Everett Transitional Care Services

In the surveyor’s words

From the most serious findings on record at Everett Transitional Care Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 12, 2022

  Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 2 residents (4), reviewed for resident-to-resident altercations. The facility failed to ensure residents were free from repeated verbal abuse and unwanted touching, resulting in psychosocial harm to Resident 4 who verbally stated they were scared of Resident 1, and placed all other residents at risk for further abuse. This constituted an Immediate Jeopardy. An Immediate Jeopardy (IJ) related to abuse was called on 06/30/2022 at 5:28 PM. The facility assessed all current residents, completed thorough investigations of incidents, and reported to the proper state offices. […]

• Actual harm, isolatedF689May 15, 2026

  Based on observation, interview and record review the facility failed to prevent an accident for 1 of 1 sampled resident (Resident 1) reviewed for burns. Resident 1 experienced harm when facility staff heated food and then failed to ensure safe temperatures prior to serving the resident, resulting in second degree burns. The facility failed to report to the appropriate state agencies at the time of the incident. This failure also placed other residents at risk of serious injury and a diminished quality of life. Findings included.Review of a facility policy titled Microwave Reheating Guidelines updated 10/01/2022 showed; Policy Statement: Foods and fluids heated in the microwave are served to residents at safe temperatures- 7. Temperature is taken prior to service to the residents. […]

• Actual harm, isolatedF686Jul 26, 2023

  Based on interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown and implement timely interventions necessary to prevent the development of facility acquired pressure ulcers for 1 of 2 residents (Residents 1) reviewed for pressure ulcers (PU). These failed practices caused harm to Resident 1, who developed an unstageable PU and placed other residents at risk for potential skin breakdown. Findings included . Review of the facility's undated policy titled, Skin Assessment, showed a full body, head to toe skin assessment would be conducted by a nurse upon admission to the facility and weekly thereafter. […]

• No harm, potential for more than minimal, widespreadF726Feb 8, 2023

  Based on interview and record review, the facility failed to ensure nursing assistant competencies were assessed and completed yearly, for four of four staff (F, R, S, and U) employee files reviewed. This failed practice had the potential to negatively affect the competency of the nursing assistants and impact the quality of care provided to residents. Findings included . Staff F, Nursing Assistant Certified (NAC), had a hire date of 10/12/2014. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff R, NAC, had a hire date of 02/15/2021. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff S, NAC, had a hire date of 06/12/2020. […]

• No harm, potential for more than minimal, widespreadF838Jul 12, 2022

  Based on interview and record review, the facility failed to perform thorough, annual review of the facility-wide assessment to evaluate and identify the resources required to meet each resident's care and service needs. These failures placed all residents at risk of unidentified and/or unmet care and service needs. Findings included . Review of the Facility Assessment Tool, dated 08/18/2021, updated April 21, 2022, showed the purpose of the assessment was to determine what resources were necessary to provide competent support and care for their resident population every day and during emergencies. The assessment was not thoroughly and comprehensively reviewed annually. […]