Inspection Reports for
Sequim Health & Rehabilitation

The complaint involved one sampled resident whose Social Security benefits were stopped because the facility incorrectly reported the resident as still residing there. The allegation was substantiated as the facility failed to complete and provide necessary documentation timely, impacting the resident's benefits.

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

The facility was found deficient in multiple areas including inaccurate PASRR assessments, incomplete care plans, failure to provide professional standard services including medication management and side effect monitoring, lack of timely bowel management, malfunctioning pressure redistribution devices, insufficient RN coverage on some days, failure to coordinate notary public services for advanced directives, and lack of timely speech therapy services. Most deficiencies were cited with minimal harm and some residents affected.

The complaint involved Resident 1 who alleged being assaulted and abused by staff during a transfer. The facility's investigation found the allegation unfounded and did not report or log it. Staff interviews revealed inconsistent documentation and failure to complete witness statements. The mandated reporting log showed no entry for the allegation.

The facility failed to timely report allegations of abuse by staff for one resident, placing residents at risk. The investigation determined the allegation was unfounded and did not require reporting or logging.

The facility failed to provide routine cleaning services for 2 of 5 sampled residents, resulting in a less than homelike environment and potential infection control issues. Staffing and scheduling challenges impacted housekeeping's ability to clean resident rooms regularly, and family members reported having to clean due to inadequate housekeeping.

The facility was found deficient in multiple areas including failure to obtain informed consent prior to administering psychotropic medications, inadequate notification to the Ombudsman on resident discharges, inaccurate resident assessments, incomplete care plans, insufficient care conferences, failure to meet professional nursing standards especially in IV therapy and enteral nutrition, inconsistent restorative services, insufficient nursing staff, and failure to ensure proper infection control practices. Several deficiencies were noted as minimal harm with some residents affected. Dietary services also failed to provide meals at proper temperatures and portion sizes.

The complaint investigation involved multiple residents and staff reporting long delays in call light responses, insufficient staffing on weekends and holidays, and inability to complete assigned tasks such as showers and wound care. Resident council meeting minutes from April to June 2024 documented ongoing concerns about call light delays and staffing shortages. The complaint was substantiated with citations issued.

The facility failed to ensure sufficient qualified nursing staff were available to meet resident needs, resulting in long call light response times and unmet care needs. Multiple residents and staff interviews confirmed staffing shortages and delays in care, placing residents at risk for diminished quality of life.

The complaint involved Resident 1 being stuck twice in a mechanical lift. The grievance was not properly filed or logged despite staff assurances. The family requested a grievance form copy but was told it was discarded. The facility investigation found equipment issues and conducted staff training but failed to document the grievance properly.

The facility failed to initiate a grievance for Resident 1 after two incidents of being stuck in a mechanical lift. The grievance form was reportedly not filed or logged, and the family was unable to obtain a copy. Staff training was conducted on battery charging and emergency release procedures, but follow-up and documentation were inadequate.

The complaint involved Resident 1's delayed MRI and spine specialist referral. The investigation found the facility did not act on the orders for over three weeks, causing prolonged pain and risk. Family and staff interviews confirmed the delay and lack of communication. The resident had an MRI scheduled only after significant delay.

The facility failed to ensure timely action on a physician's order for an MRI and spine specialist referral for Resident 1, resulting in prolonged pain and risk of health complications. The delay was confirmed through record reviews and staff interviews, showing the MRI and referral were not scheduled for over three weeks after the order.

The complaint investigation focused on Resident 1's care, including the use of an external female catheter system brought by family without physician order or staff training, inadequate toileting assistance, poor hydration monitoring, and resulting decline and hospitalization. Multiple staff and family members provided statements confirming these issues.

The facility failed to properly assess, train staff, and care plan for the use of an external female catheter system for Resident 1, who was at risk due to bowel and bladder incontinence and inadequate hydration. Resident 1 developed acute UTI, acute kidney injury, and dehydration, resulting in hospital admission. Staff interviews revealed lack of training and inconsistent monitoring of fluid intake and catheter use.

The complaint investigation focused on Resident 1's care planning and restorative therapy services. Resident 1 and staff interviews, along with record reviews, confirmed the failure to update care plans and provide consistent restorative therapy. The complaint was substantiated with citations issued.

The facility failed to update Resident 1's care plan to reflect current needs and did not provide consistent restorative therapy services, resulting in a decline in the resident's functional abilities. The deficiencies were cited with minimal harm and affected a few residents.

The investigation focused on three residents who did not receive showers as scheduled. Collateral contacts and residents reported poor hygiene and infrequent showers. Staff confirmed workload challenges and lack of monitoring processes. The complaint was substantiated by findings of inadequate bathing care and related health risks.

The facility failed to ensure dependent residents received the required frequency of showers as per their care plans, placing them at risk for diminished quality of life and infections. Staff acknowledged challenges in completing showers due to workload, and some residents reported infrequent showers. Antifungal treatments were ordered for a resident with yeast infection likely related to inadequate hygiene.

No health deficiencies were found during this survey.

The complaint investigation found that neurological assessments were not completed as required for Resident 40 after unwitnessed falls, and Resident 13 was not repositioned as ordered, with inconsistent documentation. Staff interviews confirmed these issues.

The facility failed to ensure neurological assessments were performed after unwitnessed falls for Resident 40 and failed to ensure Resident 13 was repositioned as ordered, with documentation lacking. These failures placed residents at risk for injury and diminished quality of life.

The facility was found to have multiple deficiencies including failure to provide dignified care, incomplete advance directive documentation, inadequate environment conditions, medication administration errors, insufficient resident communication aids, lack of dependent resident eating assistance, inadequate activity programming, incomplete neurological assessments after falls, failure to reposition residents as ordered, pressure injury care deficiencies, unaddressed significant weight loss, insufficient RN coverage, inaccurate nurse staffing postings, improper medication storage practices, and serious infection control failures including an immediate jeopardy related to Carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak. Staff training on dementia care was also lacking.

The facility failed to ensure weekly skin assessments were performed for one sampled resident, resulting in delayed identification and treatment of skin infections. The deficiency was cited with minimal harm and a few residents affected.

The facility failed to establish baseline care plans for two residents, failed to notify family and provide timely postmortem care for one resident, and failed to ensure oxygen was administered and monitored per physician orders for one resident. All deficiencies were cited with minimal harm and affected few residents.

The complaint investigation involved allegations against Staff E regarding threats to withhold pain medication and disrespectful behavior. Resident 1's allegation was determined to be false, but Residents 2 and 3 reported similar concerns. The facility investigation did not fully investigate all allegations, and Staff E was no longer employed. The complaint was substantiated for some residents.

The facility failed to ensure residents were treated with respect and dignity as several residents reported unprofessional and disrespectful behavior by Staff E, including threats to withhold pain medication and unsafe feelings at night. The investigation concluded that one allegation was false, but other residents reported similar concerns. Staff E was no longer employed at the facility at the time of the inspection.

The complaint investigation revealed that the facility did not complete required infection control components including facility mapping and written analysis for multiple months. Staff interviews confirmed incomplete reporting and challenges in fulfilling infection control duties. The complaint was substantiated by these findings.

The facility failed to maintain a complete Infection Prevention and Control Program, lacking facility mapping of infections for 3 of 5 sampled months and missing written monthly analysis for 5 of 5 sampled months. Staff interviews revealed challenges in completing infection control reports, and the Infection Control Log was incomplete for the specified months.

The complaint investigation revealed that the facility did not complete required infection control documentation including facility mapping and written analysis for multiple months. Staff interviews confirmed incomplete reports and challenges in fulfilling infection control duties. The complaint was substantiated based on missing infection control data and documentation.

The facility failed to maintain a complete Infection Prevention and Control Program, lacking facility mapping of infections for 3 of 5 sampled months and missing written monthly analysis for all 5 sampled months. Staff acknowledged challenges in completing required infection control reports, and the State Agency confirmed missing documentation in the Infection Control Log.

The facility failed to ensure regular care plan conferences were held with residents or their representatives, and failed to provide adequate nail care for a dependent resident. These deficiencies placed residents at risk of diminished quality of life. No correction status was explicitly stated for the deficiencies.