Avamere Olympic Rehabilitation: Neglect Investigation Delayed - WA
Nobody investigated for four days.
The director of nursing at Avamere Olympic Rehabilitation of Sequim acknowledged the delay during a federal inspection on August 12. "It was delayed and should have been started sooner," said Staff A, the administrator, after reviewing the facility's own schedule and payroll records with an inspector. Those records revealed something the administrator had not known until that moment: one of the staff members accused of neglecting residents had worked two additional shifts after the complaint was filed.
The inspection, triggered by a complaint, documented what federal regulators classified as a failure to protect residents from neglect and to respond to allegations of neglect in a timely way.
The morning of July 19, 2025, a nursing assistant identified in the inspection report as Staff E came on for the day shift and found what the Director of Nursing later described as "a lot of residents who appeared they had not been provided adequate care during the night shift." Staff E did not call a supervisor. She did not flag it as neglect. She filled out a grievance form, the kind typically used for resident or family complaints, and slid copies under the doors of the administrator and the Director of Nursing.
That choice, to reach for a grievance form rather than report a neglect allegation up the chain of command, would shape everything that followed.
The manager on duty that weekend was the Medical Records Director, identified as Staff D. She told inspectors she remembered Staff E asking for a grievance form and remembered being told what it was needed for. She said she did not recognize what Staff E described as an allegation of neglect. She did not read the form after it was filled out. She assumed Staff E was also working with the unit nurse on duty. She was not aware, she said, that any staff members had been suspended that weekend.
None were.
The Director of Nursing, Staff B, told inspectors on August 12 that not changing a resident, not providing incontinence care, and not repositioning a resident would all constitute neglect. She said the standard response to a neglect allegation was to notify a supervisor, who would notify the Director of Nursing or administrator. Accused staff would be removed from duty. Residents would be assessed for injuries or psychological harm as soon as the allegation was reported, and that assessment would be documented in the resident's chart.
None of that happened on July 19. Or July 20.
Staff B said she was not sure why Staff E had put the complaint on a grievance form. She said she was not sure whether or when the accused staff members had been suspended. She said she had not been involved in the investigation. She said she would have expected Staff E and another staff member identified as Staff H to have recognized the allegation as neglect, and she would have expected the two accused aides, Staff F and Staff G, to have been suspended immediately.
The administrator said the accused staff were suspended when he received the form, which he placed on Monday, July 21, two days after it was filed. The investigation did not begin until Wednesday, July 23, four days after Staff E documented what she had found. The administrator confirmed that timeline directly to inspectors.
Then the inspector pulled the schedule and payroll records.
Staff F, one of the two aides accused in the complaint, had worked two additional shifts between the time the grievance form was filed on July 19 and the time the investigation began on July 23. The administrator said he was not aware of that. He did not dispute the records. He confirmed the investigation was initiated four days after the allegation was documented and said it should have been started sooner.
The inspection report does not describe what happened to the residents during those additional shifts. It does not say whether Staff F worked with the same residents who had been left without care on the night of July 18. It does not describe whether any residents were assessed for harm, or when, or what those assessments found. The record is quiet on those questions.
What the record does contain is the Director of Nursing's description of what a proper response looks like: suspected neglect gets reported to a supervisor, the supervisor notifies the DNS or administrator, accused staff are removed from resident care, and residents are assessed for injuries or psychosocial harm as soon as the allegation is known. All of it gets documented in the progress notes.
That sequence did not happen here because the complaint arrived on a grievance form, and the people who received it treated it like a grievance.
Staff D, the Medical Records Director who was the manager on duty that weekend, said she did not recognize what she was being told as a neglect allegation. She did not read the form. She did not notify the Director of Nursing. She did not pull Staff F or Staff G from the schedule. The form sat under two doors over a weekend, and when the administrator picked it up Monday morning, he waited until Wednesday to open an investigation.
The Director of Nursing told inspectors she had not been involved in the investigation at all. She did not explain why. The inspection report does not say whether she was notified on Monday when the administrator received the form, or whether she learned of the allegation some other way, or when.
Inspectors cited the facility under F0600, which covers abuse and neglect, at a level of minimal harm or potential for actual harm, affecting some residents. The citation references a Washington State regulation governing the investigation and reporting of alleged neglect.
The residents who were found that Saturday morning, the ones Staff E described as appearing not to have received adequate care during the night, are not named in the inspection report. Their conditions that morning are not detailed. What they experienced during those hours, and whether anyone ever formally assessed what had happened to them, is not recorded in the document inspectors produced.
What is recorded is this: a nursing assistant saw something, reached for the wrong form, and the machinery that was supposed to protect those residents did not turn over for four days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Olympic Rehabilitation of Sequim from 2025-08-12 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: July 4, 2026 · Our methodology
AVAMERE OLYMPIC REHABILITATION OF SEQUIM in SEQUIM, WA was cited for neglect violations during a health inspection on August 12, 2025.
Nobody investigated for four days.
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.