Inspection Reports for Sequim Health & Rehabilitation

The facility failed to ensure that residents' medical records were complete, accurate, and accessible, resulting in delayed Social Security payments for one resident. The requested form to resume benefits was not completed timely due to lack of access to the resident's records after discharge.

The facility failed to ensure accurate PASRR screenings for mental health diagnoses, comprehensive care plans, proper medication administration including non-pharmacological interventions and side effect monitoring, timely bowel management, proper functioning of pressure redistribution devices, adequate RN coverage, coordination of notary public services for advanced directives, and timely provision of specialized rehabilitative services such as speech therapy. These deficiencies placed residents at risk for unmet care needs, diminished quality of life, and potential harm.

The complaint involved Resident 1 reporting being assaulted and abused by staff, including being forcibly transferred to bed and having pants removed against their will. The facility failed to log or report the allegation to the state agency within the required timeframe. The facility's investigation concluded the allegation was unfounded.

The facility failed to report allegations of abuse/mistreatment by staff on the mandated reporting log within five working days for 1 of 3 residents reviewed, placing residents at risk for repeated incidents and unmet care needs. The investigation determined the allegation was unfounded and did not require reporting or logging.

The facility failed to provide routine cleaning services to support a clean and homelike environment for 2 of 5 sampled residents, placing them at risk for diminished quality of life and potential infection control issues. Housekeeping staff reported cleaning rooms based on assigned lists, which did not include all resident rooms regularly, and staffing challenges impacted housekeeping tasks.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, failure to notify the Ombudsman of resident transfers, inaccurate resident assessments, incomplete care plans, lack of care conferences, failure to meet professional standards in medication and IV therapy administration, inconsistent restorative services, inaccurate enteral nutrition administration, inadequate staffing, improper food preparation and serving, and failure to comply with infection control protocols.

The complaint investigation found substantiated issues with staffing shortages leading to delayed responses to call lights, with residents reporting wait times from 15 minutes up to 4-5 hours for assistance. Staff interviews confirmed insufficient staffing levels, especially on weekends and holidays, impacting the ability to meet resident needs including showers, vital signs, and wound care.

The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, as evidenced by multiple resident and staff interviews and observations showing long delays in responding to call lights and unmet care needs, placing residents at risk for decreased physical abilities and diminished quality of life.

The complaint investigation found that Resident 1 reported being stuck in a mechanical lift twice, but the facility did not file a formal grievance. Staff reported the issue was related to battery charging failures and broken emergency release, but grievance documentation was missing and follow-up was inadequate.

The facility failed to initiate a grievance for Resident 1 after she reported being stuck in a mechanical lift on two occasions. The grievance was not logged in the facility's grievance system, and staff did not follow up appropriately, placing residents at risk of denial of personal rights and diminished quality of life.

The facility failed to act timely on a physician order for an MRI and spine specialist referral for Resident 1, resulting in prolonged pain and risk of health complications. Documentation showed delays in scheduling and communication issues regarding the MRI and specialist appointments.

The complaint investigation found substantiated issues including failure to assess appropriateness, lack of staff training on external catheter use, no physician order for the catheter, inadequate toileting assistance, insufficient hydration monitoring, and failure to update care plans. Resident 1 declined rapidly, was found with bowel incontinence and minimal fluid intake, and was hospitalized with acute UTI, acute kidney injury, and dehydration.

The facility failed to provide appropriate care and services to prevent urinary tract infection for Resident 1 by implementing an external urinary catheter system without proper assessment, staff training, care planning, or ensuring adequate hydration. Resident 1 experienced decreased function, dehydration, and was hospitalized with acute UTI and acute kidney injury.

The facility failed to update care plans to reflect current care needs and failed to provide consistent restorative therapy services to Resident 1, resulting in a decline in function and potential risk for unmet care needs and diminished quality of life.

The visit was complaint-related, focusing on inadequate bathing and hygiene care for residents. The complaint was substantiated by interviews, record reviews, and observations indicating residents did not receive showers as scheduled, contributing to hygiene issues and yeast infections.

The facility failed to ensure that three sampled residents received the required bathing and hygiene care as per their care plans, resulting in risks of diminished quality of life and development of yeast infections. Staff reported challenges in completing showers due to workload and lack of monitoring processes.

The facility failed to ensure neurological assessments were performed after an unwitnessed fall and failed to ensure residents received necessary care and services with positioning based on comprehensive person-centered care plans for 2 of 5 sampled residents. This failure placed residents at risk for unidentified injuries, health complications, worsening conditions, delay in treatment, and diminished quality of life.

The facility was found deficient in multiple areas including failure to provide dignified care, incomplete advance directive procedures, inadequate environment conditions, medication administration errors, lack of communication devices for residents, insufficient assistance with activities of daily living, inadequate activity programming, failure to perform neurological assessments after falls, improper pressure ulcer care, failure to address significant weight loss, insufficient RN coverage, inaccurate nurse staffing postings, improper medication storage, and serious infection control breaches including an immediate jeopardy related to Carbapenem-resistant Acinetobacter baumannii (CRAB) transmission.

The facility failed to ensure weekly skin assessments were performed for one of three sampled residents, resulting in delayed identification and treatment of skin infections. Documentation gaps were noted, and staff interviews confirmed inconsistent completion of skin assessments.

The investigation was complaint-driven, focusing on failures related to care planning, family notification and postmortem care, and respiratory care management. The deficiencies were substantiated based on interviews and record reviews.

The facility failed to establish baseline care plans for residents, notify family and provide timely postmortem care after a resident's passing, and ensure oxygen was administered and monitored per physician orders for a resident. These failures placed residents at risk for health complications, unmet care needs, psychosocial harm, and diminished quality of life.

The complaint investigation involved allegations from Residents 1, 2, and 3 regarding Staff E's disrespectful behavior and threats to withhold pain medication. The facility investigation concluded Resident 1's allegation was false but did not adequately investigate similar concerns from Residents 2 and 3. Staff E was suspended during the investigation and later left the facility. The investigation lacked staff interviews and proper documentation of all allegations.

The facility failed to ensure residents were treated with respect and dignity, with multiple residents reporting unprofessional and disrespectful behavior by Staff E, including threats to withhold pain medication and unsafe conditions at night. The facility's investigation was incomplete, lacking staff interviews and documentation of follow-up on similar allegations.

The facility failed to complete facility mapping of infections for 3 of 5 sampled months and did not complete monthly written analysis of infections for 5 of 5 sampled months. Staff responsible for infection control reported challenges in completing required reports and attending QAPI meetings, impacting the effectiveness of the infection control program.

The facility failed to complete facility mapping of infections for 3 of 5 sampled months and did not complete monthly written analysis of infections for 5 of 5 sampled months. Staff turnover and workload challenges impacted the completion of required infection control components.

The facility failed to hold regular care plan conferences with residents or their representatives for three of five sampled residents, placing them at risk of diminished quality of life. Additionally, the facility failed to ensure proper ADL care, specifically nail care, for one resident, resulting in debris under nails and inadequate cleaning.