Port Washington Post Acute
Port Washington Post Acute in BREMERTON, WA — inspection on June 18, 2024.
Found 27 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.
Inspection Findings
Findings included .
The facility's Admissions Packet, undated, documented, You have the right to be treated with respect.
On 06/10/24 at 12:22 PM, 14 residents were seated in the dining room at six different tables.
Table 1 had one resident, Table 2 had two residents, Table 3 had one resident, Table 4 had two residents, Table 5 had two residents, Table 6 had six residents.
Staff EE, restorative aide, and Staff FF, restorative aide, began passing out trays at 12:32 PM.
Nine of the 14 residents were served at various tables at that time.
At 12:35 PM, Staff FF said they pass trays from the cart according to how they were loaded.
Staff FF stated, we can't pull a tray out and set it to the side to pull out the one behind it.
At 12:43 PM, Residents 54, 33, 15, 60, and 22 had not received trays while others at their tables had finished eating.
At 12:44 PM, residents at Table 6 questioned Staff EE as to why other residents at their table had not received their tray yet and Staff EE responded, yea, we are looking for your food.
At 1:15 PM Staff D said each table should have been served at the same time to ensure the best dining experience.
Reference WAC 388-97-0180(1-4) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included .
During a resident council meeting on 06/17/2024 at 2:56 PM, when asked about quarterly statements, Residents 11, 37 and 43 said they had never received a quarterly statement for their trust account balance. Resident 46 stated, I didn't even know I had a trust account.
Review of a document provided by the facility titled, Trial Balance, dated 06/10/2024, showed Residents 11, 43, and 46 all had a balance in their trust fund. Resident 37 had a trust fund with a balance of zero dollars.
On 06/17/2024 at 3:16 PM, Staff F, Business Office Manager, said they provided quarterly statements to residents with trust accounts every three months.
Staff F said the most recent documentation they could provide was from December 2023 and stated, if I don't have the documentation, I probably didn't do them for those months.
On 06/17/2024 at 4:05 PM, Staff A, Administrator,said the expectation was that residents or resident representatives should have been receiving quarterly statements consistently.
Reference WAC 388-97-0340(3)(a)(b)(c) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Based on interview and record review the facility failed to ensure mail was delivered unopened for 4
residents at risk for lack of privacy and a diminished quality of life.
Findings included .
Review of the Resident Rights policy, dated 08/2022, showed centers will comply with resident rights under Federal law at 42 U.S.C 483.10 (Resident Rights) and communicate those rights to patients in language/and or by a means of communication that ensures understanding.
Review of 42 U.S.C 483.10 section (h)(2) (Privacy and Confidentiality) showed the facility must respect the residents' right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.
During the resident council interview on 06/17/2024 at 2:56 PM, Resident 43 stated, the office manager opens envelopes that look like there is a check inside. Resident 46 commented, I've received my mail opened in the past and it wasn't a check.
On 06/17/2024 at 3:16 PM, Staff F, Business Office Manager, said they do open some residents' mail, however, they are usually the social security checks for Residents 30 and 25.
Staff F said they had been doing this for a long time and did not see an issue with it.
On 06/18/2024 at 2:45 PM, Resident 30 stated, I'm not happy that I was just made aware that my social security check was being opened and deposited. Resident 30 said they were approached that morning and asked to sign a form giving Staff F permission to open all future checks.
On 06/17/2024 at 4:05 PM, Staff A, Administrator, said they were unaware that mail was being opened and that staff would be educated immediately that the expectation was for mail to be opened at bedside with the resident's permission.
Reference WAC: 388-97-0500 (1) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included . <Resident 59> Resident 59 was admitted to the facility on [DATE].
The admission Minimum Data Set (MDS), an assessment tool, dated 05/15/2024, documented the resident was mildly cognitively impaired.
A review of the Electronic Health Record (EHR) showed a document titled, Resident Rights-Advanced Directives, which was signed by Resident 59 on 05/08/2024, and indicated the resident had an AD. No record of the AD was in the EHR.
A copy of the AD was requested from the facility on 06/12/2024, 06/13/2024, and 06/14/2024.
On 06/17/2024 at 2:47 PM, Staff B, Director of Nursing Services (DNS), said they did not see the AD in the EHR and stated, we don't have the documentation.
Staff B said a copy of the AD should be in the EHR. <Resident 62> Resident 62 was admitted to the facility on [DATE].
The Quarterly MDS, dated [DATE], documented the resident was cognitively intact.
A review of the EHR showed a document titled, Resident Rights-Advanced Directives, which was signed by Resident 63 on 01/09/2024, and indicated the resident had an AD. No record of the AD was in the EHR.
On 06/17/2024 at 11:44 AM Staff B, DNS said she did not see an AD in Resident 62's EHR and she said her expectation would be to follow-up with the resident and see if the family can bring it in.
Reference WAC 388-97-0300 (3)(b-c) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included . Resident 18 was admitted to the facility on [DATE] with diagnoses including depression and psychosis (a mental disorder characterized by a disconnection from reality).
The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed the resident was cognitively intact and was able to recall.
On 06/11/2024 at 8:57 AM, Resident 18 said they came to the facility with two phones, that the one that worked better and was pretty was the phone that went missing. Resident 18 recalled multiple staff members had helped the resident look for the phone, but they were unable to locate it. Resident 18 said a grievance was filed with the activity person, and that there had been no follow up or information given to the resident about the grievance. Resident 18 was upset about the phone had gone missing and stated the missing property made them feel upset and flabbergasted. On 06/18/2024 at 9:53 AM, Resident 18 said the phone that went missing was a Motorola G turquoise blue phone, that there had still not been follow up from the facility, and that they still had only their black phone. Resident 18 again said they remembered filing a grievance with the activity person.
On 06/17/2024 at 1:50 PM, Staff G, Activities Director said they had filed a missing item report with social services.
A Missing Property Report was filed on 05/21/2024 for Resident 18.
The report was filled out by Staff G, Activities Director.
The form reported, found no missing phone resident is using a phone.
Per Resident 18, the missing item was a second phone, which the Missing Property Report did not address.
Review of the Grievance Log, dated 01/10/2024 to 06/10/2024, did not show a grievance was listed for Resident 18 for missing property.
Review of the Incident Log, dated 01/10/2024 to 06/10/2024, did not show an incident was recorded for Resident 18 for missing property.
On 06/18/2024 at 10:15 AM, when asked about the missing phone for Resident 18, Staff H, Social Services Director said there should have been a missing property report, but that if the resident was upset or thought that it was theft, that it should then have been filed as a grievance.
On 06/18/2024 at 12:40 AM, Staff A, Administrator, said a grievance should have been resolved in two days.
Reference WAC 388-97-0460 .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Review of a Discharge MDS, dated [DATE], showed Resident 73 was transferred to an acute care hospital.
No documentation was found in Resident 73's EHR that showed the facility provided Resident 73 or their representative written notification detailing the reasons for the transfer or that a copy of the notice was provided to the state Ombudsman' office as required.
On 06/18/2024 at 12:27 PM, when asked if they had documentation to show the facility provided Resident 73 and State Ombudsman office written notification detailing the reasons for the resident's transfer to the hospital, Staff B, DNS, stated, I don't see either.
Reference WAC 388-97-0120 (2)(a-d) ,0140 (1)(a)(b)(c)(i-iii) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Review of a Discharge MDS, dated [DATE], showed the resident was transferred to an acute care hospital.
Review of the EHR showed no documentation that a written notice of the bed-hold policy was provided at the time of transfer.
On 06/18/2024 at 12:01 PM, when asked if there was documentation to show a written notice of the bed-hold policy was provided to the resident/resident representative at the time of discharge, Staff Z, Regional Director of Operations, said no.
Reference WAC 388-97 -0120 (4) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Based on interview and record review, the facility failed to complete a Significant Change Minimum
of life.
This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.
Findings included .
According to the Resident Assessment Instrument manual (a document directing staff when assessments of resident status are required), a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. Resident 10 was admitted to the facility on [DATE].
The admission MDS, dated [DATE], showed the resident was severely cognitively impaired.
The Electronic Health Record (EHR) showed Resident 10 was admitted to hospice on 05/11/2024, requiring a Significant Change MDS assessment within 14 days.
The EHR showed an admission MDS was completed on 04/24/2024. No further MDS assessments were found.
On 06/18/2024 at 8:55 AM, Staff B, Director of Nursing Services, said there should have been an MDS assessment completed within 14 days of Resident 10's admission to hospice.
Reference WAC 388-97-1000 (3)(b) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Based on interview and record review, the facility failed to ensure Minimum Data Sets (MDS), an
residents (Residents 73 and 18) reviewed for MDS accuracy.
The failure to accurately assess if residents had a terminal diagnosis or fall with major injury, placed residents at risk for unidentified and/or unmet care needs.
Findings included . <Resident 73> Resident 73 re-admitted to the facility on [DATE].
Review of the Significant Change MDS, dated [DATE], showed the resident was cognitively intact, received hospice services, but did not have a physician documented condition or chronic disease that may result in a life expectancy of less than six months.
A Hospice Comprehensive Assessment and Plan of Care Update Report, revised 12/28/2023, showed the hospice physician documented that Resident 73 remained eligible for hospice services, with a prognosis of six months or less to live, if the terminal diagnosis continued to run its usual course.
On 06/17/2024 at 12:31 PM, Staff CC, MDS Nurse, said Resident 73's MDS was inaccurate and should have reflected the resident's terminal diagnosis. <Resident 18> Resident 18 was admitted on [DATE].
Review of the Electronic Health Record showed Resident 18 was hospitalized from [DATE] to 05/03/2024 for a fall resulting in a right femoral (thigh bone) fracture, requiring surgical intervention.
The Significant Change MDS, dated [DATE], under section J, regarding falls, was coded as one fall with no injury and one fall with injury (except major).
Major injury was coded as no falls.
Under major injury, the MDS stated, bone fracture, joint dislocations, closed head injuries with altered consciousness, subdural hematoma [bleeding near the brain].
On 06/17/2024 at 3:59 PM when asked if the MDS for Resident 18, under section J, major injury should say zero, Staff B, Director of Nursing Services, said no, it should not say zero.
Reference WAC 388-97-1000 (1)(b) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Based on interview and record review, the facility failed to ensure a Pre-admission Screening and
for 1 of 7 residents (Resident 73) reviewed for PASRR.
This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their individualized mental health needs.
Findings included . Resident 73 re-admitted to the facility on [DATE].
Review of the 01/04/2024 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnoses of anxiety and depressive disorders, and received antidepressant, antianxiety, and antipsychotic medication during the assessment period.
Review of Resident 73's electronic health record showed the following 12/27/2023 physicians orders: duloxetine (an antidepressant medication) daily for depression; lorazepam (an antianxiety medication) every four hours as needed for anxiety; and quetiapine (an antipsychotic) twice daily, no diagnosis listed.
Review of Resident 73's Level I PASRR, dated 12/27/2023, showed the resident had no indicators of serious mental illness (SMI), to include depressive and anxiety disorders, which the resident was actively being treated for.
On 06/18/2024 at 12:07 PM, Staff B, Director of Nursing, said Resident 73's Level I PASRR was inaccurate and needed to be redone.
Reference: WAC 388-97-1915 (1)(2) (a-c) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included . Resident 18 was admitted on [DATE] with diagnoses including fall and fracture of the right femur (large thigh bone), requiring surgical intervention during hospitalization from 04/27/2024 to 05/03/2024.
The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed Resident 18 was cognitively intact, was on a scheduled pain medication regimen with as needed (PRN) pain medications and non-medication interventions for pain. Resident 18's comprehensive care plan, reviewed on 06/15/2024, documented a care area for acute/chronic pain and included interventions to monitor for signs and symptoms of pain medication but did not specify or mention opioids or opioid specific interventions.
On 06/17/2024 at 9:30 AM, when asked if a care plan should include an opioid specific section, Staff R, Licensed Practical Nurse (LPN) said that it should.
At 3:29 PM, when asked if a care plan should include a specific section on opioids, including signs and symptoms specific to opioids, Staff S, Advanced Registered Nurse Practitioner, stated, yes, and there typically is.
Reference WAC 388-97-1020(1), (2)(a)(b) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
as care needs change but right now they are done quarterly at best.
When asked who was responsible for updating the care plans, Staff B said the facility did not have an MDS nurse on site so it would have been herself or the care managers.
Reference WAC 388-97-1020(2)(c)(d) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
time, that the dressing on a pressure ulcer should be checked every shift, and that if a resident's brief
On 06/17/2024 at 10:37 AM, Staff B, Director of Nursing Services (DNS), said a pressure dressing
then stated, I would expect nursing to follow up after brief change, with the expectation that the NA would notify the nurse. Resident 69's comprehensive Care Plan showed the pressure ulcer dressing should have been monitored every shift to ensure it was intact and adhering and that any loose dressing should have been reported to the treatment nurse. <Resident 40> Resident 40 was admitted to the facility on [DATE] and had a diagnosis of stage 4 pressure ulcer (bed sore).
The MDS, an assessment tool, dated 04/20/2024, showed the resident was cognitively intact and was dependent to substantial maximum assist with activities of daily living.
On 06/13/2024 at 2:03 PM, no dressing was observed prior to wound care by Staff P, LPN. Resident 40 said, they did not know when it fell off and Staff P said the NAs do not tell her when the dressing is not on.
A review of Resident 40's care plan stated monitor dressing to ensure it is intact and adhering.
Report loose dressing to Treatment Nurse.
On 06/13/2024 at 2:51 PM, Staff B, DNS, said her expectation was to monitor the dressing and when a resident did not have a dressing in place, she expected the nursing staff to put one on the resident.
Reference WAC 388-97-1060 (3)(b) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Review of Resident 61's weight record showed on 03/11/2024 the resident weighed 121 pounds (lbs.) On 04/04/2024 they weighed 115 lbs., a loss of 4.8% in 24 days.
Review of the EHR showed no documentation or indication the facility identified the weight loss until 04/14/2024 (10 days later) when a nurse's note documented Resident 61 was on alert for weight loss and had reported it was due to not liking the food the facility provided.
A nutrition evaluation, dated 04/22/2024, documented Resident 61 had lost 6.5 percent of total body weight over the previous 90 days, which was not planned or desired. A goal was established to stop weight loss by improving meal intake and total calorie consumption.
The RD recommended the resident the resident receive large portions of protein and two carton of milk three times a day.
On 06/11/2024 at 2:23 PM, Resident 61 reported they had lost weight since admitting to the facility.
They reported eating well at breakfast but had poor intake for lunch and dinner because the facility primarily served vegetables and some form of pasta for those meals, which they did not like. Resident 61 said they had informed Staff H, Social Services Director (SSD), and multiple other staff members on multiple occasions about his dislike of pasta and vegetables and had completed a food preference form, but the kitchen continued to frequently serve pasta and vegetables for lunch and dinner.
Review of the EHR showed the RD's recommendations were never implemented.
Additionally, review of Resident 61's tray card on 06/17/2024, showed the likes/dislikes sections remained blank.
On 06/17/2024 at 2:27 PM, when asked if Resident 61's food preferences had been input into the dietary computer Staff N, Regional RD, stated, No.
On 06/18/2024 at 12:12 PM, when asked if they implemented the RD's 04/22/2024 recommendations, Staff B, DNS, stated, Not that I see.
Reference WAC 388-97 -1060 (3)(h) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
medicated.
When asked if the nurse should have notified the provider if a patient was having zero out
it was appropriate to not provide a non-pharmacological intervention for 4/10 pain, Staff R, LPN said
On 06/17/2024 at 3:29 PM, when asked if they had been notified of any symptoms of oversedation for Resident 18, or if they were aware that Resident 18 had not had any as needed (PRN) doses of opioid pain medication since 05/22/2024, Staff S, Advanced Registered Nurse Practitioner, said no to both questions.
Reference WAC 388-97-1060(1) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included .
Review of the C-cart controlled medication ledgers for May and June 2024, showed facility nurses failed to count controlled medication at shift change, and/or failed to sign the ledger to validate the count was accurate, for one or both shifts, on the following dates: May-5/02/2024, 5/04/2024, 5/06/2024, 5/09/2024, 5/10/2024, 5/18/2024, 5/20/2024, 5/25/2024, 5/26/2024, and 5/31/2024.
June- 06/03/2023, 06/09/2023, 06/03/2023, 06/14/2023, 06/15/2023, 06/16/2023, 06/17/2023, and 06/18/2023.
Review of the A-cart controlled medication ledger for June 2024 showed facility nurses failed to co-sign the controlled medication ledger for one or both shift changes, on the following dates in June- 06/01/2023, 06/02/2023, 06/04/2023, 06/08/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/12/2023, 06/16/2023, 06/17/2023, and 06/18/2023.
On 06/18/2024 at 9:46 AM, Staff GG, Regional Director of Operations, said it was their expectation that both nurses performed a controlled medication count and co-sign on the ledger that the count was correct.
When asked if that was consistently occurring Staff GG stated, no.
Reference WAC 388-97-1300(1)(b)(ii), (c)(ii-iv) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
behaviors documented in the EHR to understand if the medication was working.<Resident 38>
documented Resident 38 was moderately cognitively impaired.
Resident 38 was prescribed lorazepam (benzodiazepine, slows down nervous system) for anxiety and citalopram (anti-depressant) for major depressive disorder. Resident 38's EHR showed no documentation of monitoring target behaviors or for side effects for lorazepam.
There was no documentation of monitoring for adverse side effects for the citalopram.
On 06/17/2024 at 1130 AM, Staff B, DNS, said adverse side effects and target behavior monitoring for benzodiazepines and anti-depressants should be documented in the EHR. <Resident 18> Resident 18 was admitted to the facility on [DATE] with diagnoses including depression and psychosis.
The Significant Change MDS, dated [DATE], showed the resident was cognitively intact, with frequent mood disturbances such as feeling down, depressed, or hopeless. Resident 18 was prescribed Abilify, an antipsychotic for psychosis. No monitoring orders for adverse side effects were found in the EHR. Resident 18 was prescribed sertraline, an antidepressant for depression. No behavior monitoring orders were found in the EHR.
On 06/17/2024 at 0359 PM, Staff B, DNS, confirmed that there were no adverse side effect monitoring orders for the antipsychotic (Abilify) and no behavior monitoring orders for the antidepressant (sertraline), for Resident 18, and said there should have been.
Reference WAC 388-97-1060(3)(k)(i) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Based on observation, interview, and record review the facility failed to ensure a medication error
medications in accordance with physician orders and/or manufacturer's guidelines for 1 of 3 residents (Resident 39) observed during medication pass.
This resulted in a medication error rate of 8 percent.
These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects.
Findings included . <Resident 39> On 06/18/2024 at 7:41 AM, Staff P, Licensed Practical Nurse (LPN), prepared to administer cyclosporine ophthalmic emulsion (used for allergic eye conditions.) Staff P administered three drops into Resident 39's left eye and two drops into the right eye.
After waiting 33 seconds, Staff P then administered two drops of Refresh ophthalmic solution (lubricating eye drops) into the resident's right eye and four drops into the left eye.
Review of the June 2024 Medication Administration Record (MAR) showed an order for cyclosporine ophthalmic emulsion, instill one drop in both eyes three times a day, and an order for Refresh plus ophthalmic solution, instill one drop into both eyes four times a day.
Review of cyclosporine manufacturer's guidelines showed if it was being administered with another lubricating eye drop, you must wait 15 minutes before administering.
The manufacturer's guidelines for Refresh ophthalmic eye drops, showed it needed to be administered at least 5 minutes after the administration of other eye drops.
On 06/18/2024 at 7:50 AM, Staff P, LPN, confirmed they administered more than one drop of the cyclosporine and Refresh, to each eye.
Staff P stated, hat happens a lot with those [eye drops].
When informed that the manufacturer's guidelines for cyclosporine ophthalmic emulsion eye drops, said they should be separated by 15 minutes from administration of other lubricating eye drops Staff P, LPN, indicated they did not know that the eye drops should be separated.
Reference WAC 388-97-1060 (3)(k)(ii) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
expiration date.
when it was opened/prepared, and discarded the syringe.
Reference WAC 388-97-1300(1)(b)(ii), (c)(ii-v), 1300 (2) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Licensed Practical Nurse (LPN), stated, 20Fr/30cc Foley changed.
New drainage bag as well. UA
LPN, said they filled out a paper, immediately put the sample on ice, and then put the sample in the laboratory box located next to the nursing station.
Staff R, LPN, then added that sometimes they put ice packs into the laboratory box with the specimen, instead of putting the sample on ice.
When asked if it was appropriate that the two urine samples for a resident were both rejected due to the sample being frozen, Staff R, LPN, said it was not okay.
When asked if it was acceptable that a urine sample was not sent to lab unfrozen, until after an antibiotic had already been started, Staff R, LPN, said no.
On 06/17/2024 at 10:37 AM, when asked about the process for urine samples after collection, Staff B, Director of Nursing Services (DNS), said they recently switched the laboratory that they use, that they no longer send urine in cups, that urine needed to be put in the correct tubing and then stored in the urine refrigerator.
When asked to show the refrigerator that urine was being kept in, Staff B, DNS, was unable to locate a thermometer.
When asked if they were aware of the frozen urine samples, Staff B, DNS, said they were aware, and this was why they switched to the urine fridge.
When asked if it was acceptable that two urine samples for a resident were rejected due to the sample being frozen, Staff B, DNS, said it was not appropriate for the first sample to be frozen.
At 3:29 PM, when asked if there were any lab results from the orders on 05/03/2024 or 05/06/2024, Staff S, Advanced Registered Nurse Practitioner (ARNP), said there was no suitable result for the sample on 05/03/2024 and they had not received any results for the STAT 05/06/2024 sample.
When asked if staff had followed up with the provider, over the STAT sample on 05/06/2024 not having any results, Staff S, ARNP stated, no, I have to be persistent.
Reference WAC 388-97-1620 (6)(b)(i) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included . Resident 19 was admitted to the facility on [DATE].
The Quarterly Minimum Data Set (MDS), an assessment tool, dated 05/25/2024, showed the resident was cognitively moderately impaired and had an indwelling urinary catheter.
On 05/30/2024, a urinalysis and culture were ordered, on 05/31/2024 collected, on 06/02/2024 received by lab, and on 06/04/2024 at 9:29 AM, reported to facility.
Laboratory/Diagnostic Test Values-Monitoring Policy, undated, reported that the nurse was responsible for documenting a nurse note that included receipt of lab/diagnostic test result, provider notification, resident representative (if indicated), and new orders received.
The policy also said that for general laboratory test values, for non-critical abnormal labs, the provider should be called with the results and called again in 24 hours if no answer.
For critical laboratory test values, asymptomatic, the provider should be called and repeat calls should occur every 30 minutes if no response.
Nursing progress notes in the Electronic Health Record were reviewed and no provider notification was noted from the date of facility notification on 06/04/2024, to the date the provider first documented the positive UTI on 06/05/2024.
On 06/17/2024 at 3:29 PM, when asked when they were notified of the UTI, Staff S, Advanced Registered Nurse Practitioner, said they had to look up the result themselves and that there was no notification of the UTI by staff to the provider.
On 06/18/2024 at 12:52 PM, when asked if they could provide documentation that the provider was notified of Resident 19's lab results of a UTI, Staff B, Director of Nursing Services (DNS), provided a provider progress note which showed the provider discussed results of the urinalysis with the patient on 06/05/2024. No documentation of provider notification by staff was provided.
Reference WAC 388-97 -1260 (3)(a), (4)(b),-0320 (1)(b) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included . Resident 35 admitted to the facility on [DATE] and had a 04/04/2024 order for a regular, pureed diet, with thin liquids. Resident 125 admitted to the facility on [DATE], with an order for a regular, pureed diet, with thin liquids.
Observation of the breakfast meal on 06/14/2024 from 8:18 AM - 8:50 AM, showed Resident 35 and 125 were served regular texture scrambled eggs, chopped sausage, with pureed pancakes.
On 06/14/2024 at 9:59 AM, Staff D, Head Cook/Dietary Manager in Training, said the facility had a process in place to ensure residents received the correct diet type and texture.
Staff D explained residents' meal trays were triple checked for accuracy prior to delivery to the resident.
The first check was performed by the cook who read the tray card to identify the diet type and texture and prepared the tray accordingly.
The tray then went to the dietary aide to place cold food and beverages on the tray.
The dietary aide then checked the prepared diet type and texture against the type and texture on the resident's tray card to validate accuracy.
The tray was then placed on a tray cart for delivery.
The third check occurred by the direct care staff removing the tray from the tray cart before delivery it to the resident.
At 10:03 AM, when asked how the regular textured scrambled eggs and chopped sausage made it through the facility's triple checks without it being identified and were served to Residents 35 and 125, Staff D said the facility had a new cook who was scheduled to train on how to read resident tray cards that day (06/14/2024), but the dietary aide called off.
Staff D explained she assumed the duties of the dietary aide and prepared the cold dishes and beverages for the meal, thus was unable to provide the new cook the level of oversight that they normally would.
Additionally, Staff D said Staff X, Certified Dietary Manager (CDM), a CDM from another facility who was training Staff D for the Dietary Manager position, had not arrived for the day.
Staff D confirmed staffing issues resulted in the new cook not being trained to read tray cards as scheduled, Staff D's inability to provide the level of oversight they normally would contributed to the diet texture errors.
Refer to F-F803 Reference WAC 388-97-1020(1) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Review of the tray card on 06/14/2024 and 06/17/2024, showed Resident 61's likes/dislikes still had not been input into the dietary computer, thus were not reflected on the tray card.
On 06/17/2024 at 2:27 PM, when asked if Resident 61's food preferences had been input into the dietary computer Staff N, Regional RD, stated, No.
Refer to F-F802.
Reference WAC 388-97-1100(1) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included . Resident 67 was admitted to the facility on [DATE].
The admission Minimum Data Set, dated [DATE], documented Resident 67 was cognitively intact.
On 06/11/2024 at 9:07 AM, Resident 67 was observed with three unopened apple juice containers on the bedside table. Resident 67 said they were on a cardiac diet and had allergies to apples but still received apple juice every day with breakfast.
On 06/12/2024 at 3:09 PM, Resident 67 was observed with two unopened containers of apple juice sitting on the bedside table.
On 06/14/2024 at 7:39 AM, Resident 67 was observed with one unopened container of apple juice on the breakfast tray.
A Life Enrichment Evaluation, dated 05/03/2024, showed Resident 67 had a known allergy to apples.
No other documentation in the electronic health record documented the apple allergy.
On 06/17/2024 at 10:38 AM, in a joint interview with Staff D, Dietary Manager/Cook and Staff N, Regional Registered Dietitian, both staff said they are informed of resident preference/allergies when the resident is admitted to the facility either by evaluation or word of mouth from other staff members.
Staff D said she had just been informed about Resident 67's apple allergy that morning.
Reference WAC 388-97-1120 (2)(a) .
Resident 40 and Staff P entered Resident 40's room with the same box of medium gloves that were in
gloves but I don't know if you noticed there is no hand sanitizer in the rooms and there are not medium gloves in the room, I typically put them in my pocket and did not today.
At 2:51 PM, Staff B, Director of Nursing (DNS), said her expectation would be for staff to wash their hands when changing gloves during a dressing change and to not take a box of gloves from one resident's room to another resident's room.<Resident 69> Resident 69 was admitted to the facility on [DATE].
The admission MDS, dated [DATE], showed the resident was cognitively intact and had a stage 2 pressure ulcer (bedsore).
On 06/12/2024 at 11:51 AM, Staff P was observed performing wound care.
Outside of Resident 69's room, Staff P put on a gown for Enhanced Barrier Precautions, put down supplies on a tray in the room, then came back outside of the room to put on gloves without using any hand sanitizer or washing her hands.
Staff P touched Resident 69's tray, then went and grabbed more gloves, placed extra gloves on the resident's bed, touched the trash can, put on additional gloves (double gloved), and then helped the resident turn to left side.
Staff P removed her gloves and put on new gloves from the pile on the resident's bed, without using any hand sanitizer.
Wound cleanser was sprayed on a gauze stack, gauze was then used to wipe the resident's skin, was then thrown away, and additional gauze was used for cleaning.
Staff P removed sticky residue from Resident 69's skin from a previous dressing.
Staff P removed their gloves and then put on new gloves from pile of gloves on Resident 69's bed, no hand sanitizer was used, then patted the wound area dry with gauze, and an oil emulsion dressing was cut to size and placed on wound.
Staff P, LPN, tucked the resident's brief further under them, did not change gloves or use hand sanitizer, then applied skin barrier film on the skin around the wound, an abdominal (ABD) pad was applied with paper tape along the edges, gloves were changed without any hand santizer, and then the resident's brief was changed.
On 06/17/2024 at 10:27 AM, Staff P was interviewed on wound care.
When asked what should be done when entering a room with enhanced barrier precautions, Staff P said you should wash your hands when you enter and exit, and that you should wear gloves and a gown with patient care.
When asked when hand sanitizer should be used, Staff P said before gloves, before entering room, between glove changes, after any task, going from patient to patient, and for many instances.
When asked if it was appropriate to add a glove after you have been using another glove (without changing prior gloves), Staff P said no.
When asked if you can take your gloves off and put new gloves on, without using hand sanitizer, Staff P responded, you should not.
Staff P stated, this facility does not have hand sanitizer inside the room.
Reference WAC 388-97-1320 (1)(c), -1320 (2)(b) .
505240 06/18/2024
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included .
Resident 67 was admitted to the facility on [DATE].
The Admission Minimum Data Set, dated dated [DATE], documented Resident 67 was cognitively intact.
On 06/11/2024 at 9:07 AM, Resident 67 was observed with three unopened apple juice containers on the bedside table. Resident 67 said they were on a cardiac diet and had allergies to apples but still received apple juice every day with breakfast.
On 06/12/2024 at 3:09 PM, Resident 67 was observed with two unopened containers of apple juice sitting on the bedside table.
On 06/14/2024 at 7:39 AM, Resident 67 was observed with one unopened container of apple juice on the breakfast tray.
A Life Enrichment Evaluation, dated 05/03/2024, showed Resident 67 had a known allergy to apples. No other documentation in the electronic health record documented the apple allergy.
On 06/17/2024 at 10:38 AM, in a joint interview with Staff D, Dietary Manager/Cook and Staff N, Regional Registered Dietitian, both staff said they are informed of resident preference/allergies when the resident is admitted to the facility either by evaluation or word of mouth from other staff members.
Staff D said she had just been informed about Resident 67's apple allergy that morning.
Reference WAC 388-97-1120 (2)(a)
505240
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 505240 B.
Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
Findings included .
<Resident 35>
Resident 35 admitted to the facility on [DATE].
Review of the 04/03/2024 Minimum Data Set (MDS, an assessment tool), showed the resident had severe cognitive impairment, was on a mechanically altered diet, and required substantial to maximal assistance with eating.
Review of a diet order, dated 04/04/2024, showed Resident 35 was on a pureed diet (food that has been blended, mixed, or processed into a smooth and uniform texture)
Review of a progress note, dated 05/13/2024, showed Resident 35 had an episode of choking at breakfast, requiring staff to intervene and perform the Heimlich maneuver to clear the airway.
Review of a swallowing problem care plan (CP), dated 05/21/2024, showed Resident 35 had intermittent episodes of coughing and choking with meals and staff were directed to alternate small bites and sips, check the resident's mouth after meals for pocketed food and debris, keep the head of bed elevated 45 degrees during meals and for at least thirty minutes afterwards, instruct the resident to eat slowly, and to chew each bite thoroughly and provide the diet as ordered.
Review of a progress note, dated 05/21/2024, showed the nurse was called to Resident 35's room due to the resident coughing and having difficulty swallowing during the lunch meal.
The nurse alternated providing small bites of food followed by small sips of fluid, but the resident's coughing with attempts to swallow persisted.
505240
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 505240 B.
Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.