Avamere Rehabilitation of Shoreline

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 24, 2022

  Based on observation, interview, and record review, the facility failed to implement written infection control policies and procedures, follow standards of practice related to hand hygiene/washing, donning (put-on) and doffing (removal) of Personal Protective Equipment (PPE), and the required isolation/transmission-based precautions when providing housekeeping and maintenance services to fourteen of fourteen residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) reviewed for quarantine and isolation precautions. […]

• Immediate jeopardy, patternF689Jun 27, 2022

  Based on observation, interview, and record review, the facility failed to ensure that policies and procedures for elopement were effectively implemented by providing necessary supervision, and implementing resident directed care plans for 6 of 6 residents (Residents 1, 2, 3, 4, 5 and 6) reviewed for elopement and/or avoidable incidents. The facility did not implement its policy and procedure for Resident 1 who was at risk for elopement and was found wandering alone on a busy street by a concerned citizen which required intervention by law enforcement officers. […]

• Actual harm, isolatedF600Sep 19, 2022

  Based on observation, interview, and record review, the facility failed to prevent abuse (physical and verbal) for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This failure caused harm to Resident 1 who sustained physical injuries including significant bruising and scratches on his left arm, was punched in the head, and psychosocial harm in the form of anger, frustrations, which affected his sleep patterns and mood. Findings included . The Code of Federal Regulations (CFR) define abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. […]

• Actual harm, isolatedF686Feb 11, 2022

  Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and treat a resident's skin condition, and develop and implement timely interventions to minimize the risk and the development of pressure injuries for 1 of 3 residents (Resident 1) reviewed for pressure injury/ulcers. These failures caused harm to Resident 1 who developed an in-house acquired pressure injury and placed other residents of the facility at risk for harm and unmet care needs. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. […]

• Actual harm, isolatedF689Feb 11, 2022

  Based on observation, interview and record review, the facility failed to provide adequate supervision and implement the care plan for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and falls. These failures caused harm to Resident 1 and placed other residents at risk for harm and injury. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses list included stroke and muscle weakness. A review of Resident 1's admission Minimum Data Set (MDS) assessment, dated [DATE], showed the resident had intact cognition and needed two-person physical assistance from staff with bed mobility and transfers. […]