Avamere Rehabilitation of Issaquah

In the surveyor’s words

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

• Immediate jeopardy, isolatedF607Feb 6, 2024

  Based on observation, interview and record review, the facility failed to implement their abuse and neglect policy for 1 of 1 resident (Resident 35) reviewed for injuries of unknown origin. Facility failure to identify, report, and investigate, multiple bruisesof unknown origin to Resident 35's upper/middle/lower back, both breasts, and knee placed Resident 35 at risk for potential continued abuse and psychosocial harm and all residents at risk for abuse, and psychosocial harm. An Immediate Jeopardy (IJ) was called on 01/31/2024 at 5:15 PM related to CFR 483.12 F-607, Develop/Implement Abuse/Neglect Policies. The IJ was determined to have begun 01/24/2024 when the bruises were initially identified by staff. […]

• Actual harm, isolatedF686Feb 6, 2024

  Based on observation, interview, and record review the facility failed to ensure 1 of 5 sampled residents (Resident 61) reviewed for Pressure Ulcers (PUs), received the necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. Resident 61 experienced harm when they developed a facility acquired coccyx (tailbone) and inner left knee PU when staff did not consistently implement ordered pressure offloading measures and the resident was not consistently repositioned in bed. This failure placed all other residents at risk for PU development, and a diminished quality of life. […]

• Actual harm, isolatedF697Feb 6, 2024

  Based on observation, interview, and record review the facility failed to ensure 1 of 6 sampled residents (Resident 61), reviewed for Pain Management received the necessary treatment and services as ordered to manage pain with wound care. Resident 61 experienced harm and self-reported severe levels of pain during wound care when the facility failed to consistently premedicate the resident with ordered as needed pain relieving medication 30-60 minutes prior to dressing changes. This failure placed all other residents at risk for potentially unnecessary pain during wound care, and a diminished quality of life. […]

• Actual harm, isolatedF689Jun 15, 2023

  Based on observation, interview, and record review the facility failed to provide supervision and ensure care was provided to residents at the level of care they were assessed to require for 2 of 3 residents (Residents 33 &34) reviewed for falls. The facility failed to ensure incident investigations were completed thoroughly to identify the root cause of the incident, update the incident investigations and incident log to reflect when an injury occurred, for 3 of 3 residents (Resident 33, 34 & 35) reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF727Feb 6, 2024

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) provided at least eight hours of direct care supervision per day for 4 of 51 days reviewed. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs. Findings included . Review of the facility's Daily Nurse Staff Documentation showed on four days (12/16/2023, 12/30/2023, 01/13/2027, and 01/27/2024 - all Saturdays) from 12/16/2023 through 02/04/2024 there was no Registered Nurse on site for eight hours as required by federal regulations. […]