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Deficiency Records for Edmonds Care

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.

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?
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-06-05 2024-07-03 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-06-05 2024-07-03 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-05-28 2024-07-03 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-04-08 2024-05-22 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-04-08 2024-05-22 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-30 2024-01-11 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
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
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
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

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