Enumclaw Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Enumclaw Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 23, 2026

  Based on observation, interview, and record review, the facility failed to implement pressure offloading interventions timely for resident's assessed to be at increased risk for skin breakdown to prevent the development of pressure injuries (PI) for 2 of 3 residents (Residents 1 & 2) investigated for development of new PI after admission. Resident 1 experienced harm when they developed two avoidable deep tissue pressure injuries (DTPI) after admission, one on each heel, that resulted in pain, affected their mobility and care routines, and delayed their rehabilitation and discharge goals. Resident 2 experienced harm when they developed a Stage 3 PI on their sacrum that resulted in pain, affected their ability to sleep, comfort, and decreased their bed mobility. […]

• Actual harm, isolatedF689May 24, 2024

  Based on interview, and record review the facility failed to ensure the correct type of sling was used to safely transfer 1 of 3 residents (Resident 1) reviewed for mechanical lift transfers. Resident 1 experienced harm when they were transferred incorrectly and sustained a spinal injury. Findings included . <Facility Policy> According to the facility's policy titled Fall Evaluation and Management, after a fall residents would be evaluated, cared for, and appropriate notifications made. Review of the Quarterly Minimum Data Set (MDS - an assessment tool) dated 04/20/2024, showed Resident 1 had adequate hearing and adequate vision with corrective lenses. […]

• No harm, potential for more than minimal, widespreadF812Jun 13, 2025

  Based on observation, interview, and record review the facility failed to store, prepare, and serve food under sanitary conditions. Failure to ensure food items in the dietary department were properly stored, labeled, and out-of-date foods were identified and discarded, staff used appropriate hand washing and sanitation, placed residents at risk for consuming expired/contaminated foods, and potential exposure to food-borne illness. Findings included . <Facility Policy> According to the facility's updated October 2017 Food Storage policy, food storage areas would be kept clean at all times. The policy showed all food received by the facility would be dated with the month and year, except for perishable food with use-by dates of 30 days or less. […]

• No harm, potential for more than minimal, widespreadF825Nov 3, 2023

  Based on interview and record review the facility failed to provide the Specialized Rehabilitative Services of Physical Therapy, (PT) , that 14 ( Residents 53, 15, 59, 7, 26, 12, 51, 45, 43, 35, 1, 36, 63, 10, ) of 22 residents reviewed for therapy services were assessed to require. Failure to provide PT placed residents at risk for decline in physical and functional mobility, deterioration of muscle strength, delay of discharge, non payment of Skilled Nursing Facility stay by their insurance companies, and diminished quality of life. Findings included Resident 53 Resident 53 was admitted [DATE] for skilled services. Review of 09/19/2023 Hospital Therapy Notes showed Resident 53 required mobility/transfer training, strengthening, and adaptive equipment. […]

• No harm, potential for more than minimal, widespreadF835Nov 3, 2023

  Based on interview and record review the facility administration failed to obtain and use resources to manage the facility effectively and efficiently to maintain substantial compliance with federal regulatory requirements. The Administration failed to ensure residents received the Specialized Rehabilitation Services they were assessed to require, failed to ensure the facility could meet the needs of the resident population by not admitting residents with Specialized Rehabilitation Services needs and/or retaining residents whose needs the facility could not meet. In addition, the Administration failed to provide administrative oversight and monitoring of facility personnel, systems, practices, and policies related to infection control. […]