A list of the most recent deficiencies for Edmonds Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2024-01-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-21 | 2023-10-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-30 | 2023-10-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-30 | 2023-10-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-30 | 2023-10-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-30 | 2023-10-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-30 | 2023-10-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-30 | 2023-10-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-30 | 2023-10-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-30 | 2023-10-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-30 | 2023-10-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-30 | 2023-10-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-08-30 | 2023-10-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-30 | 2023-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-30 | 2023-10-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-30 | 2023-10-12 | N |
| Keep all essential equipment working safely. | Health | 2023-08-30 | 2023-10-12 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-30 | 2023-10-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-30 | 2023-10-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-13 | 2023-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-13 | 2023-05-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-13 | 2023-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-13 | 2023-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-09 | 2023-01-18 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-12-09 | 2023-01-18 | Y |
| Install proper backup exit lighting. | Fire Safety | 2022-05-17 | 2022-08-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-17 | 2022-08-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-17 | 2022-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-17 | 2022-08-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-17 | 2022-08-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-27 | 2022-07-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-27 | 2022-07-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-27 | 2022-07-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-27 | 2022-07-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-27 | 2022-07-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-27 | 2022-07-11 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-27 | 2022-07-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-05-27 | 2022-07-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-27 | 2022-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-27 | 2022-07-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-27 | 2022-07-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-27 | 2022-07-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-27 | 2022-07-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-27 | 2022-07-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-27 | 2022-07-11 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-27 | 2022-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-27 | 2022-07-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-27 | 2022-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-07-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-27 | 2022-07-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-27 | 2022-07-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-27 | 2022-07-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-17 | 2022-06-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-17 | 2022-06-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-17 | 2022-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-17 | 2022-06-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-17 | 2022-06-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-17 | 2022-06-17 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-05-17 | 2022-06-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-17 | 2022-06-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-17 | 2022-06-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-17 | 2022-05-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-08 | 2022-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-08 | 2022-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-13 | 2022-01-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-13 | 2022-01-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2022-01-24 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-13 | 2022-01-24 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-13 | 2022-01-24 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-13 | 2022-01-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-02 | 2021-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-02 | 2021-09-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-02 | 2021-09-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-14 | 2021-05-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-04-14 | 2021-05-14 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-04-14 | 2021-05-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-13 | 2019-10-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-13 | 2019-10-29 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-09-13 | 2019-10-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-13 | 2019-10-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-09-13 | 2019-10-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-13 | 2019-10-29 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-13 | 2019-10-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-13 | 2019-10-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-13 | 2019-10-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-13 | 2019-10-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-13 | 2019-10-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-09-13 | 2019-10-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-13 | 2019-10-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-13 | 2019-10-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-13 | 2019-10-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-13 | 2019-10-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-13 | 2019-10-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-13 | 2019-10-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-13 | 2019-10-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-28 | 2019-10-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-28 | 2019-10-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-28 | 2019-09-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-28 | 2019-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-28 | 2019-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-28 | 2019-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-28 | 2019-09-13 | N |
