Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Issaquah during CMS and state inspections, most recent first.
The facility did not ensure timely and accurate completion of PASRR assessments for several residents with serious mental illness or intellectual disabilities. Multiple residents were admitted or experienced significant changes in condition without required Level 2 evaluations, despite documented indicators of SMI on Level 1 PASRR screenings. Staff interviews confirmed that necessary referrals and documentation were not completed as required.
The facility did not have a documented water management plan to prevent Legionella, and staff failed to follow hand hygiene and contact precaution protocols during resident care. Staff provided incontinence care without changing gloves or performing HH between dirty and clean tasks, and an Activity Assistant entered a contact precautions room without required PPE or hand hygiene.
The facility did not disburse trust fund balances to several residents or their representatives within the required 30-day period after discharge, with some accounts remaining undistributed for over a month. This failure was confirmed by record review and staff interview, showing that trust funds were not reconciled in accordance with policy and state regulations.
Two residents experienced unresolved grievances related to missing personal items—dentures and a hearing aid—after staff failed to follow the facility's grievance policy, did not log or investigate the concerns, and did not communicate outcomes to the residents or their representatives.
The facility did not ensure accurate MDS assessments for two residents, resulting in one resident's mental health status and skin condition being incorrectly documented, and another resident's discharge destination being inaccurately coded. These errors were confirmed by the MDS Coordinator upon review of clinical records and interviews.
The facility did not update care plans for two residents, resulting in outdated interventions such as incorrect fall prevention measures and tube feeding instructions, and failed to conduct timely care conferences for another resident with multiple diagnoses. Staff confirmed that care plans and care conferences were not maintained according to policy.
Staff failed to consistently follow physician orders and medication administration protocols, including not documenting administered medications, signing off on uncompleted tasks, not clarifying unclear or changed orders, and administering medications outside of prescribed parameters. These actions affected several residents, including those with pain management needs, wound care, and other medical conditions.
Three residents dependent on staff for ADLs did not consistently receive required assistance with personal hygiene, including bathing, shaving, and nail care. One resident was repeatedly observed with long facial stubble and reported not receiving scheduled showers or shaving, while another had long fingernails despite being scheduled for regular nail care. A third resident was observed with long chin hairs and broken nails, with documentation not matching observed care. Staff interviews confirmed expectations for care and documentation were not met.
The facility did not ensure that two residents' code status preferences, as indicated on their POLST forms and physician orders, were accurately reflected in all care documentation. In both cases, documentation such as the care plan and Kardex listed the residents as Full Code, despite their wishes and orders for DNAR status. Staff interviews confirmed reliance on these documents for care decisions, highlighting the inconsistency in records.
Two residents with significant cognitive and physical impairments did not receive individualized activity programs as outlined in their care plans. Documentation and observations showed limited engagement in preferred activities, with one resident mostly found sleeping and another rarely participating in group events. The activity director confirmed inconsistent implementation of activity preferences and a lack of regular reassessment or updates to care plans.
The facility failed to obtain timely and complete laboratory services for two residents, resulting in missed or invalid blood tests that were ordered by physicians to monitor complex medical conditions and medication levels. In both cases, required labs were either not performed or not documented as completed, and staff did not follow expected procedures for addressing missed lab draws.
The facility failed to accurately assess and implement safety measures for three residents, including not obtaining or following physician orders for independent outings, not consistently applying fall prevention interventions for a resident with severe impairments, and not performing required smoking safety assessments or updating care plans for a resident who smoked independently. These lapses resulted in unaddressed accident hazards and inadequate supervision.
Failure to Complete Timely and Accurate PASRR Assessments for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed and obtained prior to admission for several residents with serious mental illness (SMI) or intellectual disabilities. For multiple residents, Level 1 PASRR screenings identified indicators of SMI, such as mood disorders, anxiety, depression, and bipolar disorder, yet no required Level 2 evaluations were completed prior to admission as mandated. In some cases, the PASRR forms were incomplete, unsigned, or not properly indicating the need for further evaluation, and referrals for Level 2 assessments were either delayed or not documented at all. One resident was admitted with a diagnosis of bipolar disorder and required antipsychotic medication, with a Level 1 PASRR indicating SMI, but no Level 2 evaluation was completed before admission. Another resident with anxiety and depression, also requiring psychotropic medications, was admitted without a Level 2 evaluation despite SMI indicators on the PASRR. For a third resident, two separate Level 1 PASRRs over a seven-month period both indicated the need for a Level 2 evaluation due to a mood disorder, but no such evaluation was found in the records. Staff interviews confirmed that these evaluations should have been completed and that documentation was lacking. Additional deficiencies included a resident with dementia and depression whose PASRR form was not signed or dated and lacked a Level 2 evaluation, and another resident who experienced a significant change in health status, including a suicide attempt and use of multiple psychotropic medications, but was not referred for a Level 2 PASRR until eight months after the change. Staff acknowledged these omissions and delays during interviews, confirming that the required processes were not followed as specified.
Failure to Implement Infection Control and Water Management Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program. Specifically, the facility did not have a documented water management plan to prevent the growth of Legionella and other waterborne pathogens. The Maintenance Director was unable to provide documentation of a water management plan, committee meetings, or testing records, and was unaware of high-risk areas in the water system. The Infection Preventionist provided a policy stating that a water management committee should review the plan quarterly, but there was no evidence this occurred. The Administrator confirmed the absence of a water management plan. Additionally, staff failed to perform proper hand hygiene (HH) and follow contact precaution protocols. During incontinence care for a resident dependent on staff for all activities of daily living and receiving tube feeding, staff did not change gloves or perform HH when moving from dirty to clean tasks, and contaminated clean linens and equipment with soiled gloves. Staff also failed to dispose of dirty linens appropriately. In another instance, an Activity Assistant entered a resident's room on contact precautions without performing HH or donning required personal protective equipment, and did not wash hands upon leaving. Staff interviews confirmed awareness of the correct procedures, but these were not followed during the observed events.
Delayed Disbursement of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that resident trust fund balances were reimbursed to the appropriate parties within the required 30-day period following discharge or death, as mandated by both facility policy and state regulations. Specifically, for four out of seven discharged residents reviewed, trust fund balances were either not disbursed within the required timeframe or remained undistributed beyond 30 days. For example, one resident's balance was not closed out and disbursed until 64 days after discharge, another after 59 days, and a third after 34 days. In one case, a resident's trust fund balance remained active and undistributed 33 days after discharge. Facility policy required that trust funds be disbursed within seven days for discharged residents and within 30 days for deceased residents. However, record review and staff interviews confirmed that these timelines were not met for the affected residents. The Business Office Manager acknowledged that the trust accounts for these residents should have been disbursed as required but were not, resulting in delays in reconciling the residents' accounts.
Failure to Initiate and Resolve Grievances for Missing Personal Items
Penalty
Summary
The facility failed to properly initiate, log, investigate, and resolve grievances for two residents who reported missing personal items, as required by their grievance policy. For one resident with moderate cognitive impairment and dental issues, staff documented a grievance regarding ill-fitting dentures and initiated some follow-up with the dental provider. However, when it was discovered that the resident's dentures were missing, staff did not complete a new grievance communication form or inform the administrator, resulting in the issue not being tracked or resolved according to policy. Another resident, who had hearing difficulties and used hearing aids, lost one hearing aid after returning from a hospital stay. Multiple staff members and the resident's representative were aware of the missing hearing aid, and the outside provider also notified staff about the loss. Despite this, there was no documentation in the facility's grievance or investigation logs acknowledging or investigating the missing hearing aid, and the administrator was not made aware of the issue. Interviews with staff revealed that the facility's process for missing items was not followed, as staff failed to initiate grievance forms and did not communicate the outcomes to the residents or their representatives. The lack of oversight and failure to track grievances through to their conclusion resulted in unresolved concerns regarding residents' missing personal items.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident with multiple complex medical diagnoses, including anxiety disorder and depression, the annual MDS did not indicate the presence of a Serious Mental Illness (SMI) as determined by a prior Level 2 PASRR evaluation, despite documentation showing the resident required specialized behavioral health services. Additionally, a quarterly MDS for the same resident inaccurately reported the presence of a pressure ulcer, scar, or non-removable dressing/device, even though nursing progress notes and a weekly skin audit documented intact skin with no wounds or such devices present during the assessment period. The MDS Coordinator confirmed these inaccuracies during interviews and acknowledged the importance of accurate MDS coding for care planning. For another resident, the discharge MDS was incorrectly coded to indicate discharge to an acute care hospital, while nursing progress notes documented that the resident was actually discharged home in stable condition with their spouse. The MDS Coordinator reviewed the assessment and confirmed the error, stating that the MDS required modification to accurately reflect the resident's discharge disposition.
Failure to Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated and revised as needed for two residents and did not conduct timely care conferences for another resident. For one resident who was dependent on staff for toileting and transfers and at risk for falls, the care plan directed staff to keep the bed in the lowest position, but repeated observations showed the bed was not in the lowest position. Additionally, the care plan still included interventions for cellulitis and antibiotic administration, despite the resident no longer having cellulitis or receiving antibiotics. Staff interviews confirmed that the care plans were outdated and needed revision. Another resident with complex medical needs, including a feeding tube, had conflicting care plan interventions regarding the type and amount of tube feeding formula. The care plan was not updated to reflect the current physician order for a fiber formula, as confirmed by staff. For a third resident with multiple diagnoses, including stroke and difficulty swallowing, there was no evidence of quarterly care conferences, and the resident was unaware of any meetings regarding their care plan or denture issues. Staff acknowledged that care conferences should occur quarterly and as needed for significant changes, but documentation was lacking.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were followed and medications were administered within the prescribed parameters for multiple residents. In several instances, staff did not document administered medications as required, such as when a charge nurse gave a non-narcotic pain medication to a resident but failed to record the administration in the Medication Administration Record (MAR). Additionally, staff signed off on tasks, such as diabetic nail care, that were not completed as ordered, as evidenced by observations of a resident with long, untrimmed fingernails despite documentation indicating the care had been performed. There were also failures to clarify physician orders when changes occurred. For example, after a resident's wound care order was changed from daily to every other day, staff continued to administer a narcotic pain medication daily without clarifying the order with the prescriber. Another resident had a vitamin order lacking a specified dosage, which was not clarified before administration. In some cases, staff administered medications outside of the ordered parameters, such as giving a suppository without first administering a required liquid laxative, or providing pain medications in dosages or for pain levels not consistent with the physician's instructions. Multiple residents received as-needed (PRN) pain medications in ways that did not align with their prescribed parameters. For instance, residents were given narcotic pain medications for pain scores that did not meet the threshold specified in the orders, or were given lower doses than ordered for higher pain scores. Staff interviews confirmed that medications were not always administered as ordered and that orders were not always clarified when necessary, leaving residents at risk for unmet care needs and other negative health outcomes.
Failure to Provide Required ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff for personal hygiene and grooming. One resident, with cognitive impairment and multiple diagnoses including heart failure and malnutrition, was observed on several occasions with long facial stubble and reported not receiving scheduled showers or shaving assistance. Documentation showed significant gaps between bathing offers, and there was no record of staff reapproaching the resident after refusals or documenting these refusals as required by facility policy. Another resident, who was dependent on staff for personal hygiene and required assistance with nail care, was observed multiple times with long fingernails. The resident stated that staff were supposed to clip their nails but did not do so. Staff interviews confirmed that nail care should be provided weekly and as needed, with refusals documented, but observations indicated this care was not consistently provided. A third resident, also dependent on staff for personal hygiene and requiring weekly diabetic nail care, was observed with long, curly chin hairs and fingernails extending past the fingertips, including broken and jagged nails. Documentation indicated that scheduled nail care was marked as completed, but observations contradicted this, and staff confirmed that shaving and nail care should be provided as needed. There was no documentation of refusals for personal hygiene or bathing, and staff only addressed the long nails after they were noticed during an observation.
Failure to Accurately Reflect Resident CPR Status in Records
Penalty
Summary
The facility failed to ensure that physician orders and resident records accurately reflected the residents' wishes for Cardiopulmonary Resuscitation (CPR) status as indicated on their Physician Orders for Life Sustaining Treatment (POLST) forms. For one resident, the POLST form and physician orders indicated Do Not Attempt Resuscitation (DNAR), but other documentation, including a revised care plan and Kardex, incorrectly listed the resident as Full Code, directing staff to perform CPR. The facility's POLST binder did contain the correct DNAR form, but this was not consistently reflected across all records. Staff interviews confirmed that the records did not match the resident's wishes and required correction. For another resident, a significant change in health status led to a transition from life-prolonging care to hospice care, with a new POLST form indicating DNAR and selective treatment. However, the resident's Kardex still listed them as Full Code. Staff interviews revealed that care staff relied on the Kardex and care plan to determine code status and initiate CPR if indicated. The inconsistency between the POLST, physician orders, and care documentation resulted in a failure to ensure that staff had accurate information regarding the residents' code status.
Failure to Implement Individualized Activity Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized activity plans and ensure activity programs met the needs of each resident for two of five residents reviewed. For one resident with no speech, poor vision, and total dependence on staff for daily activities, the care plan identified preferences such as listening to music, being around pets, group activities, and religious practices. However, activity participation records showed the resident was mostly documented as sleeping during 1:1 activities, with only a few days marked as active. Observations confirmed the resident was consistently found lying in bed with no music playing, and there was no evidence of participation in group or religious activities. The activity director acknowledged that music was not played in the room due to concerns about disturbing the roommate and had not considered alternatives like headphones. The director also admitted that staff did not consistently offer or assist the resident with preferred activities. Another resident with severe memory impairment and dependence on staff for mobility was assessed to enjoy music, animals, news, and religious activities. The care plan directed staff to provide daily activity materials, assistance to group activities, pet visits, and 1:1 activities. Despite this, activity documentation showed minimal participation in group activities, with only a few instances recorded over two months. Observations found the resident lying in bed with only the television on, and there were no activity progress notes or quarterly assessments completed. The activity director stated that reminders for activities were inconsistent and that residents who were sleeping were not disturbed. The director also admitted to not conducting regular assessments or updating care plans as residents' needs changed. The facility's policy required an activities program addressing each resident's intellectual, social, spiritual, creative, and physical needs, promoting self-expression and choice. However, the facility did not consistently implement individualized activity plans or ensure that residents received activities aligned with their preferences and needs, as evidenced by documentation, observations, and staff interviews.
Failure to Obtain Timely Laboratory Services for Two Residents
Penalty
Summary
The facility failed to provide timely laboratory services for two residents who required physician-ordered blood tests. For one resident with multiple complex medical conditions, including anemia, heart failure, kidney, and lung disease, laboratory tests were ordered to monitor inflammation and infection as part of wound care management. The initial blood specimen collected was invalid due to the age of the sample, and the tests were not performed. A subsequent order for the same tests resulted in another invalid specimen for one of the tests, again due to specimen age. Despite repeated orders, one of the required tests was never successfully obtained over a period of more than six weeks. For another resident receiving heart failure medication, there was a standing order for regular blood draws to monitor medication levels. The scheduled lab draw was not completed as ordered, and there was no documentation in the progress notes explaining the missed lab or any follow-up. Staff interviews confirmed that the expected procedures for reattempting lab draws and documenting refusals or missed labs were not followed.
Failure to Ensure Resident Safety and Accident Prevention
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for multiple residents, resulting in deficiencies related to accident hazards and resident safety. One resident with a history of substance abuse and behavioral issues was able to leave the facility independently on two occasions without a physician's order or proper assessment of their ability to do so safely. Documentation showed that staff did not inform the physician when the resident left the facility, and the care plan was only updated after these incidents to include procedures for signing out, notifying representatives and the physician, and following up with the resident while out of the facility. Another resident with severe memory and vision impairment, who was dependent on staff for transfers and at high risk for falls, did not have prescribed fall prevention interventions consistently implemented. Observations revealed that the resident's bed was not kept in the lowest position as ordered, fall mats were not placed on both sides of the bed as directed, and non-skid footwear was not used, despite clear care plan instructions and physician orders. Staff interviews confirmed that these interventions were expected to be in place to prevent falls and injuries. A third resident, who was dependent on staff for transfers and used a wheelchair, was allowed to smoke independently without consistent quarterly safety assessments as required by the care plan. The resident kept smoking supplies at the bedside in a locked drawer, which was not reflected in the care plan, and had not signed a current smoking policy and consent after a change in facility ownership. Staff acknowledged that several required smoking safety assessments were missed, and the facility's smoking policy did not address the practice of keeping supplies at the bedside for independent smokers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Issaquah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarwood At Timber Ridge | 1.5 mi | — | 27 | 0 |
| Marianwood Health And Rehabilitation | 2.5 mi | — | 22 | 0 |
| Bellevue Post Acute | 7.7 mi | — | 63 | 0 |
| Covenant Shores Health Center | 8.5 mi | — | 25 | 0 |
| Renton Health & Rehabilitation | 9.3 mi | — | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.