Olympic View Post Acute: Medication Safety Failures - WA
The failures at Olympic View Post Acute put Resident 127 at risk during treatment for pneumonia and sepsis, a potentially fatal blood infection. Federal inspectors found the patient's midnight antibiotic doses were consistently delayed between April and May 2025, with one dose arriving at 6:27 AM instead of midnight.
Resident 127 had been admitted with orders for IV cefazolin every eight hours at 8:00 AM, 4:00 PM and midnight. The antibiotic was delivered through a PICC line, a long catheter threaded through the arm to a vein near the heart. Consistent timing is critical for maintaining therapeutic blood levels of antibiotics.
The pattern of delays was extensive. On April 25, the midnight dose came at 2:53 AM. On April 27, it arrived at 6:27 AM. April 28 brought a 5:31 AM administration. April 30 saw another 5:35 AM dose. May 2 delivered the antibiotic at 4:50 AM. May 5 brought a 4:23 AM administration.
Staff C, the facility's Resident Care Manager, admitted on May 9 that nurses "failed to administer Resident 127's IV cefazolin in accordance with the physician's order or professional standards of practice."
The medication delays were compounded by falsified treatment records. Resident 127 had physician orders requiring nurses to measure the external length of the PICC catheter and the patient's arm circumference every 72 hours with dressing changes. These measurements help detect complications like catheter migration or arm swelling.
Nurses signed off on the medication administration records claiming they took these measurements on April 26, April 29, May 5 and May 8. But no measurements were ever documented in the patient's electronic health record.
When confronted, Staff C acknowledged "there was no documentation to show staff measured Resident 127's arm circumference and PICC line external length upon admission or with the 72 hour PICC dressing changes." Asked directly if nurses falsely signed for tasks they didn't complete, Staff C said yes.
The falsification extended to other critical care tasks. Resident 127 had orders to monitor the IV insertion site for signs of infection every shift. Staff failed to sign off on this monitoring on April 24 at 6:00 AM, April 26 at 6:00 PM, April 28 at 6:00 AM, and April 29 at 6:00 PM.
The patient required continuous oxygen at two liters per minute to maintain oxygen saturation above 92 percent. Staff failed to document oxygen administration on April 26 evening shift, April 29 day shift, and April 29 evening shift. They also missed documenting oxygen saturation checks on April 26 evening, April 28 day shift, and April 29 evening.
In May, the problems continued. Staff failed to sign off on changing the patient's IV tubing every 24 hours as ordered on May 3, May 4 and May 8. They missed documenting PICC measurements on May 1 and May 8, despite signing they completed the task on May 5 with no corresponding documentation.
A second resident faced similar documentation failures. Resident 20, admitted with depression and atrial fibrillation, had multiple gaps in medication and monitoring records during April 2025.
The patient was ordered high-calorie, high-protein supplements three times daily. Staff left blank documentation boxes on April 13, April 15, and April 16 at 2:00 PM. The same pattern appeared for Eliquis, a blood thinner critical for atrial fibrillation patients, with missing documentation on the same dates and times.
Mental health monitoring showed extensive gaps. Staff were ordered to monitor for antidepressant medication side effects every shift but left blank boxes on April 9, April 16, April 17, April 18, April 23, April 24, and April 28 across multiple shifts.
Antipsychotic medication monitoring showed identical gaps on the same dates. Documentation of target behaviors for insomnia and major depressive disorder was similarly incomplete, with missing entries spanning multiple shifts across eight days in April.
Staff C explained on May 9 that "blanks on the MAR/TAR meant it was not given, or it was not done." The Director of Nursing confirmed on May 12 that blank spaces indicated treatments were "not documented on the MAR or TAR."
Yet Staff C also stated on May 12 that "it was the expectation nurses administer medications and perform treatments as ordered by physician, and to only sign for tasks they completed."
The inspection revealed a systematic breakdown in medication administration and documentation affecting patients with serious medical conditions. Resident 127's pneumonia and sepsis required precise antibiotic timing to prevent treatment failure and potential complications. Resident 20's heart condition and depression demanded consistent medication administration and monitoring.
The facility's failure to maintain accurate treatment records made it impossible to verify whether patients received ordered care. The admission by management that nurses falsely signed for incomplete tasks undermined the reliability of all documentation.
Federal regulations require nursing facilities to ensure services meet professional standards of quality. The inspection found Olympic View Post Acute failed to meet this standard for two of 32 residents reviewed, placing them at risk for "ineffective treatment of disease processes, medication adverse side effects and other potential adverse health outcomes."
The violations occurred despite the facility having written policies and physician orders clearly outlining required care. The gap between written requirements and actual practice created dangerous conditions for vulnerable patients dependent on skilled nursing care for recovery.
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.
The failures at Olympic View Post Acute put Resident 127 at risk during treatment for pneumonia and sepsis, a potentially fatal blood infection.
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.