Edmonds Post Acute

In the surveyor’s words

From the most serious findings on record at Edmonds Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 15, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents and staff were protected from COVID-19 (a contagious disease), and failed to ensure the all components of an effective infection control program were operationalized to provide a safe and sanitary environment to help prevent the development and spread of communicable diseases and infections. 1. The facility failed to ensure timely notification of COVID positive staff, and/or prevent staff with signs and symptoms (s/s) of COVID-19 from working on the floor/unit, and increased the likelihood for the spread of COVID-19 between residents and staff. 2. […]

• Immediate jeopardy, isolatedF690Apr 14, 2021

  Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent catheter-associated injury or urinary tract infections for 2 of 5 residents (Residents 1 and 2) with an indwelling urinary catheter (tube for drainage of urine). The facility failure to provide adequate & timely assessment, close monitoring and timely reporting of condition changes, and interventions, such as checking for proper placement of a urinary catheter and/or consideration of all possible causes for reduced/obstructed urine flow through the catheter, contributed to harm for Resident 1 who developed an acute life threatening medical condition related to catheter placement/migration. […]

• Actual harm, isolatedF684Apr 13, 2023

  Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) reviewed for falls received complete and timely assessments after a fall with a head injury. The facility had specific guidelines for monitoring residents' neurological status after a fall with head trauma yet did not follow these for Resident 1 who experienced harm with an unrecognized change in level of consciousness, potential pain, and delayed medical response. Findings included . Review of the Admission Evaluation form, dated [DATE], showed Resident 1 admitted to the facility on [DATE] with diagnoses that included recurrent falls and weakness. […]

• Actual harm, isolatedF686Mar 8, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services to prevent the development and worsening of pressure injury for 2 of 4 residents (Resident 1 & 2) reviewed for pressure injuries (PI). Failure to complete on-going skin assessments and develop & implement a PI care plan with individualized interventions resulted in harm (wound deterioration) to both residents who developed pressure ulcers. Findings included . According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instruction manual, v1.17.1, a PI is defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. […]

• Actual harm, isolatedF689Aug 2, 2021

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or implement interventions to prevent accidents for 4 of 6 residents (Residents 1, 3, 4, 5) reviewed for abuse or neglect. Failure to do so resulted in Resident 1 experiencing a fall with [CONDITION(S)], which was actual harm, and placed Resident 3 at risk for injury from future falls. In addition, failure to adequately supervise Residents 4 and 5 for unsafe smoking behaviors placed the residents at risk for potential burn injuries or environment safety hazards. Findings included . FALLS Resident 1 was admitted to the facility on [DATE], with multiple medical diagnoses, including [CONDITION(S)] (sensation of dizziness or loss of balance) and diabetes. […]