The complaint came during a federal inspection at Life Care Center of Port Townsend that uncovered widespread failures in basic patient care. Inspectors found nurses giving opioid medications outside prescribed dosages, missing daily weight checks for a heart failure patient, and ignoring hospice recommendations for a cancer patient's mouth lesions.
Resident 42 said the facility's "one great deficiency" was dental hygiene. He explained that his brother had brought toiletry supplies including a toothbrush, and that he could brush his own teeth if staff brought the supplies and helped him rinse and spit. Inspectors observed his teeth were yellow with a whitish substance near his upper and lower gums.
The next day, Resident 42 told inspectors he still had received no dental care. His teeth remained visibly discolored.
Staff S, a certified nursing assistant, told inspectors she provided oral care "every meal" and would brush residents' teeth if they couldn't do it themselves. But when asked specifically about Resident 42, she said she wasn't normally on his hallway and assumed others "are doing it."
Staff F, the resident care manager, acknowledged Resident 42 would not allow anyone near his mouth but needed someone to set up oral care supplies since he couldn't get out of bed and was visually impaired. She said oral care should have been offered after every meal.
"It should be on their KARDEX," Staff F said, referring to an electronic area where nursing assistants receive care instructions. When she checked Resident 42's records, she found no oral hygiene tasks listed. "It should have been there."
Staff F entered Resident 42's room to observe his mouth directly. Upon leaving, she said she could see plaque and food buildup along his gums. When asked if this was acceptable, she said no. "I could even smell Resident 42's mouth."
Wrong Doses, Missing Weights
The medication failures involved three residents receiving improper opioid dosages or blood pressure medications despite dangerous vital signs.
Resident 23, who had congestive heart failure, was supposed to receive daily weights with specific reporting requirements. Doctor's orders called for weighing the patient every day shift before breakfast, with instructions to report weight gains of three pounds in one day or five pounds in a week.
Between March 27 and April 9, staff recorded only two weights: 252 pounds on March 27 and 244.2 pounds on April 3. No weights were documented on 12 other days during that period.
Staff F acknowledged the missed weights, saying some dates were missing because the resident couldn't be weighed due to a surgical incision location. But she said staff should have notified the provider when weights couldn't be obtained, and no such documentation existed.
The same resident received incorrect opioid doses repeatedly. Orders specified 2.5 milligrams of Oxycodone for pain levels of 4-6, and 5 milligrams for pain levels of 7-10. Staff also were required to attempt non-medication interventions like repositioning and ice before giving the drug.
Instead, nurses gave 5-milligram doses when pain levels were documented at 3 out of 10 on April 1, 3, and 7, and at 5 out of 10 on April 5. No documentation showed staff attempted required non-medication approaches on any of these dates.
Resident 23 was taking three blood pressure medications and two diuretics simultaneously. Despite this combination, the patient had dangerously low blood pressure readings of 99/55, 99/54, and 96/50 on consecutive days. Staff F said there should have been parameters specifying when to hold blood pressure medications, but none existed.
Cancer Patient's Ignored Treatment
Resident 28, who had mouth cancer and was receiving hospice care, presented a different failure. Inspectors observed visible lesions on the resident's bottom lip extending into the gum line.
Hospice had recommended applying A&D ointment to the cancer lesions to prevent drying and cracking. The recommendation was documented in a January 11 hospice admission summary. But no provider orders existed for the recommended ointment, and no wound care orders addressed the cancer lesions.
Staff Q, a certified nursing assistant, said staff provided oral care with green sponges and mouthwash. Staff U, a licensed practical nurse, described the care as "pain management and oral care" with no further wound care orders.
When shown the hospice assessment, Staff F said the recommended treatment hadn't been transcribed to provider orders and the provider should have been notified of the recommendations.
Staff B, the director of nursing services, said the recommendations should have been reviewed, reported to the provider, and transcribed if approved. "That did not happen and does not meet their expectations."
Kitchen Contamination
The inspection revealed extensive problems in food service areas. The dietary manager was observed working in the kitchen without required hair restraints on three separate occasions over two days.
Dishwasher temperature logs showed systematic failures to maintain sanitizing temperatures. In March 2025 alone, breakfast wash cycles fell below the required 150 degrees on 14 days, and rinse cycles fell below 180 degrees on 12 days. Similar patterns occurred during lunch and dinner cycles.
The dietary manager acknowledged the temperatures were "repeatedly outside of the required ranges to ensure that kitchenware was properly sanitized." During the inspection, a dishwasher cycle reached only 139 degrees for washing and 175 degrees for rinsing, both below sanitizing standards.
Food was observed stored on top of a medication cart, with crumbs scattered on the surface while three nurses worked nearby without intervening.
Infection Control Lapses
Staff handling oxygen equipment for Resident 39 placed a nasal cannula on the floor, then stored it improperly in the oxygen concentrator handle. The housekeeping worker later replaced the equipment but failed to clean the concentrator first.
A certified nursing assistant provided catheter care for a resident on enhanced barrier precautions without wearing the required gown. The resident was on these precautions specifically because of having a urinary catheter.
During dining room service, an activity assistant repeatedly touched her eyeglasses and other surfaces without performing hand hygiene between contact with different food items and residents.
Laundry staff transported clean and dirty linens together in the same cart, with dirty hangers stored on top of clean items. The environmental services director acknowledged that dirty and clean items should not be stored together.
The facility's infection preventionist said the observed practices did not meet expectations, but several staff members appeared unclear about basic hygiene requirements during interviews.
Life Care Center of Port Townsend received citations for failing to meet professional standards of quality, provide adequate assistance with daily living activities, ensure proper medication management, maintain appropriate food service standards, and implement effective infection control programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Port Townsend from 2025-04-11 including all violations, facility responses, and corrective action plans.