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Health Inspection

Bremerton Trails Post Acute

July 13, 2024 · Bremerton, WA · 2701 Clare Avenue
Citations 2
CMS Rating 1/5
Beds 125
Provider ID 505123
Healthcare Facility
Bremerton Trails Post Acute
Bremerton, WA  ·  View full profile →
Inspection Summary

BREMERTON TRAILS POST ACUTE in BREMERTON, WA — inspection on July 13, 2024.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF744
Minimal harm or locked, compartments for controlled drugs. Some affected

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>

505123

Form Approved OMB

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

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)

505123

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BREMERTON, WA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BREMERTON TRAILS POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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