Port Washington Post Acute: Infection Control Failures - WA
The infection control violations at Port Washington Post Acute placed residents at risk for facility-acquired infections during some of the most vulnerable moments of their care. Federal inspectors documented the failures during a June 2024 inspection, finding staff routinely ignored basic hygiene protocols designed to prevent the spread of dangerous bacteria and viruses.
Staff P, the licensed practical nurse, performed wound care on Resident 62, who had venous stasis ulceration caused by damaged valves in leg veins. On June 13, inspectors watched as Staff P changed gloves multiple times during the dressing change but never used hand sanitizer or washed her hands between glove changes.
Thirty-two minutes later, Staff P entered the room of Resident 40, who had a stage 4 pressure ulcer. She carried the same box of medium gloves from Resident 62's room and again changed gloves multiple times without hand sanitizer or hand washing during the wound care.
When confronted about the violations, Staff P told inspectors: "When I was in school we were told to use hand sanitizer when changing gloves but I don't know if you noticed there is no hand sanitizer in the rooms and there are not medium gloves in the room. I typically put them in my pocket and did not today."
The Director of Nursing said her expectation would be for staff to wash their hands when changing gloves during dressing changes and to never take a box of gloves from one resident's room to another resident's room.
The infection control breakdowns extended beyond wound care. Staff routinely ignored isolation protocols designed to protect residents with antibiotic-resistant infections or other communicable conditions.
Resident 324 had a Contact Precautions sign posted outside their door directing staff to perform hand hygiene and wear a gown and gloves before entering. On June 11, Staff JJ, a physical therapy assistant, worked with Resident 324 at bedside without wearing gloves or a gown.
Two other residents required Enhanced Barrier Precautions, an expanded infection control protocol for patients at high risk of spreading multi-drug resistant organisms. The precautions require staff to wear gowns and gloves during high-contact activities like dressing, bathing, transferring, changing briefs, wound care and device care.
Resident 53 had the required Enhanced Barrier Precautions sign outside their door. On June 10, Staff II, a nursing assistant, entered the room and placed a meal tray on the overbed table. The assistant then placed their arms around the resident, lifting and boosting them up in bed, and used the bed controls to elevate the head of the bed. No gown or gloves.
Staff AA, a certified nursing assistant, violated the same protocols with Resident 10. On June 11, inspectors observed Staff AA positioning the resident in bed without required protective equipment, boosting the resident up and tucking pillows under their back and backside for positioning.
When informed of these observations, Staff E, the facility's infection preventionist, acknowledged the violations: "If Staff II and Staff AA provided care that required direct contact, they should have gowned and gloved. Staff JJ should have gowned and gloved prior to entering the room, just as the sign directed."
The same nursing assistant, Staff AA, also failed to follow basic hand hygiene during meal delivery. On June 10, inspectors watched as Staff AA delivered meal trays to four different resident rooms without using hand sanitizer when coming out of any room.
Staff AA later acknowledged the violation: "When they deliver meal trays they should have used hand sanitizer after every tray when before going into the room and then when they came out of a resident's room."
The most extensive infection control failure occurred during wound care for Resident 69, who had a stage 2 pressure ulcer. On June 12, inspectors documented a detailed sequence of violations as Staff P performed the wound care.
Staff P put on a gown outside the room for Enhanced Barrier Precautions, placed supplies on a tray inside, then came back outside to put on gloves without using hand sanitizer or washing hands. Inside the room, Staff P touched the resident's tray, grabbed more gloves, placed extra gloves on the resident's bed, touched the trash can, then put on additional gloves over the first pair.
After helping the resident turn, Staff P removed gloves and put on new ones from the pile on the bed without hand sanitizer. The nurse cleaned the wound with gauze, removed sticky residue from previous dressing, then again removed gloves and put on new ones from the bed pile without hand sanitizer.
Staff P patted the wound dry, applied an oil emulsion dressing, tucked the resident's brief without changing gloves or using hand sanitizer, applied skin barrier film, placed an abdominal pad with paper tape, changed gloves again without hand sanitizer, then changed the resident's brief.
When interviewed about proper wound care protocols, Staff P demonstrated knowledge of the requirements but explained the facility's limitations: "You should wash your hands when you enter and exit, and you should wear gloves and a gown with patient care. Hand sanitizer should be used before gloves, before entering room, between glove changes, after any task, going from patient to patient."
Staff P acknowledged that adding gloves over used gloves was inappropriate, as was removing gloves and putting on new ones without hand sanitizer. "This facility does not have hand sanitizer inside the room," Staff P said.
The facility's own policies required strict adherence to infection control protocols. The Hand Hygiene policy, revised in August 2019, mandated that all personnel follow handwashing procedures before and after direct contact with residents, before and after entering isolation rooms, before applying gloves and after glove removal. The policy specifically stated that glove use does not replace hand hygiene.
The Enhanced Barrier Precautions policy, revised in August 2022, required gowns and gloves during high-contact resident care activities that provide opportunities for multi-drug resistant organisms to contaminate staff hands and clothing.
Beyond the infection control failures, inspectors found the facility failed to accommodate a resident's documented apple allergy. Resident 67, who was cognitively intact and on a cardiac diet, repeatedly received apple juice with breakfast despite having a known allergy to apples.
On three separate days in June, inspectors observed unopened apple juice containers on Resident 67's bedside table. The resident explained they had allergies to apples but still received apple juice every day with breakfast.
A Life Enrichment Evaluation from May 3 documented Resident 67's apple allergy, but no other documentation in the electronic health record mentioned the allergy. The Dietary Manager and Regional Registered Dietitian said they had just been informed about the apple allergy the morning of June 17, more than a month after it was documented.
The infection control violations placed residents at heightened risk during their most vulnerable medical procedures, while basic communication failures left at least one resident repeatedly exposed to a known allergen despite clear documentation of the problem.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Port Washington Post Acute from 2024-06-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
PORT WASHINGTON POST ACUTE in BREMERTON, WA was cited for violations during a health inspection on June 18, 2024.
Staff P, the licensed practical nurse, performed wound care on Resident 62, who had venous stasis ulceration caused by damaged valves in leg veins.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at PORT WASHINGTON POST ACUTE?
- Staff P, the licensed practical nurse, performed wound care on Resident 62, who had venous stasis ulceration caused by damaged valves in leg veins.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in BREMERTON, WA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from PORT WASHINGTON POST ACUTE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 505240.
- Has this facility had violations before?
- To check PORT WASHINGTON POST ACUTE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.