Sequim Bay Post Acute
SEQUIM BAY POST ACUTE in SEQUIM, WA — inspection on April 28, 2026.
Found 3 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.
Review of the facility policy titled, Change in Condition and Notification Policy, dated 06/01/2025, showed the facility would make notifications regarding the resident's condition, to the resident and resident representative based on the resident's clinical status, decision making capacity and preference. Resident 1 was admitted to the facility on [DATE] for aftercare following a hip fracture and diagnosis including peripheral vascular disease (impaired blood flow to the extremities).
The admission Minimum Data Set (MDS) dated [DATE] showed the resident was cognitively intact and felt it was very important to have family and close friends involved in discussions about their care.
Review of the Incident report, dated 01/23/2026, showed a clear fluid filled blister to Resident 1's right heel was discovered, the blister measured 4 centimeter (cm) x 5 cm and assessed to be a stage 2 pressure injury.
The incident report did not indicate a resident representative was informed of the discovery of the pressure injury.
Review of the incident report on 01/28/2026 related to a fall, indicated the Power of Attorney (POA - person who makes decision on resident's behalf)/family would be notified the following shift.
Review of the incident report on 02/16/2026 related to a fall, showed the POA/Family was notified via phone call.
Review of the incident report on 02/17/2026 related to a fall, showed the POA/family was notified via phone call.
Review of the incident report on 02/23/2026 related to a fall, showed the POA/family was notified via phone call. On 04/23/2026 at 1:23 pm, Resident 1 said they would expect the facility to report the wound to her POA.On 04/23/2026 at 1:24 pm, Resident 1 POA said she was not made aware of the wound until she accompanied the resident to their orthopedic appointment on 02/09/2026. On 4/23/2026 at 4:19 pm, Staff C, RCM, RN said resident representatives should be made aware of resident changes such as weight loss, medications, and wounds.
Resident representatives should be notified if there was a new stage 2 pressure injury, but they added they might not if the resident was considered alert and oriented. On 04/23/2026 at 5:20 pm, Staff B said they would expect staff to notify the resident representative regarding a new stage 2 pressure injury.
Refer to F686
Reference WAC 388-97-0320(1)(a) -(d)(2)(a)(b) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
505128 04/28/2026
Sequim Bay Post Acute 650 West Hemlock St Sequim, WA 98382
during the day. On 04/16/2026 at 3:20 pm, Staff G, Nursing assistant, said she usually placed the heel
only had socks on because they thought the resident had been working with therapy. On 04/23/2026
dressing in place; the resident was not wearing heel protectors.
Two sets of heel protectors were observed on the floor between the dresser and the closet, one larger dark blue pair and one smaller light blue pair. On 04/20/2026 at 3:25 pm, Staff F, Registered Nurse (RN) said all residents in the facility are at risk for pressure wounds, they know what intervention are in place by the care plan and or orders in the MAR or TAR. Resident 1 was to wear heel protectors when she was in bed only, due to her being a fall risk and that the resident was out of bed the better part of the day and did not feel that pressure was significant during the day.
Staff F said she discouraged the use during the day due to the residents fall risk. On 04/20/2026 at 3:51 pm, Staff E, RN, said that residents were assessed for pressure risk when they are admitted and interventions were put into place on the care plan.
Staff know what interventions were in place through the care plan and orders on the MAR/TAR. Resident 1 had an order for heel protectors, but when she attempted to transfer it would increase her fall risk, the resident wanted to wear them all the time, Staff E wanted the resident to be safe, and said Resident 1 was not supposed to wear the heel proctors unless she was in bed. On 4/23/2026 at 4:19 pm, Staff C Resident Care Manager, RN said all residents were at risk for pressure injuries, Residents were assessed on admission and intervention such as repositioning and heel protectors were included on the care plan.
Documentation for these interventions were usually found on the TAR. On 04/23/2026 at 5:21 pm, Staff B, Director of Nursing Services, RN, said when residents were admitted they were assessed for pressure risk and care plan interventions were added to the care plan.
Staff know what interventions were in place for each resident by the care plan, Kardex or orders in the MAR/TAR.
Staff B said they ensured the care plan was being followed while out rounding, and during daily meetings.
They educated staff and adjusted the care plan as needed. On 04/23/2026 at 11:56 pm, Staff D, RCM, RN, said newly admitted residents were assessed for pressure injury risk and interventions were placed on the care plan.
They said interventions such as frequent repositioning or keeping heels off of the bed would be included and care plans were developed by the nursing staff.
Staff D said the first interventions were added to Resident 1 on 01/23/2036 after the discovery of the Stage 2 pressure wound.
Staff D said she would not have expected any interventions to be on the care plan, as she did not admit with any wounds; everyone should have their heels floated and weekly skin checks. On 04/28/2026 at 12:20 pm, Staff C, RCM, RN, said Staff H initiates the care plan and nursing staff update them.
Staff C said there should be interventions on the care plan if the resident was identified at risk for pressure injuries and some intervention included would be frequent repositioning and floating the heels.
Staff C did not see any interventions for risk for pressure injury included on Resident 1's care plan.
Staff C confirmed the first interventions were placed on the care plan after the discovery of stage 2 pressure injury. On 04/28/2026 at 12:53 pm, Staff B, DNS, RN, said if a resident was at risk for pressure injury they would expect interventions on the care plan such as skin prep to heels, heel boots, and scheduled off-loading.
Staff B said the care plans were initially developed by Staff H, reviewed Resident 1's care plan and did not see interventions placed on the care plan until the pressure wound was noted.
Staff B could not identify why there was no intervention for pressure prevention on the care plan prior to the discovery of the Stage 2 pressure injury.
See also F-F686
Reference WAC 388-97-1020 (1)(2)(a)(b)
505128 04/28/2026
Sequim Bay Post Acute 650 West Hemlock St Sequim, WA 98382
was not put in to add the more specific details.
After reviewing the February and March 2026 TAR for
04/28/2026 at 11:56 am, Staff D, RN, RCM, said they did not look at the AFO when the wound was
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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.