Bremerton Trails Post Acute

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

yelling, Quit slamming that door please! At 7:46 PM, a resident returned from outside and the door slammed behind them. At 7:50 PM, the door slammed, and a resident yelled from their room about it.

During an interview on 09/30/2025 at 3:46 PM, Staff E, Maintenance Director, was asked what the facility had been doing to alleviate the noise from the exterior door near the 70's rooms. Staff E said they tried weather stripping to muffle, but it had already come off. When asked what the facility did when this concern was brought up in April 2025 at the Resident Council meeting, Staff E said that was when they put the weather stripping on, that has now peeled off. Staff E said that they had talked to staff about using other entrances, but it is what it is. During an interview on 10/01/2025 at 8:44 AM, Staff D, Charge Nurse/Registered Nurse, was asked if they get frequent complaints about the exit door. Staff D said maintenance was aware and the complaint was only for a few people, due to the alarm going off if they did not do the alarm fast enough. When told of the observation of the door slamming multiple times and the alarm going off, with three different residents heard upset about it from their rooms, Staff D acknowledged

this was not homelike. During an interview on 10/01/2025 at 10:02 AM, Staff A, Administrator, was asked how the facility had attempted to make the environment more homelike due to the exit door slamming at night. Staff A said it was an emergency fire door, they should not be going out the door in the first place.

Staff A said they could put more sealant around the side and will now update the residents to not use that door since it is an emergency door. Reference F585Reference WAC 388-97-0880.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

speak to Staff R, Activities Aide, while staff was handing out daily papers (Resident 12 was not at the facility that morning after 10 AM due to dialysis treatment (filtering of the blood) outside of the facility). The progress note by Staff R, on 09/22/2025, documented Resident 12 had an issue with a nursing aide, and both the Administrator (Staff A) and Assistant Director of Nursing (Staff F) were notified about the situation.

During an interview on 09/23/2025 at 10:12 AM, Resident 12 alleged physical abuse by Staff AA, Certified Nursing Assistant (CNA), and neglect by Staff BB, CNA.

On 09/23/2025 at 11:19 AM (over 24 hours since the initial progress note regarding allegation), Staff A, Administrator, was informed by this writer of the allegations by Resident 12 about Staff AA, regarding physical abuse, and Staff BB, regarding neglect.

During an interview on 09/29/2025 at 9:43 AM, Staff R clarified they were informed by Resident 12 about

the physical abuse allegation at about 9:30 AM on 09/22/2025.

Review of the facility's investigation for Resident 12, showed the physical abuse allegation investigation was started on 09/22/2025. The investigation included the time the allegations were submitted to the online mandatory reporting line, on 09/23/2025 at 2:05 PM.

During an interview on 09/30/2025 at 12:01 PM, Staff F, Assistant Director of Nursing/ Infection Preventionist/ Licensed Practical Nurse, when asked if they had reported the allegation to the state when

the investigation started, said they had not. When asked why not, Staff F said that from the statements received from Resident 12, it did not look like it was abuse or neglect. Staff F also acknowledged they were unable to interview Resident 12 until 09/23/2025.

During an interview on 09/30/2025 at 12:45 PM, Staff B, Director of Nursing Services, said the facility had 24 hours to report an allegation of abuse that did not result in injury. When asked if it met expectations that

the facility was made aware by Resident 12 of an allegation of abuse at 9:30 AM on 09/22/2025, but the facility did not report until 09/23/2025 in the afternoon, Staff B said it was reported the next day so they felt that was within the appropriate timeframe.

Reference F610Reference WAC 388-97 -0640(5)(a).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

3:18 PM, Resident 8 opened their top drawer of their dresser and three white pills were seen in a medicine cup. At 3:34 PM, Staff Q, Licensed Practical Nurse (LPN), came into the room and Resident 8 said the three pills were melatonin. Review of Resident 8's [DATE REDACTED] MAR, showed Resident 8 had melatonin ordered

on [DATE REDACTED] for once a night at bedtime. From the MAR, Resident 8 had 6 documented nights of receiving melatonin, [DATE REDACTED] to [DATE REDACTED], before they were found with 3 of the pills (3 out of 6 nights were not taken).During an interview on [DATE REDACTED] at 10:04 AM, Staff D, Charge Nurse/RN, said their expectation for nurses regarding watching residents take their medication, was that nurses would stay in the room with the resident until all their medications had been correctly administered. During an interview on [DATE REDACTED] at 3:19 PM, Staff B, DNS, said the nurse should make sure residents have taken their medication, fully swallowed,

before they leave the room. MEDICATION WITHOUT OPEN DATE:On [DATE REDACTED] at 12:25 PM, during medication cart review an insulin pen was located in the top drawer in the Olympic 2 cart. The insulin pen had a sticker where staff were to put the date opened, which was left blank.On [DATE REDACTED] at 12:39 PM, Staff Z, LPN, said that insulin pens are to be dated when taken out of the refrigerator and used. Staff Z confirmed that a date was not on the insulin pen and said it should be. Staff Z said she would discard the insulin because she did not know when it was opened.On [DATE REDACTED] at 10:21 AM, Staff B, DNS/RN, was told of the undated insulin pen located in Olympic 2 med cart. Staff B said it should have had an open date on it.

Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0825

Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to provide Occupational Therapy (treatment that evaluates and treats people who have injuries, illnesses, or disabilities to help them live as self-sufficiently as possible by developing, recovering, or maintaining skills needed for everyday activities of life) for 2 of 3 (Resident 112 and 69) residents reviewed for therapy services. This failure placed residents at risk of decreased physical function, delay in returning home, and decreased quality of life.Findings included .RESIDENT 112Resident 112 was admitted on [DATE REDACTED] with fractures from a motor vehicle accident. Resident 112's physician order, dated 08/26/2025, showed an order for OT [occupational therapy] evaluation and treat.

Resident 112's medical provider admit visit, dated 08/27/2025, showed the assessment/plan was for OT eval and treat.On 11/05/2025 at 2:20 PM, Staff QQ, Occupational Therapist, said they had completed Resident 112's evaluation on 09/18/2025. When asked why Resident 112's occupational therapy evaluation was not completed upon admission, Staff QQ said there were no occupational therapists available.Resident 112's occupational therapy evaluation, dated 09/18/2025, showed Resident 112's start of care was 09/18/2025.On 11/05/2025 at 3:19 PM, Staff RR, Director of Rehabilitation (DOR), said Resident 112 had

an order for occupational therapy on admission but the facility did not have an occupational therapist available. Staff RR said Resident 112 did not receive occupational therapy until 09/18/2025. Staff RR said

they did not know if the medical provider was notified.RESIDENT 69Resident 69 was admitted on [DATE REDACTED] with back fractures.Resident 69's physician orders, dated 08/29/2025, showed an order for OT [occupational therapy] evaluation and treatment.Resident 69's medical provider notes, dated 09/05/2025 and 09/09/2025, showed the assessment and plan was to continue OT.Resident 69's occupational therapy evaluation, dated 09/16/2025, showed the start of care was 09/16/2025.On 11/10/2025 at 11:46 AM, Staff RR, DOR, said they were unable to initiate occupational therapy for Resident 69 on admission because

they did not have an occupational therapist available. Staff RR said they initiated occupational therapy for Resident 69 on 09/16/2025. Staff RR said they were unaware if the medical provider was informed of the delay in initiating occupational therapy for Resident 69.FINAL INTERVIEWOn 11/10/2025 at 2:52 PM, Staff A, Administrator, said they expected when a resident had a physician order for therapy it would be provided.

Staff A said they had the resources to obtain occupational therapy services. Staff A said they were unaware

the facility did not have an Occupational Therapist available for Resident 112 and Resident 69.Reference WAC 388-97-1280(1)(a)(b)(4).

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. .Based on interview and record review, the facility failed to provide accurate and complete access to all resident records for 1 of 1 annual recertification survey. These failures had the potential risk of causing a delay in the survey process, not addressing resident concerns and a diminished quality of life. Findings included .On 09/22/2025 at 9:50 AM, the survey team entered Bremerton Trails Post Acute. The survey teams' business cards were provided to Staff B, Director of Nursing Services, for access to Point Click Care (PCC, the electronic health care (EHR) system used for record maintenance). On 09/22/2025 at 10:09 AM,

during the Entrance Conference with Staff A, Administrator, and Staff B, Director of Nursing Services (DNS), they were reminded that surveyors needed access to all medical records within required timeframe.

The Grievance log was also requested at this time. On 09/22/2025 at 11:33 AM, the Grievance log was provided with the last date of entry documented as 09/08/2025. On 09/22/2025 at 2:17 PM, PCC access was provided to surveyors.On 09/23/2025 at 8:37 AM, Staff A and Staff B were informed that the PCC access provided did not have access to all medical records, including Medication Administration Records (MAR), Treatment Administration Records (TAR), various assessments, care plans, nutritional reports and laboratory results. Staff A and Staff B said they did not know why and would address the problem immediately.On 09/24/2025 at 8:49 AM, Staff A and Staff B were again informed that surveyors still did not have access to all medical records, including various assessments, nutritional reports and laboratory results.On 09/24/2025 at 3:57 PM, Staff A was updated about continued lack of access to the complete medical record Staff A said they did not know what the problem was and did not know what to do. Staff A said it was out of their hands. On 09/26/2025 at 9:28 AM, Staff B was informed of continued lack of access to complete medical record. Staff B said that they were told by their corporate office that the ownership company was hesitant to give access to all medical records. On 09/26/2025 at 11:04 AM, a second log in was provided to allow visualization of laboratory results. On 09/29/2025 at 8:20 AM, Staff A was emailed, requesting an updated Grievance log and Accident and Incident Log, including all entries up to date (09/28/2025). On 09/29/2025 at 9:05 AM, the exact same Grievance log received on 09/22/2025 was provided.On 09/30/2025 at 2:12 PM an updated Grievance log (through 09/30/2025) was provided but was still missing reported Grievances.Reference F-F585.Reference WAC 388-97-1720

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