Sequim Bay Post Acute: Pressure Wound Care Failures - WA
That image captured something inspectors at Sequim Bay Post Acute had been documenting for days: a resident who had already developed a Stage 2 pressure wound on her heel, surrounded by the tools meant to prevent exactly that, while staff offered conflicting explanations for why she wasn't wearing them.
The deeper problem wasn't the heel protectors on the floor. It was what inspectors found when they looked at the care plan. There had been no pressure injury prevention interventions documented for this resident at all, not repositioning schedules, not heel offloading, nothing, until after the wound had already formed.
Staff C, the Resident Care Manager, reviewed the care plan on April 28 and confirmed it plainly. There were no interventions for pressure injury risk included before the Stage 2 wound was discovered. The first protections were added to the plan only after the injury appeared.
Staff B, the Director of Nursing Services, looked at the same care plan and reached the same conclusion. She said she would have expected to see interventions for any resident identified at risk, things like skin preparation for the heels, heel boots, scheduled offloading. She reviewed Resident 1's plan. She could not identify why none of those interventions had been there before the wound was noted.
Nobody had a good answer for that.
Staff D, another Resident Care Manager, said the first interventions were added on January 23 after the Stage 2 wound was discovered. She said she would not have expected interventions beforehand because the resident had not been admitted with any wounds. She added that everyone should have their heels floated and weekly skin checks. But that standard, apparently, had not been documented in this resident's plan.
Staff E, a registered nurse, offered a different explanation for the heel protectors themselves. She said the resident wanted to wear them all the time, but wearing them during transfers increased the fall risk. So the order was heel protectors in bed only. Staff F, another registered nurse, said the same thing, that she had actively discouraged daytime use because of the fall risk, and that the pressure concern during waking hours was not significant enough to warrant it.
That rationale might have been defensible if it had been documented and followed consistently. It wasn't.
Staff G, a nursing assistant, told inspectors on April 16 that she usually put the heel protectors on when the resident went to bed. When asked whether the resident had them on during the day before that previous evening, Staff G said she recalled the resident had only socks on, because staff thought she had been working with therapy.
Thought. Not confirmed. Not documented. Thought.
When inspectors returned a week later, on April 23, the resident was in her wheelchair without heel protectors. The protectors were on the floor. The resident had a dressing on her foot. The wound was already there.
The staff statements, taken together, reveal something more troubling than a single missed intervention. Multiple nurses at multiple levels of the organization described a system in which pressure injury prevention was supposed to flow from admission assessment to care plan to documented orders in the MAR and TAR, and each of them confirmed that system had not functioned for this resident. Staff B said staff knew what interventions were in place by reviewing the care plan. Staff E said the same. Staff C said the same. But the care plan had nothing on it.
Staff C, on April 28, said there should have been interventions on the care plan if the resident was identified as being at risk. She did not see any. Staff B, the Director of Nursing, said she ensured care plans were being followed through rounding and daily meetings. She had no explanation for the gap.
The facility's own internal logic, as described by its nursing leadership, required that a resident assessed as being at risk for pressure wounds would have documented prevention interventions before a wound developed. The Director of Nursing confirmed that logic. The Resident Care Managers confirmed it. And then each of them confirmed it had not happened here.
What the inspection does not resolve is how long the resident had been at risk before anyone wrote down a plan to protect her. Staff D said the wound was discovered on January 23. The inspection took place in late April. The care plan, by the accounts of the facility's own nursing leadership, had been missing its pressure prevention section for that entire window before the wound appeared.
On April 23, the resident sat in her wheelchair with a dressed wound on her foot. The heel protectors, both pairs, were on the floor a few feet away.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sequim Bay Post Acute from 2026-04-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SEQUIM BAY POST ACUTE in SEQUIM, WA was cited for violations during a health inspection on April 28, 2026.
The deeper problem wasn't the heel protectors on the floor.
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.