Resident 112 arrived at the facility in late August after a motor vehicle accident left them with fractures. Their physician ordered occupational therapy evaluation and treatment on August 26. The medical provider's assessment the next day confirmed the plan for occupational therapy.
Nobody started the therapy.
Staff QQ, an occupational therapist, didn't complete Resident 112's evaluation until September 18 — nearly a month after admission. When inspectors asked why the evaluation wasn't done when the resident arrived, Staff QQ said there were no occupational therapists available.
Staff RR, the facility's Director of Rehabilitation, confirmed Resident 112 had the therapy order on admission but couldn't receive treatment until September 18 because no occupational therapist was available. Staff RR didn't know if anyone had notified the medical provider about the delay.
The second resident faced the same problem. Resident 69 was admitted with back fractures and received physician orders for occupational therapy evaluation and treatment on August 29. Medical provider notes from September 5 and September 9 showed the plan was to continue occupational therapy.
But Resident 69's occupational therapy evaluation didn't happen until September 16. Staff RR told inspectors they couldn't start therapy on admission because they had no occupational therapist available. Staff RR was unaware if the medical provider had been informed about this delay either.
The administrator seemed surprised by the staffing gaps. Staff A told inspectors on November 10 that they expected therapy to be provided when a resident had a physician order for it. They said the facility had resources to obtain occupational therapy services and were unaware that no occupational therapist was available for either resident.
Federal inspectors found the delays placed residents at risk of decreased physical function, delays in returning home, and decreased quality of life. Occupational therapy evaluates and treats people with injuries, illnesses, or disabilities to help them live as independently as possible by developing skills needed for everyday activities.
The inspection was conducted in response to a complaint. Both residents had sustained fractures that required rehabilitation services their doctors deemed medically necessary. The therapy orders came from physicians and medical providers who expected treatment to begin promptly.
For Resident 112, the motor vehicle accident injuries required immediate attention. The physician's order came the day after admission, suggesting the urgency of beginning occupational therapy evaluation and treatment. Instead, the resident waited 23 days.
Resident 69's back fractures also warranted prompt therapy intervention. Medical provider notes from early September showed continued plans for occupational therapy, but the resident had to wait 18 days after the initial order for evaluation to begin.
The facility's rehabilitation director acknowledged the delays but couldn't explain why medical providers weren't notified. This left doctors potentially unaware that their treatment plans weren't being followed, preventing them from making alternative arrangements or adjusting care plans.
The administrator's statement that they had resources to obtain occupational therapy services raised questions about why those resources weren't deployed when residents needed them. The facility appeared to have the means to provide the required services but failed to do so.
State inspectors classified the violation as causing minimal harm or potential for actual harm. However, delays in rehabilitation services can have lasting consequences for residents recovering from fractures, particularly those from traumatic injuries like motor vehicle accidents.
The inspection found that some residents were affected by the facility's failure to provide required occupational therapy services. The violation occurred under Washington Administrative Code 388-97-1280, which requires facilities to provide or obtain specialized rehabilitative services as required for residents.
Both residents eventually received their occupational therapy evaluations, but only after weeks of delay that could have impacted their recovery and rehabilitation outcomes. The facility's lack of available occupational therapists left residents without medically necessary services their physicians had specifically ordered upon admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bremerton Trails Post Acute from 2025-11-18 including all violations, facility responses, and corrective action plans.