Avamere Rehabilitation Of Shoreline

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documented it in the TAR.On 11/13/2025 at 4:02 PM, Staff C, Resident Care Manager, stated nursing staff should check the physician's orders and have correct documentation after administration of medications.

Staff C stated a treatment dressing should be labeled with the nurse's initials and date and time it was done. Staff C stated Staff D was not supposed to document Resident 1's treatment administration until it was done.On 11/13/2025 at 4:24 PM, Staff B, Director of Nursing Services, stated they expected nursing staff to follow physician orders, and if something did not seem right to get clarification. Staff B further stated

they expected staff to document after treatment was completed.In a follow-up interview on 11/14/2025 at 11:50 AM, Staff B stated that Staff D should have followed the physician's orders for Resident 1 and checked it off after completing the tasks.Reference: (WAC) 388-97-1620(2)(b)(i)(ii).

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of Shoreline

1250 Northeast 145th Street Seattle, WA 98155

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

they did not stage any wounds. Staff E stated that they put their documentation into the wound evaluations.

When asked about the evaluations completed for Resident 2, Staff E stated that they did not stage the wounds, that they followed the previous wound care provider's assessment, and if it basically looked the same then that is what they would document. Staff E stated they were not wound care certified. When asked if assessing/evaluating was under an LPN's scope of practice, Staff E stated, I never really thought of that, I am not sure. I will have to get back to you.On 11/14/2025 at 5:00 PM, Staff B, Director of Nursing, stated Staff E had been the facility's wound nurse and that they were not wound care certified. When asked if Staff E could complete wound assessments, Staff B stated, the company calls them evaluations. When asked what an evaluation meant, Staff B stated, I don't [do not] know if I have an answer to that, and stated

they were aware their software system classified the evaluation as a full assessment. Staff B stated that an assessment was more specific. When asked if the Wound Care Specialist's assessment from 06/19/2025, 07/03/2025, and 07/10/2025 contained the same assessment as their AvaWound Evaluation #1-V 2, Staff B stated, they look alike. Staff B stated that assessing was not under the scope of practice of an LPN and that

they could not provide supporting documentation to show that another Wound Care Specialist or RN was with Staff E during the completion of wound care evaluations. When asked if it was appropriate for Staff E to use the Wound Care Specialist's assessment under their own documentation when they were not present, Staff B stated, no, and that it was not best practice. When asked what stage Resident 2's wound was at upon discharge, Staff B stated according to their evaluations a Stage 4 and on another note, it stated a superficial wound. Staff B further stated maybe the documentation was not accurate and that they would expect nursing staff to document accurately.On 11/14/2025 at 6:45 PM, Staff A, Administrator, stated they would expect there to be a competency skills checklist completed for Staff E. Staff A stated 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. On 11/14/2025 at 6:54 PM, Staff F, Human Resources/Payroll, stated they could not find a competency skills checklist completed for Staff E. Staff F stated Staff E was hired on 07/28/2023, and that they would expect there to be a checklist completed for them. Staff F stated that they had reached out to their corporate payroll and had not found anything either.Reference: (WAC) 388-97-1680 (2)(a)(b)(i).

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