows an agenda for conducting the meeting showing tracking and trending: "Compliant" 3). Documentation supports the Medical Director Oversight committee meets monthly after the QAPI committee: "NON-COMPLIANT" Comments: "NOT CURRENTLY IN PLACE" F 880 Infection Prevention & Control SS=L CFR(s): 483.80(a)(1)(2)(4)(e)(f) F 880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 39 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 39 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 40 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 40 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews the facility failed to take appropriate additional actions related to a respiratory illness outbreak. Moreover the facility failed to take prompt steps in reporting the concern to the Department of Health, State and local authorities. These failed practices may have contributed to multiple residents and staff contracting respiratory like illnesses. The facility was aware of eight residents with symptoms of respiratory illness and/pneumonia by 02/19/2020 but failed to contact the Department of Health to request further guidance and assistance until 02/26/2020. On 03/06/2020, the facility was asked to provide a census from February 1, 2020. The facility provided a census of 120 residents. As of 03/8/2020, based upon the facility hospitalization tracking form, 54 residents were transferred to the hospital with respiratory like symptoms, 19 residents tested positive for Coronavirus disease (COVID-19) with several pending lab results, and 14 residents expired (#118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, #131). The total sample size was 54. In addition several residents expired within the facility and the status of those residents are pending. Additionally the facility failed to operationalize their infection prevention and control program to provide a safe, sanitary and to help prevent the development and transmission of communicable diseases and infections. Refer to example #2 below. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 41 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 41 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 1). During a record review on 03/8/2020 of the infection control surveillance program the records reflect that from 02/03/2020 to 02/23/2020 fourteen Facility Acquired Infections of Pneumonia and Lower Respiratory cases occurred at the facility. The Department of Health, State and Local authorities were not notified until 02/26/2020. In addition the facility Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20. It reflects that 54 residents had changes in condition (such as changes in vital signs, mental status changes, agitation, respiratory distress) and 54 residents were sent to multiple hospitals, 19 residents were tested positive for COVID-19 and 14 residents died. The Hospitalization Tracking Form does not reflect the date or location of COVID-19 testing. On 03/08/2020 at 3:15 PM the Executive Director clarified that the Hospitalization Tracking Form was being updated daily by the facility when they recieve the updates from the hospital. Continued Record Review on 3/10/20 of the Hospitalization Tracking Form and Electronic Health Record reveals: 1). Resident #118 admitted to facility on 2/12/20 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Cancer of Bladder, Chronic kidney disease. Resident was transferred to the hospital on 2/18/20 with shortness of breath. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired on 2/26/20. 2) Resident #119 admitted to facility on 01/29/2020 with diagnoses of Encephalopathy, Neoplasm Cancer, Hypertension (HTN), Asthma, and Malnutrition. The resident was transferred to the hospital on 02/24/2020 with weakness and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 42 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 42 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 confusion. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19, and expired. The last medical provider evaluation was dated 02/18/2020. 3) Resident #120 admitted to facility on 4/29/17 with diagnosis of Pneumonia, Diabetes (DM), HTN, Heart Failure, and Anemia. The resident was transferred to the hospital on 02/24/2020 with respiratory distress. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired. The last medical provider evaluation was dated -02/19/2020. 4) Resident # 121 admitted to facility on 12/12/19 with diagnosis of subarachnoid hemorrhage, and Acute Respiratory Failure. The resident was transferred to the hospital on 02/24/2020 with an elevated temperature. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired 02/24/2020. 5). Resident # 122 admitted to facility on 2/11/20 with diagnoses of kidney failure, Atrial Fibrillation (A-Fib), Cerebral Infarct, Pleural Effusion. Resident was transferred to the hospital on 2/26/20 with Pleural effusion. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19, and expired on 3/1/20. 6). Resident #123 admitted to facility on 11/18/19 with diagnoses of Dysphagia, Epilepsy, Congested Heart Failure (CHF), DM. The facility infection control report for January 2020 identified that resident acquired a respiratory infection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 43 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 43 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 Pneumonia. Resident was transferred to the hospital on 2/27/20 with increase respiratory rate, clammy. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19, and expired on 3/5/20. 7). Resident #124 admitted to facility on 5/20/19 with diagnoses of COPD, Acute Respire Failure, DM, CHF, and A-fib. Resident was transferred to the hospital on 2/27/20 with shortness of breath. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired on 3/1/20. 8). Resident #125 admitted to facility on 2/19/2020 diagnoses of CHF, Pneumonia (PNA), and COPD. Resident was transferred to the hospital on 2/27/20 with respiratory distress. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired on 3/4/2020. 9). Resident #126 admitted to the facility on 1/28/2020 with diagnosis of CHF, Diabetes (DM) and Atrial Fibrillation (A fib). Resident was transferred to the hospital on 2/28/20 increase confusion. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with COVID-19 and expired on 2/29/20. 10). Resident #127 admitted to facility on 1/19/2020 with diagnoses of COPD, CHF and PNA. Resident was transferred to the hospital on 2/28/20 with respiratory distress. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 44 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 44 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 COVID-19 and expired on 3/1/20. 11). Resident #128 admitted to facility on 11/1/2019 with diagnoses of CHF, and Respiratory Failure. Resident was transferred to the hospital on 3/2/20. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired on 3/2/20. 12). Resident #129 admitted to facility on 2/24/2020 with diagnoses of CHF, and PNA. Resident was transferred to the hospital on 3/2/20 with abnormal vital signs. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident tested positive for COVID-19 and expired on 3/3/20. 13). Resident #130 admitted to facility on 6/4/2015 with diagnosis of Heart Failure, PNA. Resident was transferred to the hospital on 3/2/2020. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated that later the resident test for COVID-19 with pending results and expired on 3/5/20. 14). Resident #131 admitted to facility on 09/11/2019 with diagnoses of Urinary Tract Infection, and Pneumonia. The Resident was transferred to the hospital on 03/04/2020 with elevated temperature, diaphoretic, and wheezing. Review of the Hospitalization Tracking Form Transfer since 2/19 reflects transfers from 2/3/20 - 3/7/20 indicated resident expired on 03/04/20. The last medical provider evaluation was dated 02/28/2020. During an interview on 03/07/2020 at 12:35 PM with the IP Nurse she acknowledged having concerns and seeing a cluster with respiratory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 45 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 45 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 infections occurring in the facility on approximately 02/12/2020 and had a discussion with MP1. The IP Nurse stated "I did not consider calling the Department of Health because it was Flu season and the residents at the facility commonly have Pneumonia. The residents were being treated with antibiotics by the medical providers and being tested for Rapid Flu ". Additionally she communicated the respiratory infection concerns with the facility leadership on 02/26/2020. During further interview, she denied being instructed or directed by anyone to contact the Department of Health prior to 02/26/2020. She also confirmed having concerns about the respiratory infections, but did not considered reviewing the facility policy in regard to outbreaks. She confirmed that the Director of Nursing (DON) was the person providing oversight for the Infection Control Program (ICP) and served as the back-up person for the IP Nurse. The former DON was not available for an interview. On 03/08/2020 near 3:00 PM during the interview with Medical Provider 1 (MP1) she acknowledged seeing an unusual occurrence of a respiratory illness occurring within the facility starting near 02/19/2020. On or near that date (02/19/2020) three additional facility residents had pneumonia, cough and fever. She further indicated Medical Provider 2 (MP2), the supervisor of MP1, and the Infection Preventionist (IP) Nurse were informed of her suspicions and advised IP Nurse to call the Department of Health. MP1 also communicated with professional colleagues regarding any atypical (not normal) illnesses that they may be seeing or treating in the community; no atypical illnesses had been identified. MP1 explained having another discussion with the IP Nurse in regards to the atypical respiratory illness. By or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 46 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 46 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 near 02/23/2020 six more residents were having respiratory illness symptoms. MP1 indicated she had been consulting with MP2 on a case by case basis regarding residents that may be having issues or concerns. During further interview on 03/11/2020 it was revealed that on 02/26/2020 during a collaborative discussion with the MP2, the IP Nurse and Leadership the facility finally decided that the Department of Health needed to be notified. COVID-19 testing was initiated on 02/26/2020 and facility admissions were stopped. On 02/28/2020 near 11:30 PM the facility was informed the test results were positive for COVID-19. On 03/08/2020 at 2:30 PM during an interview with Medical Provider 2 it was validated that he was the primary care provider for greater than nighty percent of the residents at the facility and that he was also the Medical Director. He concurred with all the interview comments shared by MP1. He further validated there was an atypical respiratory illness occurring within the facility, that he was in agreement with the notification to the Department of Health and the last time he was on site was 03/02/2020. During an interview on 03/08/2020 at 3:15 PM the Executive Director (ED) validated that MP2 was the primary care provider of greater than 90% of the facility residents and that he was also the Medical Director for the facility. The Executive Director confirmed that she was not informed of any respiratory infections concerns within the facility until 02/26/2020. She further explained that on 02/26/2020 the MP1, MP2 and IP Nurse discussed calling the Department of Health, which was done by the IP Nurse. The ED clarified that the Hospitalization Tracking Form was being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 47 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 47 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 updated daily by the facility when they recieve the updates from the hospital. Review of facility policy on 03/08/2020 titled "Infection Prevention and Control Program (IPCP) and Plan - Outbreak Control and Management "last revised on 03/04/2020 and it revealed: Purpose Outbreak surveillance and controls should be considered a high priority of Infection Prevention and Control. (IPC). An outbreak is an occurrence of more cases than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. For example: Policy "If an outbreak is identified, the facility must: Take the appropriate steps to diagnose and manage cases, implement appropriate precautions, and prevent further transmission of the disease as well as documentation of follow-up activities in response; and comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. The approach of investigating an outbreak includes but is not limited to: Determining if an outbreak has occurred Developing a case definition Case finding Analyzing the outbreak Formulating a hypothesis regarding the mechanism of transmission Designating control measures Evaluating control measures During a record review on 3/12/2020 of the facility Quality Assurance & Performance Improvement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 48 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 48 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 (QAPI) monthly meeting minute it reveals that the facility conducted a meeting on 01/27/2019 and the IP Nurse attended the meeting, but the Medical Director or representative was not in attendance. Additionally no infection control issues or concerns were discussed. On 02/19/2020 another QAPI meeting was conducted the IP nurse nor the Medical Director or was not in attendance. Further review of the QAPI meeting agenda does not include any discussions of the Facility Acquired Infections in relations to the eight Pneumonia and Lower respiratory concerns. 2). On 03/07/2020 near 1:00 PM multiple interviews and observations occurred within the facility. Those being observed or interviewed were direct care facility staff, other assisting staff and ancillary housekeeping/laundry staff. Random separate interviews occurred with 3 facility Certified Nursing Assistants (CNA) and 1 Federal agency staff. a). Facility CNA1 reported he had worked for the facility for approximately 15 years. He stated that if he need to clean/sanitize any item that he would use the Sani-Cloth Bleach disinfecting wipes. When questioned if he had received training on the use of the Sani-Cloth Bleach wipes he stated "NO". When questioned regarding the amount of time the item being cleaned needed to remain wet for the sanitizing properties to be effective he stated "I don 't know". b). Facility CNA2 reported she had worked for the facility for the past 4 years. She stated if she had to clean or disinfect any item she would use the Sani-Cloth Bleach disinfecting wipes. When questioned if she had received training on the use of the Sani-Cloth Bleach wipes she stated "NO". When questioned regarding the amount of time FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 49 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 49 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 the item being cleaned needed to remain wet for the sanitizing properties to be effective she "I am not sure. " c). Agency staff 2 was interviewed on that same dated regarding the use of the Sani-Cloth Bleach wipes. He stated he "I am not sure" what the wet contact time is for the disinfecting wipes. He denied receiving training on the use of the product. During an interview on 03/07/2020 at 12:35 PM with Adm Staff 3 she stated the facility was under droplet precautions. In addition acknowledged that the Staff were educated on the use of the Santi wipes during the month of February. The facility expectation is for the staff to use the Santi wipe according to the manufacture recommendations. On 3/7/2020 at 9:00 AM Laundry Staff 1 was observed delivering residents clothing to multiple rooms with a droplet precaution signs at the door. Later that same day, during further investigation she acknowledged that she did not change her gown, mask or gloves as she delivered the clothing from room to room. During a re-interview on 3/08/2020 she stated since she was not a direct care staff, she thought "She did not need to change her PPE." During an interview on 03/08/2020 at 4:00 PM with Adm Staff 2 she indicated that the Laundry Staff 1 should have removed her disposable gown, gloves and mask before leaving each room. Review of facility policy on 03/08/2020 titled "Infection Prevention and Control Program (IPCP) and Plan revised on 03/04/2020 reveals: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 50 of 51 PRINTED: 04/04/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 505334 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101 NORTHEAST 120TH STREET LIFE CARE CENTER OF KIRKLAND (X4) ID PREFIX TAG 03/16/2020 KIRKLAND, WA 98034 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 50 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 Droplet Precautions: Droplet precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets larger than 5 um in size) containing microorganism. Donning and Removal of Personal Protective Equipment: Removal of PPE at doorway before leaving resident room or in anteroom On 03/13/2020 near 3:45 PM, the Executive Director was informed of an immediate jeopardy situation related to failed infection control surveillance with identifying a respiratory infection and PNA outbreak which began on 02/12/2020. In addition the failure to report the outbreak to the Department of Health timely. The facility needs to ensure once it identifies outbreaks, it will timely notify the Department of Health and get guidance and assistance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T5T611 Facility ID: WA19100 If continuation sheet Page 51 of 51