Perimeter Rehabilitation Suites by Harborview

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to develop a comprehensive Care Plan for four of four residents (Resident (R) 13, R29, R114, and R242) reviewed for activities and one of four residents (R117) reviewed for Pre-admission Screening and Resident Review (PASARR). The Care Plan failed to address activity needs and interventions for R13, R29, R114, and R242 and failed to address a diagnosis of post-traumatic stress disorder (PTSD) and related interventions. These failures placed the residents at risk for unmet physical and psychosocial care needs and the inability to meet their maximum practicable level of functioning.

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure five of six residents (Resident (R) 11, R13, R29, R190, and R204) reviewed for bed rails out of 196 residents who used bed rails were assessed for safety with and need for bed rails before their use. This deficient practice had the potential to place the residents at risk of injury or entrapment related to bed rail use.

Inspectors wroteBased on resident, resident guardian and staff interviews, record review, facility policy review, and review of the facility's investigation, the facility failed to ensure three residents (Resident (R) 35, R236, and R5) out of five residents reviewed for abuse were free from abuse out of 51 total residents sampled. R236 crawled into bed with R35 and began to kiss her. In addition, R5 was verbally abused and threatened by a Resident Care Aide (RCA)1. This had the potential for R5 to suffer emotional and psychological harm (Cross Reference F607, F609, F610).

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to implement their abuse policies for capacity to consent for sexual activity for two residents (Resident (R) 35 and R236), of five, out of 51 sampled residents sampled. In addition, the facility failed to implement their abuse policies by failing to immediately separate both residents and implement supervision. This had the potential for on-going sexual contact. (Refer to F600)

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure an allegation of sexual abuse was reported timely to the Administrator and to the State Survey Agency (SSA) for two of five residents (Resident (R) 35 and R236) reviewed for abuse out of 51 sampled residents. This failure increased the risk of other vulnerable residents being abused.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to provide the resident's responsible party a written notice of transfer, notice of bed hold practices and complete information on the process to appeal the transfer, including appeal agency contact information for a sample of two of two residents (Resident (R)144 and R238) reviewed for hospitalizations in a total sample of 51 residents. This failure had the possibility to negatively impact residents and their responsible parties due to them not being aware of the reason for a transfer and how to appeal the transfer.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure an adequate and ongoing program of activities to meet the needs of one of four residents (Resident (R) 29) reviewed for activities who was dependent on staff for all stimulation and engagement. This failure placed R29 at risk for increased self-injurious behaviors and unmet psychosocial needsFindings include:Review of the facility's policy titled, Activities, dated 01/01/2026, revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on staff interviews, record review, and review of the Activities Director (AD) Job Description, the facility failed to ensure that a qualified activity professional was employed. This deficient practice had the potential to affect the 210 residents who resided in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure emergency tracheostomy care supplies were kept within close proximity for one of four residents (Resident (R) 243) reviewed for tracheostomy care. This deficient practice had the potential to place R243 at risk of going without oxygen for over two minutes in the event of tracheostomy failure, which could lead to oxygen deprivation and brain damage.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure one of one Resident (R) (R43) reviewed for the provision of dental services was provided with routine services out of a survey sample of 51. This deficient practice had the potential to place R43 at risk of infections and pain associated with the lack of routine dental services.

Inspectors wroteBased on observation, record review, resident and staff interviews, and policy review, the facility failed to ensure one of three residents (Resident (R) 13) reviewed for nutrition was served thickened liquids as ordered by the physician. This deficient practice had the potential to place R13 at risk of choking or aspiration of liquids into the lungs

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the clinical records were complete for one of one resident (R) 79) reviewed out of a total sample of 34 residents. This deficient practice had the potential to create the opportunity for inaccurate medical records to be accessible to staff.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to adhere to infection control practices and policies during incontinence care for two of three residents (Resident (R) 172 and R181) observed for incontinence care in the sample of 51 residents. The deficient practice had the potential to place R172 and R181 at risk of cross-contamination and infection.

Inspectors wroteBased on record review, observation, staff interviews, review of maintenance documentation, and review of facility policy, the facility failed to ensure siderails were securely attached to the bed for one (Resident (R) 190) of six reviewed for side rails out of a sample of 51 residents. The deficient practice had the potential to place R190 at increased risk of injury related to side-rail use.

Inspectors wroteBased on observations, record review, interviews, and a review of the policy titled Elopements and Wandering Residents, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one of 52 sampled residents (R) (R49) related to ensuring that R49's unit was secure to prevent elopement. On 12/18/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. On 12/18/2025 at 3:15 pm, the Administrator, Director of Nursing, [NAME] President of Operations, and Chief Compliance Officer were notified that IJ was identified to have existed on 7/1/2025, when Resident (R) (R49) eloped from the facility by exiting the second-floor secured unit. [...]

Inspectors wroteBased on record review, interviews, and a review of the policy titled Resident Rights, the facility failed to ensure one of 18 sampled residents (R) (R16) was informed of their rights regarding treatment, financial liability, and resident rights upon admission to the facility. The deficient practice resulted in a resident not having informed consent, not knowing their financial liability, or what their rights were.

Inspectors wroteBased on interviews, record review, document review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect the rights of one of eight residents (R) (R6) reviewed for abuse. Specifically, to be free from exploitation by a staff member. This failure had the potential to cause emotional distress or financial burden for R6.

Inspectors wroteBased on interviews, document review, and review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three staff, Floor Technician (FT) (FT1), completed and documented a criminal background history, including a history of abuse, neglect, or exploitation, before employment. This failure had the potential to contribute to a substantiated allegation of exploitation for a facility resident (R) (R6).

Inspectors wroteBased on resident and staff interviews, record review, and a review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure an allegation of misappropriation of resident property was thoroughly investigated for two of eight residents (R) (R5 and R28) reviewed for abuse. This failure had the potential to contribute to further misappropriation of property in the facility.

Inspectors wroteBased on interviews, record reviews, a review of the policy titled MDS 3.0 Completion, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code the quarterly Minimum Data Set (MDS) assessment for one of 52 sampled residents (R) (R20) related to a urinary tract infection (UTI) that was not coded when a resident returned from the hospital. This failure had the potential to result in incomplete care planning.

Inspectors wroteBased on record review, staff interviews, and a review of the policy titled Diagnostic Testing Services, the facility failed to ensure a change of condition requiring immediate attention was addressed on time for one of seven residents (R) (R4) reviewed for change of condition. This failure had the potential to lead to increased pain or internal damage related to R4's dislocated left hip arthroplasty.

Inspectors wroteBased on the interview and record review, the facility failed to assess and provide one of 48 sampled residents (R) (R124) with sufficient fluid intake via gastric tube feeding to maintain proper hydration and health. As a result, R124 was admitted to an acute care hospital on [DATE] and died on [DATE] from septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on [DATE] at 3:00 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the physician failed to assess laboratory orders for routine monitoring for two of 48 sampled residents (R) (R124 and R213). On 6/2/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on 6/2/2025 at 3:00 pm. The noncompliance related to the IJ was identified to have existed on 4/2/2025. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/4/2024.

Inspectors wroteBased on the interview and record review, the facility's previous Director of Nursing (DON) failed to administer the facility in a manner that enabled the use of resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of 48 sampled residents (R) (R124). The facility's systemic failure to notify R124's physician of abnormal laboratory results, assess, and provide R124 with sufficient intravenous (IV) fluids, interventions/fluid intake to maintain proper hydration and health, placed the resident at risk. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to provide adequate supervision to prevent accidents for one of nine sampled residents (R) (R122) reviewed for accident hazards. Harm was identified to have occurred on 4/23/2025 when R122 sustained an injury of unknown origin resulting in ecchymosis and swelling around the right periorbital area.

Inspectors wroteBased on interviews, record review, and a review of the facility's policy titled Resident and Family Grievances, the facility failed to acknowledge family concerns as grievances via email and failed to investigate grievances for one out of 48 sampled Residents (R) (R384). In addition, the facility failed to provide results for the concerns and grievances reported by residents during the Resident Council Meetings. The facility census was 214 residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy titled Nursing Services and Sufficient Staff, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility census was 214.

Inspectors wroteBased on observations, interviews, and resident council minutes reviews, and staffing record reviews, the facility failed to provide a registered nurse (RN) to provide care for eight hours a day during the weekends. This failure to provide an RN eight hours a day during the weekends could result in reduced quality of care and one-star staffing levels.

Inspectors wroteBased on observations and staff interviews, the facility failed to post the nurse staffing data daily at the beginning of each shift. The facility did not ensure the nurse staffing data was posted daily in a prominent place readily accessible to residents, staff, and visitors. This practice had the potential to affect all residents in the facility. The facility census was 205.

Inspectors wroteBased on record reviews of the facility assessment and staff interview, the facility failed to complete the facility assessment. This deficient practice has the potential to affect all residents. The facility census was 214 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain staffing requirements by receiving a one-star staffing rating and having excessively low weekend staffing. The deficient practice could result in a lack of needed care provided to the residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Infection Surveillance and Laundry, the facility failed to 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. The facility failed to ensure an ongoing system of surveillance for infections and failed to ensure the laundry room and equipment were kept clean, ensure washers were functioning properly, and ensure clean and dirty linens were stored appropriately. The deficient practices had the potential to affect all residents in the facility. The facility census was 212.

Inspectors wroteBased on observations and staff interviews, the facility failed to have handrails that were firmly secured and affixed to the corridor walls on three of the three resident floors of the facility (Second Floor, Third Floor, and Fourth Floor). Specifically, handrails were loose and crooked throughout each floor. The deficient practice had the potential to affect the residents who can use handrails on all floors.

Inspectors wroteBased on resident and staff interviews, record reviews, and a review of the facility's policy titled Resident and Family Grievances, the facility failed to ensure that resolutions were provided for concerns discussed in the Resident Council meetings.

Inspectors wroteBased on staff interviews, record review and review of the facility's policies titled Notification of Changes, and Change of Room or Roommate, the facility failed to notify two of five sampled residents (R) (R381and R6) responsible parties of changes; and failed to notify one resident's (R) (R194) physician of a change in condition and transfer to the hospital.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, and comfortable environment for residents receiving showers in two of the three shower rooms (Third Floor Shower room and Fourth Floor Shower room) in the facility. The shower rooms contained unsecured doors, soiled linens, resident gowns on the floor, unmarked toiletry items, trash, masks, and gloves on the floor, in addition to unclean toilets and equipment.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure medication carts were locked and secured when unattended by authorized staff. This failure had the potential to allow unauthorized access to medications and biologicals by staff, residents, and visitors. The facility's census was 214 residents.

Inspectors wroteBased on observations, resident and staff interviews, and review of facility policy titled Standardized Menus, the facility failed to serve food that was palatable, attractive, and hot for four of seven sampled residents (R) (R62, R114, R472, and R473) reviewed for food palatability. This failure had the potential to affect 203 of 214 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Resident Funds Management Policy and Procedure, the facility failed to ensure one of 48 sampled residents (R) (R114) responsible parties (RP) had immediate access to the resident's funds.

Inspectors wroteBased on observation, interview, and review of the facility's policy titled Confidentiality of Personal and Medical Records, the facility failed to safeguard the personal and medical information of residents. In addition, the facility failed to ensure computer screens located on the medication carts were locked when not in use by a nurse who displayed residents' personal and medical information. This affected two out of 48 sampled residents (R26 and R213).

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to report an allegation of abuse incident for one of 48 sampled residents (R) (R101).

Inspectors wroteBased on observations, resident and staff interviews, record review and review of the facility's policy titled, Maintaining Minimum Data Set (MDS) Assessments, and the MDS Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure MDS assessments was accurately coded for two of 48 residents (R) (R114 and R155).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan to include activities of daily living (ADL) and legal blindness for one out of 48 sampled residents (R) (R387).

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled Comprehensive Care Plans and Fall Prevention Program, the facility failed to ensure that care plans were updated for three of 19 sampled residents (R) (R372, R393, and R122 ).

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure Activities of Daily Living (ADL) care was provided for one of four residents (R) (R212) reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide podiatry services for one of 48 sampled residents (R) (R 384). The deficient practice had the potential to lead to a lack of nail care and inappropriate foot care.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Restorative Program, the facility failed to ensure two of eight Residents (R) (R95) and (R183) received restorative therapy.

Inspectors wroteBased on record review, interview, and review of the facility policy titled Nurse Aide Training Program, the facility failed to ensure each Certified Nursing Assistant (CNA) employed by the facility had a minimum of twelve hours of nurse aide training per year, for one of five CNAs reviewed for the required training.

Inspectors wroteBased on family member and staff interviews, record review, and review of the facility policy titled, Elopement Policy: Procedure for Locating Missing Resident, the facility failed to notify the State Reporting Agency and the Police of an elopement in a timely manner for one of seven sampled residents (R) (R1).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with resident rights, which included measurable objectives and timeframes to meet a resident's medical needs for four of 33 sampled residents (R) (R11, 72, 125, and 162) Related to (1) antidepressant medication usage for R11; (2) observing for side effects and behaviors for the resident's antidepressant medication usage for R72; (3) observing for side effects and behaviors for R125's antidepressant medication usage; (4) for risk of falls for R162.

Inspectors wroteBased on observation, record review, and interview, the facility failed to date and label resident food items in the refrigerator, failed to keep the refrigerator clean, and failed to keep the microwave clean in between uses. This failure had the potential to affect all residents that resided on the third-floor unit, 65 residents out of 220 residents in the building.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an environment that was free from accident hazards for one of 45 sampled residents (R) (R162).

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for three of seven residents (R11, R72 and R125) reviewed for unnecessary medications.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were secured in locked compartments when not within direct line of sight of the staff observed during medication administration on two of three floors (Fourth Floor and Third Floor).

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain clinical records that are complete, accurate, readily accessible, and systematically organized for one of 33 sampled residents (R) (R125) reviewed for medical records accuracy.

Inspectors wroteBased on observations and interview, the facility failed to ensure staff administered medications in a manner to prevent the spread of infections for two of four residents (R) (R201 and R216) observed during medication administration.