Avamere Transitional Care Of Puget Sound

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to implement the appropriate use of transmission-based precautions (TBP) for 1 of 4 hallways (North front) when reviewed for TBP. This failure placed residents and staff at an increased risk for communicable diseases and a decreased quality of life. Findings included .Observation on 09/23/2025 at 6:15 AM showed room [ROOM NUMBER] with a TBP sign posted on the door. The sign instructed staff to put on an N95 mask, eye protection, a gown and gloves when entering the room and to keep the door closed. Observation and interview on 09/23/2025 at 6:15 AM showed Staff H, Certified Nursing Assistant (CNA), entered room [ROOM NUMBER] in a surgical mask. Staff H did not put on an N95 mask, gown or eye protection. Staff H remained in the room for eight minutes and exited the room with a bag of soiled linens still wearing the surgical mask. Staff H stated the resident in room [ROOM NUMBER] had Covid-19 (a highly contagious respiratory virus). Observation on 09/23/2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and report an allegation of abuse for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed all residents at risk for unidentified and ongoing abuse/neglect and lack of protection from abuse.Findings included .Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that facilities are to report all staff-to-resident allegations of abuse, neglect, mistreatment, sexual and/or physical abuse/assault to the State hotline, report to law enforcement and to document on the State incident reporting log within five days. Review of the facility's policy titled, Abuse and Neglect - Clinical Protocol, undated and provided to surveyor on 09/15/2025, under Assessment and Recognition, documented, The nurse will assess the individual and document related findings. Assessment data will include injury assessment (bleeding, bruising, deformity, swelling, etc.), pain assessment, current behavior, . vital signs .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure that the correct texture of food was served to a resident with a prescribed therapeutic diet for 1 of 1 residents (Resident 1) reviewed for prescribed therapeutic diets. This failure placed the resident at risk for choking, aspiration pneumonia (a lung infection that occurs when food, liquids, or other substances are inhaled into the lungs instead of being swallowed), hospitalization, and a decreased quality of life. The facility had corrected the above deficiency prior to the complaint survey, and it is constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of the admission minimum data set (MDS, a required assessment tool), dated 03/09/2025 showed Resident 1 admitted to the facility on [DATE] and had a diagnosis of dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to investigate an unexpected death to rule out mistreatment for 1 of 4 sampled residents (Resident 52) and failed to investigate an allegation of abuse for 1 of 4 sampled residents (Resident 114) when reviewed for Abuse. This failure placed residents at risk of abuse, neglect, avoidable death, retaliation from staff, and a diminished quality of life. Findings included . Resident 52 Review of the electronic health record (EHR) showed that Resident 52 admitted to the facility on [DATE], discharged on [DATE] and had a diagnosis of essential hypertension (high blood pressure). Review showed that Resident 52 unexpectedly died at the facility. Review of provider's orders showed Resident 52 received amlodipine for high blood pressure to be held if the systolic blood pressure (SBP, top number in a blood pressure reading) was less than 100. Review of the [DATE] medication administrator record (MAR) showed Resident 52 had a blood pressure of 92/49 and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 2 of 12 sampled residents (Residents 107 and 307) reviewed for resident assessment. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 107 Resident 107 admitted to the facility on [DATE] with diagnoses of congestive heart failure and atrial fibrillation (abnormal fluttering heartbeat). The resident was able to make needs known. Review of the admission nursing database assessment dated [DATE] showed the resident reported pain level at a 7 out of 10 daily. Review of the medication administration record showed the resident received tramadol (a narcotic pain medication) four times between 07/17/2024 and 07/21/2024 for a reported pain level between 6 out of 10 and 8 out of 10. Review or the providers orders showed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 12 sampled residents (Residents 113, 44, 108, and 306) reviewed for Care Plan. This failure placed residents at risk for unidentified outcomes or goals, inconsistent or lack of interventions, and diminished quality of life. Findings included . Resident 113 Resident 113 was admitted to the facility on [DATE] with diagnoses that included a recent fall with complications, which resulted in orthopedic surgery to the right knee with external fixation (surgery that used pins and wires to keep bones from moving), and surgery to the right leg. The five-day admission Minimum Data Set (MDS), an assessment tool, dated 07/22/2024, showed the resident was cognitively intact, required the use of a wheelchair due to recent surgery, and had not been diagnosed previously with any mental health conditions. Observation and interview on 07/25/2024 at 1:54 PM showed Resident 113 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Somal, [NAME] Based on observation, interview and record review, the facility failed to follow provider's orders, ensure medications had safe monitoring and hold parameters, and notify the provider of changes in condition and medication errors for 8 of 10 sampled residents (Residents 52, 44, 206, 8, 112, 1, 107, and 9) when reviewed for Quality of Care. These failures placed residents at risk of decline in condition, lack of timely interventions to prevent death, avoidable side effects, and a diminished quality of life. Findings included . <Blood Pressure Medication Administration> Review of a policy titled Change in a Resident's Condition or Status, revised February 2021, showed the nurse would notify the resident's provider when there had been an accident or incident involving the resident or significant change in the resident's physical/emotional/mental condition. Review of a policy titled Blood Pressure, Measuring, revised [DATE], showed hypotension (low blood pressure) was defined as blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide a working doorbell for handicap residents visiting the courtyard for 1 of 1 courtyard reviewed for accident hazards. This failure placed residents at risk for accidents, anxiety, feelings of entrapment, and a diminished quality of life. Findings included . During an interview on 07/25/2024 at 1:55 PM, Resident 113 stated both ends of the courtyard had doors that were too heavy for them to open, and that there was a button that no one responded to. They stated the facility was not offering any handicap options for residents, and they were stuck in the courtyard until a staff member came by. Observation on 07/25/2024 showed the courtyard had doors at each end which were heavy and opened into the courtyard. Observation showed a doorbell next to each door. Observation showed pressing the doorbells did not result in staff response. During an interview on 07/30/2024 at 2:49 PM, Staff N, Maintenance Director, stated they were aware the doorbells in the courtyard did not function and was unsure for how long they had not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide nonpharmacological interventions before administrating as needed pain medications for 2 of 5 sampled residents (Residents 44 and 1) when reviewed for unnecessary medications. This failure placed residents at risk of taking unnecessary medications, experiencing avoidable side effects, and a diminished quality of life. Findings included . Resident 44 Review showed the Resident 44 admitted to the facility on [DATE] with a diagnosis of essential hypertension (high blood pressure). Review of provider's orders showed orders for oxycodone (a narcotic pain medication) and acetaminophen (a pain medication) to be provided as needed (PRN). Review did not show an order for nonpharmacological interventions (NPI, pain interventions that do not use medication, e.g. massage or repositioning). Review of the July 2024 medication administration record (MAR) showed that Resident 44 received oxycodone four times and acetaminophen three times. Review did not show…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in 2 of 2 medication rooms (North and South medication rooms) and 2 of 2 medication carts (South High and South Low) when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective medications, risk for drug diversion and diminished quality of life. Findings included . Review of the facility's policy Nursing Care Center Pharmacy Policy and Procedure Manual, dated 2007, showed controlled substances (addictive medications) stored in refrigerators should be secured in a separately locked, permanently affixed compartment. Medications requiring refrigeration were to be kept between temperatures of 36 Fahrenheit (F) and 46F. The temperature of refrigerators that stored vaccines should be monitored and recorded twice a day. If using a temperature monitoring device (TMD, a digital data logger) that did not record the minimal and maximal temperatures each day, the facility should document current temperatures twice a day at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 months (April, May and June 2024) reviewed for Infection Control. The facility also failed to implement transmission-based precautions (TBP) for 1 of 2 halls (200 hall) reviewed for TBP. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life. Findings included . Review of the facility policy titled Infection Prevention Control Program (IPCP), revised October 2018, showed that the IPCP would be coordinated and overseen by an infection preventionist (IP), and the facility would follow established general and disease specific guidelines such as those of the Center for Disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the infection prevention and control program (IPCP) was overseen by a qualified individual with the time and training necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as Quality Assurance and Performance Improvement (QAPI) for 1 of 1 infection control preventionist (ICP, Staff Z) reviewed for infection preventionist qualifications. This failure placed residents, family members and staff at risk of contracting communicable diseases and a decreased quality of life. Findings included . Review of the facility policy titled Infection Prevention Control Program, revised October 2018, showed that the IPCP would be coordinated and overseen by an infection preventionist. During an interview on 07/30/2024 at 10:17 AM, Staff CC, Registered Nurse/Resident Care Manager, stated the expectation for the infection preventionist was to track vaccines, do rounds and make sure appropriate isolation precautions were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide education on the benefits and potential side effects of the Covid-19 vaccination prior to offering the vaccine for 4 of 5 sampled residents (Residents 14, 15, 20 and 34) when reviewed for vaccinations. This failure placed residents and their representatives at risk of not being given the opportunity to make an informed decision regarding their medical care, potential complications of a communicable disease, and a decreased quality of life. Findings included . Resident 14 was admitted to the facility on [DATE]. Review of the electronic health record (EHR) showed the resident declined the Covid-19 vaccine on 05/22/2024. There was no documentation found that the resident or their representative was educated on the benefits or potential side effects prior to offering the vaccine. Resident 15 was admitted to the facility on [DATE]. Review of the EHR showed the resident declined the Covid-19 vaccine on 01/08/2024 There was no documentation found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party and/or to properly notify the Office of State Long-Term Care Ombudsmen (an advocacy group for residents in a nursing home) of discharges to the hospital for 2 of 2 residents (Residents 22, and 75) reviewed for Hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and ensure that the Offices of the State Long-Term-Care Ombudsmen was aware of the facility practices and activities related to transfers and discharges. Findings included . Resident 22 Review of the discharge Minimum Data Set assessment (MDS) dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 22 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed-hold notice in writing, at the time of transfer/discharge to the hospital and/or within 24 hours of transfer/discharge to the hospital for 2 of 2 residents (Residents 22 and 75) reviewed for Hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included . Resident 22 During an interview on 08/16/2023 at 10:02 AM, Resident 22 stated that they did not recall ever being offered a bed hold. Review of the discharge Minimum Data Set assessment (MDS) dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 22 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the discharge MDS dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 22 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and/or implement comprehensive person-centered care plans (CPs) for 5 of 12 sampled residents (Residents 22, 24, 69, 18, and 130) whose CPs were reviewed. Failure to develop and implement CPs that were individualized, and accurately reflected resident care needs related to edema/swelling, nail care, use of blood thinning medications, and falls, placed residents at risk for unmet care needs and potential negative outcomes. Findings Included . Resident 22 Review of the 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 22 readmitted to the facility on [DATE] with a diagnosis of lymphedema (swelling due to buildup of fluid in the body) and was able to make needs known. It further showed that Resident 22 received diuretics (medication that help reduce fluid buildup in the body). Review of Resident 22's physician order dated 08/14/2023 showed that Resident 22 was prescribed Torsemide (a diuretic medication) to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary goods and services to prevent development of avoidable pressure ulcers (PU), and/or promote healing of identified PUs for 2 of 3 residents (Resident 177 and 24) reviewed for pressure injuries. The failure to ensure assessment and ongoing monitoring of PUs were conducted, placed the residents at risk for unidentified wound development/decline, a delay in treatment, infection, and other potential negative outcomes. Resident 177 Resident 177 admitted to the facility on [DATE]. According to the 08/14/2023 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, required extensive assistance with bed mobility, and demonstrated no behaviors or rejection of care. Resident 177 was assessed with three Stage 3 PUs (Full thickness tissue loss) with one Stage 3 identified as present upon admission. Review of Resident 177's 08/09/2023 admission nursing assessment, showed the resident admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to consistently maintain the medication refrigerator temperature log in 2 of 2 medication rooms (North and South) reviewed for medication storage. This failure placed the residents and/or staff at risk for receiving compromised or ineffective medications with unknown potency. Findings included . Review of the facility's policy titled, Storage of Medication, dated 2007, showed that medications requiring refrigeration or temperatures between 36 degrees Fahrenheit (F) and 46 degrees F were to be kept in a refrigerator with a thermometer to allow temperature monitoring. It further showed, A temperature log or tracking mechanism is maintained to verify the temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. North Medication Room Review of the refrigerator temperature log sheet from 08/01/2023 - 08/16/2023 with AM (morning) and PM (evening) time sections for documentation, showed that there were missing refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by completing the collection and analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for three of three months (May, June, and July 2023) reviewed for Infection Control. Also, the Facility failed to implement recommended control measures for an active Covid-19 disease outbreak for 07/16/2023 through 08/18/2023 and failed to implement the facility's water management program. These failures placed residents, visitors, and staff at risk for communicable diseases, related complications, and a decreased quality of life. Findings included . Tracking and trending Review of the facility's policy titled infection prevention and control program, dated October 2018 showed outcome surveillance (incidence and prevalence of healthcare acquired infections) was used as measures of the infection prevention and control program (IPCP)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program for 1 of 1 resident (Resident 61) reviewed for antibiotic use and to promote appropriate use of antibiotics and reduce the risk of antibiotic resistant organisms and unnecessary antibiotic use for 3 of 3 months (May, June, and July 2023) Reviewed for infection control. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics, and a decreased quality of life. Findings included . Review of the facility policy titled Antibiotic Stewardship - Review and surveillance of antibiotic use and outcomes revised December 2016 showed Antibiotic usage and outcome data will be collected and documented on a facility-approved antibiotic surveillance tracking form to include unit and room number, date symptoms appeared, pathogen identified, site of infection, date of culture, and stop date. Also, that the infection preventionist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of abuse to the State Agency within 24 hours and to log the incident in the facility's reporting log as required for 2 of 3 residents (Resident 230) when reviewed for abuse/neglect and/or falls. In addition, the facility failed to report Covid-19 (a highly communicable respiratory infection) cases for 1 of 1 outbreak (Dated 07/16/2023 - 08/18/2023) to the State Agency within 24 hours and log the incident in the facility's reporting log when reviewed for Infection Control. These failures placed the residents at risk for potential unrecognized abuse, spread of infection, delayed investigation, delayed corrective actions, recurrence of the incidents and a diminished quality of life. Findings included . Resident 230 Review of the discharge Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 230 admitted to the facility on [DATE] and had a planned discharge to the community on 08/03/2023 with return not anticipated. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 177 Resident 177 admitted to the facility on [DATE]. Review of the resident's physician's orders showed a 08/09/2023 order to administer daptomycin (an antibiotic medication) intravenously (IV) every 24-hours for left upper extremity cellulitis (bacterial skin infection.) Review of Resident 177's 08/14/2023 admission MDS showed the resident received no IV medications during the assessment period (08/08/2023- 08/14/2023.) Review of Resident 177 's August 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed the resident was administered IV daptomycin on 08/09/2023, 08/11/2023, 08/12/2023 and 08/14/2023. During an interview on 08/17/2023 at 11:03 AM, Staff C, Resident Care Manager, stated that Resident 177s MDS was inaccurate and needed to be corrected to reflect the administration of IV medication. Reference WAC 388-97-1000 (1)(b) Based on observation, interview and record review, the facility failed to accurately assess 4 of 12 residents (Residents 22, 55, 75 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessment was accurately completed for 1 of 5 residents (Resident 22) reviewed for Unnecessary Medications. This failure placed the resident at risk for unidentified mental health care needs and a diminished quality of life. Findings included . Review of the 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 22 readmitted to the facility on [DATE] with a diagnosis of depression. Review of Resident 22's electronic health record (EHR) on 08/16/2023 showed that the resident had a physician order dated 06/28/2023 for Mirtazapine (an antidepressant medication) to be given at bedtime for depression. It further showed that Resident 22 had an order dated 07/25/2023 for Duloxetine (an antidepressant medication) to be given in the morning for depression, anxiety, and fibromyalgia (a disorder that causes pain and tenderness throughout the body). Review of Resident 22's PASRR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet residents immediate care needs for 1 of 9 residents reviewed (Resident 177) who had recently admitted to the facility. This failure placed the resident at risk for medical complications, unmet care needs and a diminished quality of life. Findings included . Resident 177 Resident 177 admitted to the facility on [DATE]. Review of Resident 177's 08/09/2023 admission nursing assessment showed the resident had intravenous (IV) access via a Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) to the right upper arm, had a Stage 3 (Full thickness tissue loss) pressure ulcer (PU) to the sacrum, and a Stage I PU (non-blanchable redness over a bony prominence) to their left heel. On 08/16/2023 at 8:56 AM, Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 3 of 15 residents (Residents 55, 72 and 26) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . Resident 55 Resident 55 admitted to the facility on [DATE]. Review of Resident 55's Physician's orders showed a 07/12/2023 order to apply Tubigrip (a tubular bandage containing elastic fibers that provides compression) to the left lower extremity in the AM and remove at bedtime. Review of Resident 55's activities of daily living CP, initiated 06/29/2023, showed staff were directed to apply TED hose (stockings that provide graduated compression) to the resident's lower extremities in the AM and remove at bedtime, for edema management. During an interview on 08/17/2023 at 10:57 AM, Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 15 sample residents (Residents 177, 55 and 26) reviewed. This failure of the facility to obtain, follow, implement and/or clarify physicians' orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication and treatment errors, and other potential adverse outcomes. Findings included . Resident 177 Resident 177 admitted to the facility on [DATE]. Review of the resident's physician's orders showed Resident 177 had a 08/10/2023 order for oxycodone 5mg every four hours as needed for a pain level of 5-7 out of 10, and oxycodone 10 mg every four hours as needed for a pain level of 8-10 out of 10. Review of Resident 177's August 2023 MAR showed on the following occasions the resident had a pain levels between 5-7 and was administered 10 mg of oxycodone instead of 5 mgs as ordered: on 08/15/2023 at 4:55 AM with a pain level of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one of one resident (Resident 24) reviewed for ADLs. Failure to provide Resident 24 who was dependent on staff for grooming placed the resident at risk for decreased quality of care and diminished quality of life. Resident 24 admitted to the facility on [DATE] with a diagnosis of stroke with hemiplegia (paralysis of one side of the body). Resident 24's quarterly Minimum Data Set assessment (MDS), dated [DATE], showed the resident required extensive assistance with dressing and personal hygiene. Observation and interview on 08/15/2023 at 11:44 AM, showed Resident 24 lying in bed with short hair above their ears. Resident 24 stated that they were unhappy with the recent haircut they had received 2 days prior. Resident 24 further stated that their hair had become so matted in the back of their head it required the facility beautician to cut it. Resident 24 stated they were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 69 Observation and interview on 08/15/2023 at 12:32 PM, showed Resident 69 sat in their wheelchair next to their bed with their spouse. Resident 69 had bruising noted to both of their forearms and the resident stated that they bruise very easily. Review of Resident 69's Electronic Health Record on 08/15/2023 at 12:37 PM, showed an order for an anticoagulant (medication the keeps the blood from clotting) every evening for 30 days with a start date of 07/28/2023. Review on 08/16/2023 at 3:15 PM of Resident 69s Electronic Health Record showed an order to monitor/document/report to the provider any signs or symptoms of anticoagulant complications to include bruising and document a plus sign if present and a negative sign if not present. Review on 08/16/2023 at 3:22 PM of Resident 69's Treatment Administration Record (TAR) for 08/01/2023 through 08/16/2023 showed check marks for each shift, no plus or negative signs were used. Review of Resident 69s Electronic Health Record on 08/16/2023 at 3:22PM, showed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe resident environment was maintained, free of accident hazards, for 3 of 4 residents (Residents 177 and 31) reviewed for accidents. The failure to ensure resident equipment was safe, functional and in good repair, placed residents at risk for avoidable falls, fractures, pain and other potential negative outcomes. Findings included . Resident 177 During an interview on 08/16/2023 at 8:59 AM, Resident 177 reported that the footrests on their wheelchair were set to different heights and the left footrest would not lock into the straight position. According to Resident 17, when they pushed their feet down on the footrests to reposition themselves in the wheelchair, the offset height of the footrests caused unequal application of pressure and resulted in their wheelchair tilting forward/ forward right or the left footrest would swing out to the left. Resident 177 indicated this caused them lose balance and plop back down onto the wheelchair.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 1 resident (Resident 23) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received, was reconciled with the amount they were ordered to receive. This prevented staff from identifying that the facility consistently administered Resident 23 less than the ordered amount of enteral formula and placed the resident at risk for inadequate nutrition, hydration, and other adverse outcomes. Findings included . Resident 23 Resident 23 admitted to the facility on [DATE]. According to the 07/31/2023 admission Minimum Data Set (MDS, an assessment tool), the resident had diagnoses of malnutrition (occurs when the body doesn't get enough…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 2 residents (Resident 177) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Resident 177 Resident 177 admitted to the facility on [DATE]. Review of the resident's physician's orders showed a 08/09/2023 order to administer IV antibiotics (antibacterial medication) via PICC every 24-hours,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 1 of 5 residents (Resident 22) reviewed for Unnecessary Medication. Failure to provide non-pharmacological (approaches, therapies, or treatments that do not involve drugs) interventions prior to giving as needed pain medications placed residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life. Findings included . Review of the 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 22 readmitted to the facility on [DATE] with diagnoses to include fibromyalgia (a disorder that causes pain and tenderness throughout the body) and was able to make needs known. It further showed that Resident 22 received opioids (a class of drugs used to reduce pain). Review of the July 2023 Medication Administration Record (MAR) from 07/01/2023 - 07/31/2023 showed that Resident 22 had an order with a start date of 06/05/2023 for acetaminophen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary antidepressant medications for 1 of 5 residents (Residents 22) reviewed for Unnecessary Medications. Failure to ensure Resident 22's behaviors were consistently monitored and documented placed the resident at risk for receiving unnecessary medications, adverse side effects and poor quality of life. Findings included . Resident 22 Review of the 5-Day Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 22 readmitted to the facility on [DATE] with a diagnosis of depression. It further showed that Resident 22 received antidepressant medication and was able to make needs known. Review of Resident 22's electronic health record (EHR) on 08/16/2023 showed that the resident had a physician order dated 06/28/2023 for Mirtazapine (an antidepressant medication) to be given at bedtime for depression. It further showed that Resident 22 had an order dated 07/25/2023 for Duloxetine (an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.