Avamere Rehabilitation of Burien

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 (Resident 21, 24, & 64) of 4 residents reviewed for dental services received the care and services they required to preserve their dental health. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to obtain and/or renew guardianship papers, and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 4 of 7 residents (Residents 42, 78, 3, & 27) reviewed for guardianship/advance directives. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care.

Inspectors wroteBased on record review and interview, the facility failed to provide required liability notices for 1 of 3 residents (Resident 83) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage (NOMNC - a notification informing Medicare beneficiaries that their covered services will be terminated and provides information on their appeal rights) before Resident 83 was discharged from the facility, placed the resident at risk for not fully understanding their Medicare benefits and appeal rights.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for 5 of 5 units. The failure to ensure residents' windows were free of missing blind panels, resident rooms were free of wall scrapes, and handrails in hallways were in good repair left residents at risk for a diminished sense of privacy, and a less than homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled residents (Resident 44) reviewed for grievances. This failure placed residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure level I Preadmission Screening and Resident Reviews (PASRRs - a mental health screening required to be completed prior to admission to a skilled nursing facility) were accurate prior to admission for 2 of 7 residents (Residents 50 & 133). These failures placed residents at risk for inappropriate placement, unmet mental health needs, and a diminished quality of life.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents were offered the opportunity to participate in a care conference for 2 (Residents 24 & 183) of 21 sample residents whose Care Plans (CPs) were reviewed, and failed to ensure resident CPs were updated as needed for 2 (Residents 22 & 48) of 21 sample residents. These failures placed residents at risk for unmet care needs, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents with Activities of Daily Living (ADLs - personal hygiene, grooming, bathing, eating etc.) for 2 of 6 residents (Residents 70 & 44) reviewed who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Resident 24) reviewed for vision and hearing services received the care and services they required to maintain their vision. The failure to provide follow through with a needed follow up appointment placed Resident 24 at risk for worsening vision, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure mechanical lifts (lift devices used to help transfer residents who cannot bear their own weight from surface to surface) were maintained in safe working order for 2 of 2 mechanical lifts. The failure left residents at risk for unsafe transfers, falls, and injury. Failures included . <Facility Policy> According to the facility's undated Equipment Safety and Functionality Expectations policy, staff must inspect all equipment prior to use. The policy showed for mechanical lifts, safety clips must be present and attached securely prior to use, and wheels function and can lock. <Resident Council> During a Resident Council meeting on 05/16/2025 at 1:08 PM, Resident 35 expressed a concern with the facility's mechanical lifts. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to reassess the resident for bowel and bladder needs or provide the necessary care and services to ensure bowel and bladder continence was improved for 1 of 2 residents (Resident 47) reviewed for bowel and bladder needs. This failure left the resident at risk for unmet care needs, avoidable incontinence, and embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored, returned, and/or discarded when expired for 1 of 3 medication carts (Middle Medication Cart) and 1 of 1 medication rooms observed. The failure to ensure unneeded medications were returned to the pharmacy upon resident discharge and to ensure medications carts were secured when not in use by a nurse placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff followed contact precautions (a type of isolation precaution used to prevent the spread of infections transmitted by direct or indirect contact) for 1 resident (Resident 183) of 1 reviewed for contact precautions; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear and gowns used to prevent exposure to infectious materials) for one supplemental Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in long-term care settings) room (room [ROOM NUMBER]); ensure staff used appropriate Hand Hygiene (Staff R); ensure the facility was free of uncleanable surfaces; ensure urinals (plastic bottles used to pass urine for resident with mobility issues) were sanitary. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect resident's rights to be free from abuse when facility policies and procedures to monitor and identify psychological harm were not implemented for 1 of 3 residents (Resident 2) reviewed for abuse. Resident 2 experienced psychological harm and fear when they were verbally abused by a staff member. This failure placed all residents at risk of psychological abuse, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to follow transfer and discharge requirements for 2 of 2 residents (Residents 4 & 3) reviewed for transfer and discharge requirements. The failure to identify a resident's inability to make complex decisions, coordinate care with the Resident Representative (RR), the physician, and the receiving hospital and provide adequate documents for a safe care transition, placed cognitively impaired residents at risk for harm, unmet care needs, delay in care, lack of advocacy from their RR, and diminished quality of life. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (Resident 3), reviewed for medication administration was free from a significant medication error. Resident 3 experienced harm when a staff nurse, who had not completed the facility required competency review for medication administration, did not follow standard practices for medication administration when they administered potent medications belonging to another resident to Resident 3 which resulted in the resident entering a comatose state (a life-threatening change of condition), emergency transfer to the hospital, and admission to the intensive care unit. These failures placed all residents at risk of harm, significant injury, and potential death.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely laboratory (lab) services to 2 of 3 residents (Resident 1 & Resident 6) reviewed for lab services. The failure to ensure adequate lab supplies to allow nursing staff to obtain timely urine samples for diagnosis and treatment of infections placed residents at risk of illness, hospitalization, and diminished quality of life.

Inspectors wrote<Resident 85> According to the 02/05/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 85 had diagnoses including heart failure. This MDS showed Resident 85 used an AC during the assessment period. Observations on 02/20/2024 at 11:18 AM, and on 02/22/2024 at 10:29 AM showed Resident 85 had a faded bruise on their right hand. Resident 85 stated they had bruises on their hand for a while related to the AC medication. Review of the February 2024 Medication Administration Record (MAR) showed Resident 85 received the AC medication as ordered for an abnormal heartbeat. Review of the CP showed there was no CP for AC medication for Resident 85. In an interview on 02/26/2024 at 1:56 PM, Staff G (RCM) reviewed Resident 85's record and stated there should be a PO from the provider to monitor Resident 85 for bleeding and bruises but staff did not obtain one. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 5 sampled residents (Residents 32, 10, & 17) reviewed for Pressure Ulcers (PUs)/Pressure Injuries (PIs), received prescribed pressure reducing measures and repositioning on a consistent basis. Resident's 32 and 10 experienced harm when they developed facility acquired PUs. This failure placed all residents at risk for PI/PU development, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision was provided to residents at the care level they were assessed to require for 2 of 3 residents (Resident 66, & 31) reviewed for falls. Resident's 66, who had a change in condition and increased weakness, experienced harm when they fell when left unsupervised resulting in a fractured right hip and to Resident 31, who required extensive assistance from staff with toileting, was left on the toilet without supervision resulting in a fall with a skin tear and left foot fracture. These failures placed all residents at potential risk for avoidable falls, injuries, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nurse staff to provide and supervise care of residents as evidenced by information provided in a Resident/Surveyor interview, for 9 residents (Residents 10, 44, 29, 60, 32, 67, 63, 17, 240 & 7) interviewed, and 3 (Staff R, BB, & M) staff interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADLs) including showers, nail care and call light responses. Additionally, the aides from the Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct care staff absences resulting in the RNP's not being done for 3 of 9 residents (Residents 63, 17 & 44) reviewed for RNP.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared, stored, and served under sanitary conditions. Facility staff failed to: Label and date food after preparation, discard expired and spoiled foods; keep kitchen vents and fans free from dirt/dust build-up; maintain availability of running hot water in the handwashing sink; consistently perform hand hygiene when working in between areas in the kitchen; and prevent bare hand contact with ready to eat foods during food preparation. These failures contributed to an unsanitary kitchen environment and placed residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident and facility equipment was maintained and in safe operating conditions for 2 of 20 residents (Residents 7 & 60) whose mobility devices and environment were observed for safety. The facility failed to ensure: The call light cord remained intact (Resident 7); the Wheelchair (WC) tires were functional and properly inflated (Resident 20); and the dishwasher in the facility's main kitchen operated at the correct wash temperature it was specified to clean/sanitize resident dishes with according to manufacturer specifications. These failures left residents at risk for accidents, isolation, and other negative health outcomes. Failure to ensure the dishwasher maintained the appropriate temperature placed residents at risk for eating from unclean and/or inappropriately sanitized dishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 7 (Residents 77, 68, 17, 66, 10, 44, & 33) of 7 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for 10 of 20 residents (Resident's 31, 60, 80, 7, 32, 85, 44, 33, 66, & 10) whose CPs were reviewed. Failure to address the individualized care needs for each resident placed residents at risk for inconsistent and/or inadequate care, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 11 of 20 (Residents 31, 77, 29, 60, 32, 7, 17, 190, 191, 44, & 83) sample residents whose CPs were reviewed. The failure to update and/or revise CPs left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents with Activities of Daily Living (ADLs) for 8 of 11 residents (Residents 32, 67, 85, 60, 29, 77, 10, & 44) reviewed who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medical records were complete and accurate for 10 of 20 sample residents (Residents 190, 191, 83, 77, 49, 67, 85, 7, 75, & 31) whose resident records were reviewed. The facility failed to ensure the presence/use of medical devices were captured during initial admission assessment (Residents 190, 191, & 7), skin and wound evaluations identified the location of wounds (Residents 190), accurately document a resident's Activities of Daily Living (ADL) performance/ability (Resident 77), and complete daily skilled charting for Medicare (a type of payer source that provide skilled care benefits) residents as required (Residents 49, 190, 191, 67, 85, 7, 83, 75, & 31). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for 1 of 1 residents (Resident 7) reviewed for dignity concerns. This failure left Resident 7 with feelings of invalidity, and placed residents at risk for having low self-esteem, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the appropriate Advanced Directive (AD) in place for 3 (Residents 190, 191, & 29) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, and offered assistance to formulate an AD (Resident 190 & 29), obtain a copy of AD paperwork and have it readily available in the resident's record (Resident 191), and follow up to obtain guardianship (Resident 29). These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to ensure injuries of unknown origin was reported to the State Survey Agency (SSA) within the required timeframe for 2 of 6 sampled residents (Residents 10 & 66) reviewed for abuse/neglect. Failure to complete required reporting of incidents placed Resident's 10 & 66 at risk for repeated incidents and unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review the facility failed to initiate or thoroughly investigate incidents for a facility acquired pressure injury and unwitnessed falls with major injuries for 3 of 6 sampled residents (Resident 10, 66, & 31) reviewed for abuse/neglect. Facility failure to initiate an investigation for the pressure injury of unknown origin to Resident 10's toe, and failure to thoroughly investigate Resident's 66 and 31's falls with fractures placed all residents at risk for repeated incidents and unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 1 of 7 sample residents (Resident 77) and 1 closed record (Resident 68) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Minimum Data Sets (MDS - an assessment tool) were accurate and complete for 1 of 20 residents (Resident 7) whose MDS and Care Area Assessments (CAA) were reviewed. This failure placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a screening process for residents who have indicators of intellectual disability (ID), related disability (RD), or serious mental illness) assessments were accurate and revised for 2 (Residents 31 & 32) of 5 residents reviewed for PASRR. The failure to ensure PASRR screening was accurate and revised timely placed residents at risk for not receiving timely and necessary services to meet their mental health care needs and placed them at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline Care Plan (CP) within 48 hours of admission as required that documented resident-specific initial goals and treatment plans for 2 of 2 newly admitted residents (Residents 190 & 191) reviewed to ensure continuity of care upon admission. Failure to develop baseline CPs that identified the presence/use medical devices including an indwelling urianry catheter (a device that drained urine from the bladder) and non-removable splint/cast (Resident 191) placed the residents at risk for unmet care needs, potential complications, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were obtained for a Gastric tube (tube inserted through the abdomen into the stomach) and a medicated topical cream for 2 of 20 sampled residents (Resident 44 & 77) reviewed. These failures left residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 (Residents 17, 63, & 44) of 9 residents reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for a decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with indwelling urinary catheters (a device that drained urine from the bladder and into a collection bag) were provided catheter care consistent with professional standards of practice and post-catheter use monitoring was implemented for 2 of 3 residents (Residents 190 & 7) reviewed for indwelling urinary catheters and bladder function. These failures placed residents at risk for Urinary Tract Infection (UTI), undiagnosed urinary retention, dignity issues, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement personalized nutritional interventions that met resident needs or ensured residents consistently received supplemental fluids they were assessed to require for 1 of 2 residents (Resident 77) reviewed for hydration. These failures placed the residents at risk for dehydration, worsened nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 3 residents (Residents 83 & 67) reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to physician ordered flow rates (Resident 83 & 67) and maintain oxygen equipment (Resident 83) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 5 residents (Resident 190) reviewed for mood/behavior. The facility's failure to assess trauma history, develop, and implement nursing interventions placed Resident 14 and other residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their policy and procedures to ensure residents were assessed to be safe to use Bed Rails (BR) for 3 (Residents 60, 44, & 66) of 3 residents reviewed for BR's. Facility failure to attempt alternatives before implementing BR's, assess residents for safe use of BR's, or obtain informed consent for the use of BR's placed all residents at risk for harm or injury and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide social service intervention for 1 of 5 residents (Resident 32) reviewed for unnecessary medications and 5 (Residents 63, 17, 44, 60, & 31) of 5 residents reviewed who demonstrated the behavior of refusals. The failure to initiate further assessment and appropriate interventions when the resident answered positively to a self-harm question, placed the resident at risk for unmet care needs and self-harm. Failure to have a process for resident refusals and identify and seek ways to support residents needs related to refusals, placed residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure altered consistency liquids were provided and consistent with the resident's Care Plan (CP) for 1 of 2 residents (Resident 77) reviewed for hydration. This failure placed the resident at risk for aspiration (accidental inhalation of food or liquid into the airways), dehydration, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 2 garbage dumpsters and 1 of 1 recycling dumpster reviewed and inspected for outdoor garbage storage area were properly covered with a lid and the surrounding areas were kept clean as required. This failure placed the facility at risk of attracting bugs, rodents, and other disease-carrying germs/bacteria that could reproduce and grow and placed the residents at risk for acquiring these diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 1 of 3 residents (Resident 31) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent placing residents at risk for facility acquired infections. The facility staff failed to follow Transmission Based Precautions (TBP) recommendations for 2 (Medicare and North) of 5 units reviewed, failed to consistently perform Hand Hygiene (HH) before and after resident care/contact, and failed to ensure residents' surrounding environment were maintained clean and sanitary (Resident 190). These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure implementation and staff compliance with the facility's infection prevention and control program to prevent the transmission of communicable diseases, including COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) during an active COVID-19 outbreak and global pandemic. The facility failed to ensure staff and visitors followed posted Transmission Based Precautions (TBP - a set of guidelines used with certain infectious diseases to prevent transmission) for residents who had COVID-19; ensure staff and visitors were wearing the required personal protective equipment (PPE) during close contact with a resident who was COVID-19 positive; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a system to ensure all staff were tested for COVID-19 at the frequency set forth by the Secretary and the Local Health Jurisdiction (LHJ) during an active COVID-19 outbreak, causing a delay in the identification and isolation of new cases, and failed to maintain proper infection control using recommended personal protective equipment (PPE) during specimen collection and testing for COVID-19. This failure placed residents, visitors, and staff at risk for contracting COVID-19 during an active outbreak and global pandemic.

Inspectors wroteBased on interview and record review, the facility failed to ensure interdisciplinary care conferences were completed for 1 (Resident 51) of 2 residents reviewed for care conferences. This had the potential for missed concerns the resident may have and for the resident to participate in her plan of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers (PUs) and promote healing for 1 of 2 Residents (Resident 82) reviewed for PUs. The facility's failure to thoroughly assess, monitor, treat, and implement pressure relieving interventions placed the residents at risk for further skin breakdown, delayed healing, unnecessary discomfort, infection, and diminished quality of life. Findings Included . According to the undated National Pressure Injury Advisory Panel (NPIAP) PU/PI staging definitions include: a Stage 2 PU was defined as a partial-thickness wound where the wound bed was viable, pink or red, moist, and may also present as an intact or ruptured blister; [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and address a resident's significant weight loss for 1 (Resident 6) of 3 residents reviewed for nutritional status. This failure left the resident at risk for further weight loss, other negative health outcomes and a diminshed quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received ongoing communication and collaboration with the dialysis (a process to filter the blood when kidneys so not function as they should) clinic for 1 (Resident 6) of 1 residents reviewed for dialysis services. Facility failure to communicate and collaborate with the center as required leftthe residenty at risk for significant changes in their health status going unnoticed and not addressed in a timely manner, and other health risks.