Avamere Olympic Rehabilitation of Sequim

In the surveyor’s words

From the most serious findings on record at Avamere Olympic Rehabilitation of Sequim, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 9, 2025

  Based on observation, interview and record review, the facility failed to adequately and consistently assess developing/worsening skin conditions/breakdown, follow the care/treatment plan and interventions as ordered, and report changes to medical provider in a timely manner for 1 of 1 sampled resident (Resident 24) reviewed for pressure ulcers. Resident 24 experienced harm when their Moisture Associated Skin Damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to moisture) on their coccyx (tailbone) that was present on admission to the facility worsened and developed into two unstageable pressure ulcers (PU - a type of wound where the depth cannot be determined due to the presence of dying tissue or eschar, making it difficult to assess the extent of tissue… […]

• Actual harm, isolatedF689Jul 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure supervision was provided in the bathroom as directed in the care plan for 1 of 4 sampled residents (1) reviewed for accident hazard. This failure placed residents at risk for injury and a diminished quality of life. This failure caused harm to Resident 1 when the resident was left unattended, on a shower chair, in the bathroom and experienced a fall and sustained a wrist fracture and forehead hematoma. Findings included . Resident 1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Dec 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards when providing a one person transfer instead of the care planned two person transfer for 1 of 2 sampled residents (1) reviewed accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This failure caused harm to Resident 1 when transferred with one, rather than two, staff without the required lift, and sustained right ankle fractures, a left knee abrasion, and a skin tear with bruising to a left-hand finger. […]

• No harm, potential for more than minimal, widespreadF628Dec 9, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were sent to the hospital with the required and necessary information to assure the safe transition of care for 3 of 3 residents (Residents 52, 81, & 1) reviewed for hospitalization. This failure placed residents at risk of incomplete emergency care, lack of services, lack of advocacy, and a diminished quality of care.Findings included. Review of the policy titled Transfer or Discharge, Preparing a Resident for, revised 12/2016, showed the policy did not include what documents were required to ensure the facility communicated appropriate and necessary information to the hospital when a resident was transferred. The policy documented, 1. […]

• No harm, potential for more than minimal, widespreadF804Dec 9, 2025

  Based on observation and interview the facility failed to provide appetizing and palatable food for 7 of 24 sampled residents (5, 17, 24, 11, 84, 10, and 28) and 1 of 1 test tray sampled for food quality. The facility also failed to prepare pureed foods for residents following the written recipe to ensure the nutritional value was maintained. These failures placed residents at risk for a decline in nutrition and a diminished quality of life. Findings included .Resident Food1) On 12/01/2025 at 1:15 PM, Resident 5 said the food was cold.2) On 12/01/2025 at 12:38 PM, Resident 17 said they were the last to get their food on this hallway and sometimes it was cold. […]