Staff E, the designated "wound nurse" at Avamere Rehabilitation of Shoreline, admitted to federal inspectors on November 14 that they never staged any wounds during their evaluations. When asked about assessments completed for Resident 2, Staff E said they "followed the previous wound care provider's assessment, and if it basically looked the same then that is what they would document."
The nurse acknowledged they were not wound care certified.
When inspectors asked whether wound assessment fell within an LPN's scope of practice, Staff E responded: "I never really thought of that, I am not sure. I will have to get back to you."
Staff B, the Director of Nursing, confirmed that Staff E served as the facility's wound nurse despite lacking wound care certification. When pressed about whether Staff E could legally complete wound assessments, Staff B deflected: "The company calls them evaluations."
Asked what an evaluation meant, Staff B admitted: "I don't know if I have an answer to that." She acknowledged the facility's software system classified these evaluations as full assessments, noting that "an assessment was more specific."
The director confirmed that wound assessments exceeded an LPN's scope of practice. She could not provide documentation showing that a certified wound care specialist or registered nurse supervised Staff E during wound evaluations.
Staff B acknowledged the practice violated professional standards. When asked whether Staff E should use a wound care specialist's assessment in their own documentation without being present, she stated: "No, and that it was not best practice."
The documentation problems created confusion about Resident 2's actual condition. Staff B said that according to facility evaluations, the resident's wound was classified as both a Stage 4 and "a superficial wound" upon discharge.
"Maybe the documentation was not accurate," Staff B told inspectors, adding that "they would expect nursing staff to document accurately."
The facility's records showed Staff E had been copying assessments from wound care specialists who visited on June 19, July 3, and July 10, 2025. Staff B admitted these copied assessments "look alike" to the facility's internal evaluations completed by Staff E.
Administrator Staff A acknowledged the facility should have completed competency skills testing for Staff E. "It would be important to complete a competency skills checklist to see if they needed to update their skills set, or if any corrections were needed they could identify and train their staff," the administrator said.
No such testing had occurred.
Staff F from Human Resources confirmed they could not locate any competency skills checklist for Staff E, despite the nurse being hired on July 28, 2023. Staff F said they "would expect there to be a checklist completed for them" and had contacted corporate payroll without finding documentation.
The facility had operated for more than two years with an uncertified nurse performing assessments that required specialized training and fell outside their licensed scope of practice.
Federal regulations require nursing facilities to ensure staff possess the competencies necessary to provide safe, quality care. Licensed practical nurses cannot independently assess or stage wounds without additional certification and training.
The violation affected multiple residents receiving wound care from Staff E, though inspectors classified the harm level as minimal with few residents affected. The practice continued until the November inspection exposed the systematic documentation and competency failures.
Staff E's admission that they never considered whether wound assessment fell within their scope of practice highlighted the facility's failure to provide basic training on professional boundaries and legal limitations for nursing staff.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of Shoreline from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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