Bremerton Convalescent & Rehabilitation Center

F-F744

Reference WAC 388-97-1060(3)(k)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 39 505123 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505123 B. Wing 07/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bremerton Trails Post Acute 2701 Clare Avenue Bremerton, WA 98310

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 37044 Residents Affected - Some Based on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated when opened in accordance with accepted professional standards of practice, and expired medications were discarded for 3 of 3 medication carts (Olympic, Cove 1 and Cove 2) that were observed.

These failures placed residents at risk to receive expired medications and negative health outcomes.

Findings included .

<Cove 2 Medication Cart>

Observation of the Cove 2 medication cart on 07/12/2024 at 5:55 AM with Staff O, Registered Nurse (RN), revealed the following expired and/or undated medications:

1) A Lantus insulin pen for Resident 61, opened 05/28/2024.

2) A lispro insulin pen for Resident 61, was opened and undated.

3) A lispro insulin pen for Resident 27, was opened and undated.

4) A vial of lispro insulin for Resident 85, opened 05/30/2024.

5) A humolog insulin pen for Resident 6, opened 06/08/2024.

6) A lispro insulin pen for Resident 151, opened 06/04/2024.

7) A basaglar insulin pen for Resident 151, opened 06/04/2024.

8) A bottle of Vitamin E 180 mg with a best by date of 04/2024.

9) A bottle of multivitamins with a best by date of 03/2024.

10 ) A bottle of ferrous gluconate with a best by date of 05/2024.

On 07/12/2024 at 6:55 AM, Staff O, RN, said unrefrigerated insulin pens were good for 28 days after opening. Staff O confirmed the seven insulin pens referenced above and three over the counter medications were either not dated when opened or had been opened for greater than 28 days and needed to be discarded. When asked if the three over the counter medication referenced above were past their best by dates, Staff O, RN, stated, yes.

<Cove 1 Medication Cart>

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 505123 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505123 B. Wing 07/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bremerton Trails Post Acute 2701 Clare Avenue Bremerton, WA 98310

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Observation of the Cove 1 medication cart on 07/12/2024 at 6:12 AM with Staff O, Registered Nurse, revealed the following expired and/or undated medication(s): Level of Harm - Minimal harm or potential for actual harm 1) A basaglar insulin pen for Resident 148, opened 06/02/2024.

Residents Affected - Some On 07/12/2024 at 6:55 AM, Staff O, RN, confirmed Resident 148's basaglar insulin pen had been opened greater than 28 days and needed to be discarded.

<Olympic Medication Cart>

Observation of the Olympic medication cart on 07/12/2024 at 7:13 AM with Staff O, Registered Nurse, revealed the following expired and/or undated medications:

1) A bottle of Combigan eye drops and polymyxin eye drops were found in a plastic cup with no resident name or opened date on the bottles or cup. Per the manufacturer's instructions Combigan and polymyxin eye drops should be discarded four weeks after opening.

2) A bottle of brimonidine eye drops for Resident 5, opened 04/18/2024. The manufacturers' instructions state the brimonidine eye drops should be discarded four weeks after opening.

3) A lispro insulin pen for Resident 78, was opened and undated.

On 07/12/2204 at 7:28 AM, Staff O, RN, confirmed the Combigan and polymyxin eye drops were opened, undated, and not labeled with a resident name. Staff O also confirmed facility staff failed to date Resident 5's brimonidine eye drops, and Resident 78's lispro insulin pen when opened, and indicated all the above referenced medications needed to be discarded.

Reference WAC 388-97-1300(1)(b)(ii), (c)(ii-v), 1300 (2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 505123 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505123 B. Wing 07/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bremerton Trails Post Acute 2701 Clare Avenue Bremerton, WA 98310

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46751

Residents Affected - Some Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened, in 1 of 2 Nourishment Refrigerators/Freezers (Bayshore Dining Room). This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life.

Findings included .

<Nourishment Refrigerator>

On [DATE REDACTED] at 10:38 AM, the Bayshore Dining Room Nourishment Refrigerator/Freezer was observed with

the following undated, unlabeled, and opened items:

1. Tyson chicken tender bag

2. [NAME] Farm popcorn chicken bag

3. 4 ounce glass bottle of horseradish

4. 24 ounce glass bottle of salsa

5. 64 ounce plastic bottle of salsa

6. 24 ounce plastic bottle of Peppermint Califa creamer-with manufacturer expiration date of [DATE REDACTED]

7. Plastic Tupperware container with beef and rice, labeled [DATE REDACTED]

8. Slices of American cheese in the bottom drawer

On [DATE REDACTED] at 10:54 AM, Staff Z, Dietary Manager, said kitchen aids were to temp the nourishment fridges, check dates, and without a date or expired should be thrown out. Staff Z stated, they have to have it labeled and dated as soon as they put it in. We go by the expiration date on the bottle.

On [DATE REDACTED] at 11:06 AM, Staff B, Director of Nursing Services and Registered Nurse said she expected food

in all the refrigerators and freezers to be dated and labeled. Staff B stated, it should be dated right away.

Reference WAC [DATE REDACTED] (3) & 2980

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 505123 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505123 B. Wing 07/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bremerton Trails Post Acute 2701 Clare Avenue Bremerton, WA 98310

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 37044 potential for actual harm Based on interviews, the facility failed to employ a qualified social worker (defined as an individual with a Residents Affected - Some minimum of a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience in a health care setting working directly with individuals) on a full-time basis. This failure placed residents at risk for unmet psychosocial needs and a diminished quality of life.

Findings included .

On 07/09/2024 at 11:57 AM, when asked if they had a bachelor's degree, both Staff Q, Social Services Director, and Staff X, Social Services Assistant, stated, No.

Refer to:

F-F758 Free from Unnecessary Psychotropic Medications

Reference WAC 388-97-0960 (2)(a)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 505123 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505123 B. Wing 07/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bremerton Trails Post Acute 2701 Clare Avenue Bremerton, WA 98310

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 37044 potential for actual harm Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Residents Affected - Some (QA&A) committee that met at least quarterly and included the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QA&A activities. This failure detracted from the effectiveness of the QA&A committee and placed residents at risk for quality deficiencies, adverse events, and diminished quality of life.

Findings included .

On 07/13/2024 at 1:09 PM, Staff A, Administrator, said the facility QA&A committee met monthly and the included the Director of Nursing, Administrator, Social Work, Resident Care Managers, Registered Dietician, all department heads and the Medical Director. When asked for a copy of the sign in sheets/attendance sheets to show the Medical Director had attended the meeting at least once in the past two quarters, Staff A, who had just recently started at the facility, indicated they did not know where they were located and would have to find them and then email them after exit.

An email was received from Staff A on 07/16/2024 at 2:44 PM, with a document attached, titled QAPI Attendance for a 07/03/2024 QAPI meeting. The attendance sheet did not include the medical director.

On 07/17/2024 at 11:00 AM, Staff A, Administrator, said in a telephone interview that they were unable to locate any QAPI attendance sheets in the past two quarters that showed the medical director was in attendance.

Reference WAC 388-97-1760(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 505123