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Complaint Investigation

Olympic View Post Acute

September 17, 2025 · Port Angeles, WA · 1116 E Lauridsen Boulevard
Citations 2
CMS Rating 1/5
Beds 101
Provider ID 505185
Healthcare Facility
Olympic View Post Acute
Port Angeles, WA  ·  View full profile →
Inspection Summary

Olympic View Post Acute in PORT ANGELES, WA — inspection on September 17, 2025.

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

FF0553
Resident Rights Deficiencies
Potential for More Than Minimal Harm

and the plan was to order labs and start IV fluids for 48 hours for hydration.

The noted showed staff were to discontinue medications to include medications for diabetes and bipolar disorder.Resident 1's EMR (electronic medical record) showed no notification to CC 1 regarding the medications being discontinued, lab orders and/or the IV hydration.Resident 1's medical provider notes, dated 08-29-2025, showed a care conference was held with the resident and CC1.

The note showed the staff discussed multiple issues regarding Resident 1's admission, medication management and progress.On 09/17/2025 at 1:12 PM, CC2, resident advocate, said they had attended Resident 1's care conference on 08/29/2025 and the facility staff were unable to answer all CC1's questions. CC2 said it was very frustrating.Review of an email from CC1 to facility staff, dated 09/04/2025, showed CC1 addressed concerns to the team that was taking care of Resident 1 to include: the plan for Resident 1 due to their insurance ending, an assessment of Resident 1's current condition, Resident 1's medication list, a final report from PT [physical therapy], OT [occupational therapy] and ST [speech therapy].

The email showed that CC1 did not know Resident 1's plan of care and it was not discussed in the care meeting.Review of an email from facility staff, dated 09/04/2025, showed facility staff responded to CC1's questions but wrote that CC1 should let them know if they still had concerns.Review of an email from CC1 to facility staff, dated 09/05/2025, showed CC1 had questions that were not addressed in the 09/04/2025 email from facility staff and had asked for a care plan and had not received it. CC1 wrote it was a deep concern to them. CC1 requested information about a swallowing issue from the evening prior.

Facility staff responded to the email on 09/05/2025 and said they would schedule a care conference to address the rest of the questions.Review of an email from CC1 to facility staff, dated 09/10/2025, showed CC1 was following up regarding the care conference, they had not heard from the staff.Review of an email from CC1 to facility staff, dated 09/11/2025, showed CC1 had asked for a care meeting to answer CC1's questions and had not heard back.

The email showed CC1 had questions regarding medication status, therapy and discharge, and the email showed CC1 was upset at the lack of response to their questions and requests.On 09/17/2025 at 2:33 PM, Staff A, Resident Care Manager and licensed practical nurse, said they had been Resident 1's care manager since admission on [DATE].

Staff A said they had a care conference on 09/16/2025 with CC1 and that was the first time they had spoken to them.

Staff A said it was the responsibility of the license nurses on the floor to notify residents' representatives of changes in a resident's care.On 09/17/2025 at 4:00 PM, Staff B, Director of Nursing, said they expected when residents had a change in condition and/or changes to the plan of care the DPOA-HC should be notified.

Staff B said CC1 should have been notified of Resident 1's clinical change of condition, medications changes and plan of care.

When asked if CC1 should have been sent Resident 1's plan of care, Staff B said yes, they should have had that information. On 09/17/2025 at 5:33 PM, Staff C, Administrator, said they understood why CC1 was frustrated, and they should have been involved in Resident 1's care since admission to include the plan of care and changes to their medications.WAC Reference 388-97-1000(1)(a),1020 (2)(f)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Olympic View Post Acute

1116 E Lauridsen Boulevard Port Angeles, WA 98362

SUMMARY STATEMENT OF DEFICIENCIES

Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's medical provider notes, dated 08/07/2025, showed since arrival at the facility, Resident 1 had nausea and vomiting, somnolence (sleepiness), and poor intake.

The note showed the nausea, vomiting, and somnolence was possible due to medication or metabolic cause and the plan was to order labs and start IV fluids (liquids administered through a catheter in the vein) for 48 hours for hydration.

The note showed the plan was to order laboratory tests. Resident 1's physician orders, dated 08/07/2025, showed an order to draw a CMP (test to monitor electrolyte balance), CBC (blood test that measures the number and types of cells in the blood), TSH (blood test to monitor thyroid function), Hgb A1C (lab related to diabetes) and a valproic acid level (anti-seizure medication - checking for level of medication in blood).Resident 1's provider notes, dated 08/19/2025, showed labs still pending and Depakote was held pending labs.Review of Resident 1's laboratory results, dated 08/25/2025, showed results for CMP, CBC, and TSH.Review of Resident 1's laboratory results, dated 09/04/2025, showed results for a valproic level.Review of Resident 1's electronic medical record (EMR) showed no result for the Hgb A1C.On 09/17/2025 at 2:33 PM, Staff A, Resident Care Manager and Licensed Practical Nurse, reviewed Resident 1's EMAR and contacted the facility laboratory to obtain all lab results from Resident 1.

Staff A could not locate a Hgb A1C lab result and verified the CMP, CBC and TSH were not collected until 08/25/25 and the valproic acid level was completed on 09/04/2025.On 09/17/2025 at 4:00 PM, Staff B, Director of Nursing, said when medical providers order labs to be drawn they expect them to be completed timely.WAC Reference 388-97-1620(2)(b)(i)

Facility ID:

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 PORT ANGELES, 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 Olympic View Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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