Sequim Bay Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure offloading interventions were implemented consistently to prevent the development and worsening of pressure injuries (also known as pressure ulcers, that occur when soft tissues are compressed between bony prominences and external services) and that wound care was provided consistently as ordered to promote wound healing for 1 of 3 residents (1) reviewed for pressure injuries. Resident 1 experienced harm when they developed a stage 2 (partial thickness loss of skin with expose dermal tissue) pressure injury on their right heel worsened to an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure injury wound that became infected requiring antibiotic treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative was notified of significant changes related to the development of a Stage 2 pressure injury (develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period causing partial-thickness skin loss affecting the epidermis and dermis, but do not expose fat or deeper tissues) for 1 of 3 sample residents (Resident 1) reviewed for notification of changes. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, delayed medical treatment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to include pressure prevention strategies for a newly admitted resident who was at risk for pressure injury (also known as pressure ulcers, bedsores, or decubitus ulcers, occur when soft tissues are compressed between bony prominences and external surfaces) and failed to consistently implement interventions for 1 of 3 residents (Resident 1) reviewed for care planning. This failure places residents at risk of unmet care needs, development of pressure injuries, and decreased quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to follow up on reports of lost items for 1 of 3 residents (Resident 1) reviewed for grievances. This failure places all residents at risk of unmet needs, a diminished quality of life, and potential financial burden.

Inspectors wroteBased on interview and record review the facility failed to promptly update and consistently implement care planned interventions for 1 of 3 residents (Resident 1) reviewed for care planning) to maintain the resident's ability and function in preparation for discharge home. This failure places residents at risk of unmet care needs, decreased quality of life, and decline in functional ability.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' records were complete, accurate, and/or accessible, for 1 of 1 sampled resident (Resident 1) reviewed for accurate and complete medical records. Failure to maintain complete and accurate medical records, that are accessible to staff, placed residents at risk for delayed resources, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure at least eight consecutive hours of Registered Nurse (RN) coverage was provided daily, for 3 of 31 days reviewed (07/27/2025, 08/03/2025 & 08/17/2025) for RN coverage. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, and provision of nursing care and services requiring a RN.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were reviewed to ensure they accurately reflected residents' mental health diagnoses and/or selected the requirement for Level 2 PASRR referrals to be made, for 6 of 8 sampled residents (Residents 29, 1, 17, 58, 6, & 8) reviewed for PASRRs. This failure placed residents at risk for not receiving timely and necessary mental health services, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 6 of 22 sampled residents (Resident 15, 58, 8, 17, 6 & 5) reviewed unnecessary medication and for 2 of 2 nursing refrigerators (South Hall and North Hall) reviewed. The facility staff failed to label and date open vials and document, follow, or transcribe physician orders when indicated. These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their person-centered plan of care, for 5 of 8 residents (Resident 58, 8, 17, 15, &5) reviewed for bowel management, and 1 of 2 residents (Resident 5) reviewed for pressure ulcers. The failure to ensure the provision of bowel care was in accordance with physicians' orders and/or the facility bowel protocol, and that pressure redistribution devices functioned properly, placed residents at risk for delays in treatment, skin breakdown, unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and/or implement comprehensive resident centered care plans for 3 of 20 residents (Residents 45, 70, & 17) reviewed for care planning, and to ensure care conferences occurred for 1 of 2 residents reviewed (Resident 15) for care conferences. This failure placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to assist with scheduling and/or coordinating notary public services (a public officer whose function it is to administer oaths; to attest and certify, by their hand and official seal, certain classes of documents, in order to give them credit and authenticity) for 2 of 2 residents (Residents 7 & 70) reviewed for advanced directives (written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney for health care) who required notarization. This failure placed residents at risk of not having their identified healthcare decisions and preferences honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received timely specialized rehabilitative services for 1 of 2 residents reviewed for therapy services (Resident 45). This failure to complete a Speech Therapy evaluation and provide services, placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report to the state agency and/or log allegations of abuse/mistreatment by staff on the reporting log within five working days for 1 of 3 residents reviewed for abuse and neglect. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide routine cleaning services to support a clean and homelike environment for 2 of 5 sampled residents (Resident 1 and 2) reviewed for clean, homelike environment. This failure placed residents at risk for a less than homelike environment, diminished quality of life and potential infection control issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 6 residents (Residents 67, 55, 11, 24, 65 and 2) interviewed, and 6 staff (Staff B, J, H, M, N & 1 anonymous staff) interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living and restorative services. These failures placed residents at risk for unmet care needs, decreased physical abilities and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide Care Conferences (a conference where staff and residents/families talk about life in the facility, review the progress of each patient and make adjustments, as needed, to their care), for 5 of 5 sampled residents (Residents 13, 17, 23, 28, and 44) reviewed for provision of care conferences, and failed to ensure care plans were reviewed, revised, and accurately reflected resident care needs for 3 of 31 sample residents (Residents 68, 69 and 31) reviewed for care plan timing and revision. These failures placed residents at risk of not feeling involved in the development of their plan of care, unmet needs, decreased quality of care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent restorative services were provided for 4 of 6 sampled residents (Residents 17, 23, 28, and 65) reviewed for range of motion (ROM) and mobility. This failure placed residents at risk for avoidable decline and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Intravenous (IV) services were provided in accordance with professional standards of practice and facility policy for 2 of 2 residents (Resident 69 & 31) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 4 of 4 residents (Residents 28, 50, 67 & 2) with mechanical soft or puree diets, whose meals were observed during tray line. Failure to provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to prepare and serve foods in a manner that conserved nutritive value, palatability and that ensured meals served were appetizing and at the proper temperature for 5 of 8 (Residents 17, 23, 28, 32, and 8) sampled residents reviewed for dining and 2 of 2 residents (Residents 2 and 57) on pureed diets. The failure to ensure meals were served at appropriate temperatures, with a good presentation, and that were palatable, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or their legal representative, in advance, of the risks and benefits associated with the use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior) and obtain informed consent prior to administering the medications for 1 of 5 residents (Resident 77) reviewed for unnecessary medications. These failures prevented residents and/or legal representatives from making informed decisions about the use of multiple antidepressant medications, and precluded them from exercising their right to refuse/decline the proposed medications.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place which ensured the Office of the State Long-Term Care Ombudsman (an advocacy group for residents in a nursing homes) received required resident discharge information for 2 of 5 residents (Resident 43 & 31) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , not understanding their rights, and prevented the Ombudsman from having the opportunity to educate and advocate for residents during the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide residents/resident's representatives bed hold notices at the time of transfer, or within 24 hours of an emergent transfer for 1 of 5 residents (Resident 43) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 28 sampled residents (Residents 69 & 43) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to accurately identify active diagnoses, the presence and type of intravenous access, the administration of IV medications, and to assess a resident's cognitive patterns, placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 28 sample residents (Residents 132, 69 & 43) reviewed for professional standards. The failure to follow and/or clarify incomplete physician's orders, and to only sign for tasks that were completed, placed residents at risk for medication errors, unidentified and/or delayed treatment of complications related to intravenous (IV) therapy, and other potential negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 1 of 1 resident (Resident 43) reviewed for enteral nutrition. The facility failed to accurately record the amount of enteral formula and water flushes administered, to identify and clarify incomplete enteral orders to include route of administration (e.g., gastric tube), method of delivery (gravity, via pump etc.) and the time the enteral formula infusion was to start and finish. These failures placed residents at risk for receiving inadequate nutrition, hydration, weight loss and other potential adverse health outcomes.

Inspectors wroteBased on observation and interview the facility failed to ensure staff compliance with current infection control guidelines and standards of practice for donning (putting on) of personal protective equipment (PPE) for 1 of 4 residents (Resident 40), reviewed for infection control. This failure placed residents at an increased risk for exposure to cross contamination (harmful spread of illness), transmission of diseases and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate a resident grievance for 1 of 1 sampled resident (Resident 1) reviewed for grievances. This failure placed residents at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 6 sampled residents (Resident 1) reviewed for quality of care. The facility failed to act timely on a physician order referring the resident for additional diagnostic testing and a spine specialist. This failure placed residents at risk for health complications, prolonged pain, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide care and services to prevent urinary tract infection (UTI) for 1 of 3 residents (Resident 1) reviewed for quality of care. The facility implemented an external urinary catheter system without assessing for appropriateness, training staff in the use of the device, care planning the system and failed to ensure adequate hydration. These failures placed residents at risk for infection, dehydration, and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were updated to reflect current care needs for 1 of 4 residents (Resident 1) reviewed for care planning. This failure placed residents at risk for unmet care needs, decline in function, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide an ongoing program of exercise to prevent a decline in range of motion for 1 of 4 residents (Residents 1) reviewed for restorative services. Failure to provide consistent services placed residents at risk of deconditioning, loss of range of motion, inability to complete activities of daily living (ADL), and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure activities of daily living (ADLs), including showering/bathing were provided for dependent residents for 3 of 3 sampled residents (Resident 1, 2 & 3) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to: ensure their infection control and preventions practices were implemented to prevent the transmission of a highly transmissible disease Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria resistant to nearly all antibiotics and difficult to remove from the environment, a multi-drug resistant organism [MDRO]); prevent the spread of CRAB within the facility for 6 of 6 sampled residents (61, 41, 42, 70, 37 & 39) reviewed for infection control prevention; utilize the proper types of disinfectant wipes against the Carbapenem-Resistant Organism (CRO); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 3 of 30 sampled days (07/15/2023, 07/16/2023 and 07/22/2023) reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a dignified manner for 4 of 4 sampled residents (17, 54, 5 & 4) reviewed for resident rights. This failure placed residents at risk for not being groomed in their normal manner, not having privacy during personal care and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the environment had acceptable levels of noise and prevent excessive odors for 2 of 4 halls (North side halls & 200 and 300 halls) and 1 of 1 sampled residents (54) reviewed for homelike environment. This failure placed residents at risk of stress, unpleasant odors and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with professional standards for 1 of 2 medication storage areas (South) reviewed for medication storage. This failure placed residents at risk of receiving wrong or ineffective medications and treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff received dementia training for 3 of 5 sampled staff (C, D & E) reviewed for staff in-service trainings. This failure placed residents at risk of receiving care from unskilled staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure procedures were in place to assist residents with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney documentation for 2 of 2 sampled residents (Residents 22 & 31) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications and treatments were being administered per provider orders for 1 of 5 sampled residents (Resident 53) reviewed for services meet professional standards. This failure placed residents at risk for medical complications, substandard quality of care and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident communication devices were available for 1 of 1 sample resident (Resident 53) reviewed for activities of daily living. This failure placed residents at risk of not being able to adequately express themselves and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dependent residents eating assistance for 1 of 1 sampled resident (Resident 5) reviewed for activities of daily living (ADLs) for dependent residents. This failure placed residents at risk of choking, weight loss and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was an activity program to meet individual resident needs for 1 of 4 sampled residents (53) reviewed for activities. This failure placed residents at risk for becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure neurological assessments (neuros, assesses the nervous system and identified any abnormalities affecting function and activities of daily living) were performed after an unwitnessed fall and failed to ensure residents received necessary care and services with positioning based on comprehensive person-centered care plan for 2 of 5 sampled residents (40 & 16) reviewed for quality of care related to accidents and positioning. This failure placed residents at risk for unidentified injuries, health complications, worsening conditions, a delay in treatment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development was prevented and promoted wound healing by implementing and following care interventions and physician orders for 1 of 3 sampled residents (Resident 4) reviewed for pressure injuries. This failure placed residents at risk for wound complications, infection, delayed healing, increased pain and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure identified weight loss acted upon and interventions developed for 1 of 1 sampled resident (Resident 53) reviewed for nutrition. This caused harm to Resident 53 when the resident experienced a significant weight loss of greater than 5% body weight within a 30-day period and the identified weight loss was not addressed. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing hours were accurately posted and updated each shift for 7 of 14 sampled days (07/11/2023, 07/12/2023, 07/18/2023 to 07/21/2023, and 07/23/2023) reviewed for nurse staff posting. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census.