Rehabilitation & Nursing Center at Everett (the)

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement personalized care plans for two Residents (#78 and #128) out of a total sample of 34 residents. Specifically:1. For Resident #78, the facility failed to prevent the Resident from having knives at meals.2. For Resident #128, the facility failed to have a fall mat in place.

Inspectors wroteBased on observations, record review, and interviews the facility to ensure that services provided met professional standards for one Resident (#61), out of 34 sampled residents. Specifically, the facility failed to obtain and implement physician's orders to discontinue Resident #61's CAM boot (medical walking shoe, is a type of orthopedic footwear used to immobilize the foot and ankle after an injury or surgery. It is designed to provide support, stability, and protection to the foot and lower leg during the healing process) and advance his/her weight bearing status after his/her surgical specialty (podiatrist) follow up on 5/19/25.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide supervision and assistance with meals for two Residents (#56 and #28) out of a total of 34 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate supervision during the 11:00 P.M. - 7:00 A.M. shift on two of five resident units. Specifically:1. The facility failed to ensure staff were awake and alert on the [NAME] Unit when staff were found asleep and three Residents (#3, #32 and #2) were observed wandering the unit.2. The facility failed to ensure that all assigned staff were consistently awake, alert, and were not simultaneously on their break during the night shift on the Main 1 unit.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adaptative equipment during meals for two Residents (#28 and #119) out of a total of 34 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#25, #78 and #15) out of a total sample of 34 residents. Specifically,1. For Resident #25, the facility failed to accurately document treatment administrations. 2. For Resident #78, the facility failed to accurately document the completion of a physician's order.3. For Resident #15, the facility failed to accurately document the route of medication administration.

Inspectors wroteBased on observation, record review and interview the facility failed to 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.

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on record review and interviews, the facility failed to obtain informed consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#141) out of a sample of 31 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure the Physician/Nurse Practitioner were notified of recommendations made by a Wound Physician for two Residents (#141 and #53) out of a total sample of 31 residents. Specifically, 1. For Resident #141, the facility failed to ensure the Physician or Nurse Practitioner were notified of recommendations made by the Wound Physician on 8/19/24 and 8/26/24. 2. For Resident #53, the facility failed to ensure the Physician or Nurse Practitioner were notified of recommendations made by Psychiatric Nurse Practitioner.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the Minimum Data Set assessment (MDS) was accurately coded to reflect the status of two Residents (#71, #21) out of a total sample of 31 residents. Specifically: 1) For Resident #71, the MDS did not accurately assess Resident #71's functional ablities for self-care, specifically for eating and 2) For Resident #21, the facility failed to complete a discharge MDS Assessment when the Resident was discharged from the facility to the hospital.

Inspectors wroteBased on observation, policy review and interviews, the facility failed to ensure professional standards of practice were followed for one Resident (#131) out of a total sample of 31 residents. Specifically, the facility failed to ensure nursing staff did not leave medications with Resident #131 while unattended.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide activities of daily living for dependent residents for one Resident (#2) out of a total sample of 31 Residents. Specifically, for Resident #2, the facility failed to provide supervision with meals.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure standards of quality of care were implemented for one Resident (#2), out of a total sample of 31 residents. Specifically, the facility failed to identify a skin injury on the Resident's right forearm.

Inspectors wroteBased on observation, record review and interview the facility failed to a) develop a care plan for the assessed risk for developing a pressure ulcer/injury and b) failed to implement the physician's order for prevalon boots (a heel protector) for one Resident (#79) out of a total sample of 31 residents.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#48) out of a total sample of 31 residents. Specifically for Resident #48, the facility failed to ensure his/her oxygen concentrator air filter was in place.

Inspectors wroteBased on observations, record reviews, policy reviews and interviews, the facility failed to ensure it was free from a medication error rate of five percent or greater. One out of four nurses observed made two errors in 40 opportunities on one unit resulting in a medication error rate of 5%. These errors impacted one Resident (#53), out of four residents observed.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1. The facility failed to properly secure the medication cart on one of four units 2. The facility failed to properly secure the medication room on one of four units

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to obtain dental services for one Resident (#87) out of a total sample of 31 Residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#76) was free from a significant medication error, out of a total sample of 25 residents. Specifically, Resident #76 was administered insulin (medication used to treat elevated blood sugars) when his/her physician's order indicated for the insulin to be held.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to notify the physician of a refusal of a medication (an alteration in treatment plan) for one Resident (#60), out of a total sample of 25 residents. Specifically, on 8/28/23 Resident #60 refused his/her physician's ordered Haldol injection (antipsychotic medicine) and nursing failed to notify his/her physician of the Resident's refusal.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the Minimum Data Set (MDS) assessment accurately assessed one Resident's (#13) speech clarity, out of a total sample of 25 residents. Specifically, the MDS assessment for two consecutive quarters indicated Resident #13 had clear speech, which conflicts with his/her actual status.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop a person-centered communication care plan for one Resident (#116) out of a total sample of 25 residents. Specifically, the facility failed to develop a care plan to address the Resident's primary language.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that services provided to one Resident (#475) met professional standards of quality, out of a total sample of 25 residents. Specifically, the facility failed to follow a physician's order for the head of bed (HOB) to be at 90 degrees when Resident #475 was eating.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide the necessary activities of daily living care for two dependent Residents (#114 and #37) out of a total sample of 25 residents. Specifically, the facility failed to provide supervision and assistance with eating meals for Resident #114 and #37.

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide activities for 1 Resident (#475) out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure an orthotic device used for contracture management was implemented in accordance with the medical plan of care, for one Resident (#13) out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure it provided a physician's ordered medication for one Resident (#60) out of a total sample of 25 residents. Specifically, on 8/29/23 Nurse #3 did not have Resident #60's physician's ordered metformin (antidiabetic agent that manages high blood sugar levels) and Nurse #3 failed to obtain the medication from the emergency medication supply.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow up with the dentist's recommendation for two Residents (#17 and #44) out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain an accurate medical record for one Resident (#13), out of a total sample of 25 residents. Specifically, staff documented that an orthotic right hand palm protector for contracture management was administered when the palm protector was not placed on the Resident.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the call bell system for one Resident (#70), on one out of four resident care units was operable, resulting in the resident not having access to staff for potential unmet needs, out of a total sample of 25 residents.