Olympic View Care: Medication Errors & Safety Failures - WA
The most serious violations centered on Resident 127, who required IV antibiotics through a PICC line — a long catheter threaded through an arm vein to larger vessels near the heart. The resident's medical orders required dressing changes every 72 hours, with measurements of the external catheter length and arm circumference to detect dangerous complications.
Nurses signed treatment records claiming they completed these tasks on April 26, April 29, May 5, and May 8. But when inspectors checked on May 9, the PICC dressing still bore a May 5 date, proving the May 8 care never happened.
"Facility nurses had erroneously signed for tasks they did not complete," Staff C, the Resident Care Manager, acknowledged to inspectors.
The falsified documentation placed Resident 127 at risk for infection, blood clots, and loss of the critical IV access needed for antibiotic treatment of pneumonia and bacteremia. Staff C admitted there was no documentation showing nurses ever measured the catheter length or arm circumference as ordered, despite months of signed records claiming otherwise.
The facility also lacked proper physician orders for standard PICC line safety measures, including flushing the line before and after medication administration and changing needleless injection caps.
Beyond the falsified IV care, inspectors documented a cascade of medication safety failures affecting multiple residents.
Nurses failed to properly track controlled substances, signing ledgers for narcotic counts only twice in three months despite requirements for twice-daily verification. "Some nurses sign in that book, some don't," Licensed Practical Nurse Staff L told inspectors when asked about the missing signatures.
The facility administered IV antibiotics at dangerously incorrect intervals. Resident 127's cefazolin was ordered every eight hours but routinely given four to five hours late at midnight, then administered again just two to three hours later in the morning — creating 13-14 hour gaps followed by doses too close together.
Staff C confirmed the pattern: nurses consistently administered midnight doses four to five hours late, then "failed to adjust the administration time of the next dose."
Olympic View's medication storage also violated safety standards. Inspectors found expired medications on carts, including benzonatate that expired in June 2024 and mirtazapine that expired in May 2024. A tuberculin vial was improperly stored in a freezer for 56 days past its discard date.
The medication refrigerator hadn't been temperature-checked since October 2024, despite containing insulin and IV antibiotics requiring specific storage conditions.
Pain management violations affected four residents. Resident 56 received morphine 19 times over five weeks without staff offering non-opioid alternatives like ibuprofen or non-drug interventions. When the resident reported 4/10 pain and was told to wait for the next morphine dose, staff never offered other pain relief options.
"They would have taken ibuprofen," Resident 56 told inspectors after receiving morphine instead.
The facility's documentation of non-drug pain interventions was fraudulent. For Residents 37 and 40, medication records showed identical entries claiming staff used "repositioning," "relaxation," "diversional activities," and "redirection" daily — even on days when residents reported no pain. No documentation supported what interventions were actually used or their effectiveness.
"The copy and paste item was removed from the system," Director of Nursing Staff B acknowledged, admitting the documentation was meaningless.
Bowel care failures left residents suffering unnecessarily. Resident 56 had no documented bowel movements for six consecutive days in April, with no constipation medications administered despite available orders. Resident 48 experienced three separate periods without bowel movements — five days, four days, and five days — with no treatment provided.
"The bowel medications were either not started or not documented on, and it should have been done," Staff C admitted.
Wound care violations delayed healing for Resident 24, who developed a Stage 3 pressure ulcer. Despite facility policy requiring weekly skin assessments, staff completed evaluations only twice between May and June 2024 — missing more than four weeks when the ulcer could have been prevented.
The wound care nurse practitioner recommended Arginaid supplements for healing in November 2024, but the facility never provided them. The dietitian claimed the resident had received the supplement "for a whole month" but couldn't find any documentation when inspectors asked for proof.
"I can't seem to find it," Registered Dietician Staff G said while searching medication records. The supplement was only started during the inspection after inspectors questioned its absence.
Food safety violations put residents at risk of foodborne illness. Nursing station refrigerators showed dozens of out-of-range temperatures above 40 degrees Fahrenheit throughout February, March, and April 2025, with no corrective action documented. Some readings reached 49 degrees.
"Out of range refrigerator temperatures were not acceptable," Dietary Manager Staff I acknowledged.
The facility's infection control program failed basic requirements. Monthly infection tracking reports lacked signs and symptoms for 14 entries in February alone, making it impossible to determine if antibiotics were appropriate. The facility prescribed antibiotics for Resident 26 twice without meeting clinical criteria, including once for "new redness" alone.
Legal violations compounded clinical failures. Three residents or their representatives signed arbitration agreements without understanding they were waiving their right to jury trials. Resident 39, who signed while recovering from sepsis and hallucinations, said: "I think maybe we went over it too quickly. I would not have signed it. They did not explain it in totality."
The facility's quality improvement program existed only on paper. Administrator Staff A couldn't provide evidence of any performance improvement projects, QAPI meeting attendance records, or medical director participation despite federal requirements.
"I don't have a plan," Staff A told inspectors when asked for documentation of quality improvement activities.
COVID-19 vaccination documentation was completely absent. Staff A claimed all employees refused vaccination but couldn't provide any records of screening, education, or vaccination offers for any of the 12 months reviewed.
The inspection revealed a facility where basic safety protocols existed in policy but failed in practice, where staff routinely falsified medical records, and where residents suffered preventable complications from inadequate care. Resident 127's falsified IV care documentation epitomized the broader pattern — critical medical interventions signed off as completed but never performed, leaving vulnerable residents at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Olympic View Post Acute from 2025-05-13 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 20, 2026 · Our methodology
Olympic View Post Acute in PORT ANGELES, WA was cited for violations during a health inspection on May 13, 2025.
Nurses signed treatment records claiming they completed these tasks on April 26, April 29, May 5, and May 8.
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.