Port Washington Post Acute

F 0684 Level of Harm - Actual harm Residents Affected - Few

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

8's right calf wound or until 09/23/2025 for Resident 8's abdominal wound.Review of a nurses' note, dated 09/12/2025 at 1:37 AM, documented Resident 8 had a new 3 centimeter (cm) x 3 cm x 0.5 cm ulcer to the right posterior calf. The wound bed was 75percent slough (non-viable tissue consisting of dead yells, proteins and debris), with serosanguinous drainage. The resident reported the area was painful to touch.

Staff notified the provider, obtained a treatment order and the resident was referred to the wound clinic for evaluation.Review of the September TAR, after it was initiated 09/12/2025, showed an order to treat Resident 8's right lateral LE wound (not present on admission). The TAR did not document the resident's abdominal wound, use of the wound vac and the need for twice weekly dressing changes. still failed to identify the residents' abdominal wound, use of a wound vac and need for twice weekly dressing changes.

A wound consult note, dated 09/16/2025, showed the resident had a 5.5-centimeter (cm) x 2.4 cm x 0.2 cm, non-pressure wound to the right lateral LE. The wound required mechanical debridement. The provider documented devitalized (dead) tissue was removed to the level of healthy bleeding tissue which included biofilm (a thin, slimy film of bacteria that can adhere to the surface of a wound). The debridement extended down to the level of subcutaneous tissue (bottom layer of skin containing fat tissue, blood vessels, nerves and other components.) Resident 8's abdominal wound, use of wound vac, was not assessed or addressed

in the wound care.A wound consult note, dated 09/23/2025 (24 days after admission to the facility), showed Resident 8's midline abdominal wound was assessed to be 9.02 cm x 4.09 cm x 0.3 cm, and had a wound area of 36.89 cm2. This showed in the 24 days since admission, Resident 8's abdominal wound had increased in area by 9.45 cm2 The wound consult practitioner documented the wound had been present less than 30 days, the wound bed was 100% granulated with sanguineous exudate (drainage that mostly contains fresh, bright-red blood) and showed no clinical signs of signs of infection. The wound clinician recommended staff cleanse the wound with wound cleanser, pat dry with a gauze sponge, apply Hydrofera Blue (dressing used to keep wound bed moist and prevent bacteria) to the wound bed, skin prep to peri wound, and cover with a foam dressing secured by tape three times a week and as needed. This showed in

the 24 days since admission, Resident 8's abdominal wound had increased in area by 9.45 cm2.On 10/16/2025 at 4:38 PM, Staff C, Charge Nurse, said staff had found an ulcer on Resident 8's right LE and

the resident was referred to wound care for the LE ulcer. Staff C explained that Resident 8's abdominal wound was not assessed because they had not been informed the resident had an abdominal wound yet.

When asked if they could find any documentation to show staff assessed, monitored or performed dressing changes or otherwise provided care to the abdominal wound between the resident's admission to the facility and the wound consult on 9/23, Staff C said, no.On 10/30/2025 at 2:34 PM, when asked if wound care services were provided (e.g. treatment, dressing changes, assessments, monitoring etc.) during the first 16 days for Resident 8's LE ulcer or first 24 days for Resident 8's abdominal wound, Staff B, Director of Nursing, said, We found the same thing that you did. When asked if Resident 8's right LE ulcer should have been identified by staff before it had sloughed and required mechanical debridement, given they required maximal assistance from staff with lower body dressing, Staff B said, yes.Reference WAC 388-97-1060 (1).

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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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Port Washington Post Acute

140 South Marion Avenue Bremerton, WA 98312

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

8:00 AM staff documented drug not available.- 10/11/2025- 8:00 PM staff documented drug not available.10/12/2025- 8:00 PM staff documented drug not available.- 10/13/2025- 8:00 PM staff documented On hold until approved by provider.- 10/14/2025- 8:00 AM staff documented provider in facility and notified to call [pharmacy].- 10/15/2025- 8:00 PM staff documented drug not available.- 10/16/2025- 8:00 PM staff documented drug not available.- 10/17/2025- 8:00 PM staff documented drug not available.- 10/19/20258:00 PM staff documented drug not available.- 10/20/2025- 8:00 PM staff documented drug not available.Review showed 10/04/2024 - 10/20/2025 18 of 34 doses of Sacubitril-Valsartan were not administered. Additionally, it is unclear how the medication was consistently available and administered at 8:00 AM, but not available for administration at 8:00 PM. Review of the EMR showed no documentation present that showed facility staff called the pharmacy to request STAT procurement of the medication, attempted to get emergency/first dose access to the medication upon admission, or followed up with the pharmacy each day the medication was not available to determine why.Resident 7Resident 7 was admitted to the facility on [DATE REDACTED] at 5:29 PM. Review of the hospital transfer orders, dated 10/04/2025, showed an order for IV vancomycin every 12 hours for 18 days, to treat a Methicillin-resistant Staphylococcus aureus (MRSA, a type of staph bacteria that's become resistant to many of the antibiotics) infection.The AVS, dated 10/04/2025, showed the last dose of IV vancomycin administered at the hospital, was 10/04/2025 at 9:08 AM. The evening dose of IV vancomycin was not administered.Review of September 2025 MAR showed for Resident 7's 10/04/2025 8:00 PM dose of IV vancomycin was not administered, staff documented 6 drug not available.Review of the EMR showed no documentation present that showed facility staff called the pharmacy, as directed, for the resident's IV medication, that they requested STAT procurement of the medication, attempted to get emergency/first dose access to the medication, or notified

the provider of the omission and/or to obtain an interim bridge order. During an interview on 10/07/2025 at 5:49 PM, Staff C, Charge Nurse, and the nurse performing admissions at the time while training the facility's recently hired admission nurse, explained they input the orders of pending admissions into the EMR. Once the resident arrived, the floor nurse would reconcile the admissions orders with the orders in

the EMR. Once accuracy was validated, the floor nurse wound send the orders to the pharmacy via the EMR system to have the prescriptions filled. When asked if they were aware of recent instances of medications not being delivered timely and resulting in omitted doses, Staff C, said, yes, and indicated it occurred more frequently than it used to.During an interview on 10/30/2025 at 2:34 PM, when asked about Resident 1 not receiving their rivaroxaban, Staff B, Director of Nursing, explained while evaluating the facilities admission process, it was identified that several facility and agency nurses had not been provided Omnicell access. During an interview on 11/10/2025 at 1:34 PM, while discussing why three residents with admission IV antibiotics orders, and one with a compounded medication order, had several omitted doses, Staff C, Charge Nurse, said they were not aware that IV and compounded medications had to be faxed to

the pharmacy. Staff C further indicated they did not know the medication ordering deadline was 7:30 PM, and orders input and sent after that time would not be included in the next delivery unless the nurse called

the pharmacy. Staff C confirmed that acknowledge deficit contributed to delayed procurement of the medications. When asked when she became aware of the pharmacy ordering guidelines Staff C said when

the pharmacy sent them to Staff B, Director of Nursing (10/30/2025). On 11/10/2025 at 3:18 PM, Staff B stated the primary cause of the omitted medications were the lack of staff training and lack of familiarity with the medication ordering process, the existence of ordering cutoff times, their ability to order medications STAT, and lack of Omnicell access to procure first dose medications.Reference WAC 388-97-1300 (1)(a)(b) (i-ii).

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