Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Olympic Rehabilitation Of Sequim during CMS and state inspections, most recent first.
The facility failed to maintain two shower rooms in a clean, sanitary, and homelike condition, despite a policy requiring such an environment. Surveyors observed scratched toilet seats with encrusted material, black matter on tiles and under sinks, soft and damaged walls with black substances believed by staff to be mildew or mold, used wet washcloths left in the rooms, a full trash can with the lid open, a shower head resting on the floor, and black and pink matter on the shower floors. A cognitively intact, medically complex resident reported concerns about odor, lack of cleanliness, and dirty linen left from prior use, leading them to avoid further showers, while another cognitively intact resident avoided the hall shower due to its condition, a broken handle, and unstable water temperature. The housekeeping supervisor, Infection Control Nurse, DON, maintenance director, and administrator acknowledged ongoing issues with cleanliness, possible mold, poor ventilation, and the age and disrepair of the shower rooms, and no mold testing had been performed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to provide adequate bathing assistance to several residents dependent on staff for this care. Despite policy requirements, residents did not receive showers as needed, with some going days without proper hygiene. Staff cited time management and care complexity as reasons for the deficiency.
Two residents in an LTC facility were not monitored for psychosocial harm following allegations of mistreatment by staff. Despite facility protocols requiring monitoring and documentation every shift, there were gaps in the progress notes for several days. The residents reported feeling mistreated and retaliated against, but the expected monitoring was not documented.
The facility failed to maintain effective infection control by not ensuring staff had appropriate PPE and did not properly don PPE for residents on droplet precautions. Staff were observed without necessary eye protection and did not change PPE between rooms. Additionally, the facility did not include the IP on the water management team and failed to implement all control measures of the Legionella Water Management Program, including routine chlorine testing and faucet inspections.
The facility failed to provide restorative nursing services for 16 residents due to staffing shortages, as the Restorative Nurse and Aide positions were vacant. This led to unmet restorative needs and long call light response times, as reported by the Resident Council. Call light audits confirmed significant delays, with some responses taking over 60 minutes.
The facility failed to provide restorative nursing programs for 16 residents due to staffing issues, leading to a lack of necessary care to maintain or improve range of motion, strength, and mobility. A resident with dementia and osteoarthritis did not receive recommended restorative therapy for contracture management, as the facility lacked a Restorative Aide until recently. This deficiency placed residents at risk for decline in physical abilities and increased dependence on staff.
The facility failed to label and store medications properly, affecting two medication carts and one medication room. Medications like Tuberculin Purified Protein and Insulin Lispro were found opened without dates, and a Fluticasone-Salmeterol Advair Diskus was expired. In the Dungeness cart, medications were undated or past discard dates. A resident had unauthorized medication in their room, contrary to facility policy.
The facility failed to maintain complete and accurate medical records for residents requiring restorative and hospice services. A resident receiving hospice care lacked current documentation, and the facility did not have records of hospice staff visits or care provided. Additionally, restorative services were discontinued due to staffing issues, and documentation for 16 residents was missing, leading to incomplete health records.
The facility failed to ensure accurate PASRR assessments for three residents, leading to potential risks in addressing their mental health needs. A resident's PASRR inaccurately documented a mood disorder and included a non-existent dementia diagnosis, while another resident's PASRR failed to indicate a serious mental illness, despite documented psychotic disorder and severe cognitive impairment. Staff acknowledged these errors and the responsibility of Social Services in managing PASRRs.
The facility failed to document and monitor behaviors and side effects related to psychotropic medications for several residents. Specific behaviors were not recorded, and necessary tests and consents were missing. Staff acknowledged the need for improved documentation and monitoring systems.
The facility failed to inform two residents of the risks and benefits of psychotropic medications and did not obtain their consent before administration. One resident was prescribed mirtazapine and Seroquel, while another was prescribed sertraline, without documented consent or information provided to them or their representatives.
A resident with arthritis and other conditions was not provided with adaptive equipment to cut food, despite a successful trial with a pizza cutter. The facility removed the tool without documented assessment or justification, leaving the resident to eat with their hands. Staff interviews revealed a lack of communication and documentation regarding the decision, and no alternative solutions were provided.
The facility failed to document advance directives for two severely cognitively impaired residents. Despite care conference notes indicating that advance directives were established, no copies were found in the residents' electronic health records. The Social Services Director admitted to not obtaining the necessary documentation, and the DON expected staff to document the ADs.
The facility failed to properly handle resident grievances, as grievances raised during Resident Council meetings and by individual residents were not logged or investigated according to policy. Issues included dissatisfaction with CNAs, meal setup concerns, and staff behavior. The use of incorrect forms led to grievances not being reviewed by the administrator, compromising the grievance process and affecting residents' quality of life.
A resident reported that a night nurse delayed pain medication due to personal grievances. The DNS investigated the issue as a grievance but failed to report it as an abuse allegation to the state. This oversight placed residents at risk for potential abuse and neglect.
A facility failed to notify the State LTC Ombudsman of a resident's transfer, as required. The resident, who was severely cognitively impaired, was transferred without documentation of notification. The Social Services Director confirmed the lack of documentation, and the DON stated that notification should have been documented.
The facility failed to accurately document the health status and care needs of three residents in their MDS assessments. One resident receiving hospice care was not coded with a terminal diagnosis, another was incorrectly noted as participating in a restorative program, and a third was inaccurately documented as being on a weight loss regimen. Staff confirmed these discrepancies, acknowledging errors in the MDS coding.
A resident with limited upper extremity function and arthritis was not consistently assisted with oral care, leading to poor hygiene. Despite being dependent on staff for personal hygiene, the resident reported infrequent assistance with brushing teeth, resulting in the use of a fingernail to remove plaque. The issue was reported to the Resident Care Manager but was not confirmed as oral care had been provided by then.
A facility failed to provide adequate pressure ulcer care for a resident at risk, resulting in a new unstageable ulcer. Despite having a skin care plan, the facility lacked consistent preventive measures and documentation, as revealed by staff interviews and missing skin audits.
A facility failed to ensure effective communication and coordination with a hospice provider for a resident receiving hospice services. The facility did not maintain a current hospice plan of care and lacked documentation of hospice staff visits in the resident's electronic health record. Despite requests, the facility did not receive necessary hospice visit notes, and staff were unable to provide details about recent visits or care provided.
The facility failed to maintain essential equipment, with kitchen and nourishment refrigerators showing unsafe temperatures, risking foodborne illness. Additionally, water temperatures in resident rooms and dining areas exceeded safe levels, risking burns. Inadequate monitoring and documentation contributed to these deficiencies.
The facility failed to follow professional standards, risking medication errors and health complications. Antihypertensives were given to a resident despite low blood pressure, compression stockings and toe separators were not applied as ordered, a Wanderguard was used without an order, and a dressing was applied without a physician's order.
A facility failed to provide necessary care to four residents as per their care plans. A resident with edema did not receive prescribed compression stockings, while another with Hallux valgus did not have toe spacers applied despite records indicating otherwise. A third resident's bruise was not monitored according to guidelines, and a fourth resident was not properly positioned for meals, impacting their ability to eat independently.
The facility failed to monitor and document the nutritional and fluid intake of two residents, leading to significant health risks. One resident experienced a significant weight loss due to inadequate weight monitoring and lack of follow-up on nutritional interventions. Another resident exceeded their fluid restriction due to improper reconciliation of fluid intake records, with no documentation of staff identifying the issue or educating the resident on adherence. These deficiencies compromised the residents' health and quality of life.
A facility failed to ensure a cognitively impaired resident had social services to assist in obtaining a legal representative. The resident, diagnosed with dementia and anxiety disorder, had an expired Health Care Decision Declaration and no legal decision-maker. Despite the resident's complex condition, no efforts were made to establish guardianship. Interviews with staff revealed a lack of action, with the Social Services Director acknowledging no steps had been taken, and the DON confirming the responsibility lay with Social Services.
A resident in an LTC facility was prescribed cyclobenzaprine 5 mg to be taken every eight hours as needed, but the medication was incorrectly entered into the MAR as being administered routinely three times daily. Despite multiple reviews by staff, the error persisted until the resident's hospital admission. The discrepancy was acknowledged by the DON, but no clarification was made.
Failure to Maintain Clean, Homelike Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain two shower rooms (East and West) in a clean, sanitary, and homelike condition as required by its “Homelike Environment” policy. Surveyors observed multiple instances of unclean and deteriorated conditions, including deep scratches on toilet seats with brown and beige encrusted particles, black matter in shower tile grout and under sinks, soft and spongy wall areas with peeling and bubbling surfaces, and black substances believed by staff to be mildew or mold. In Shower Room East, surveyors also found used, wet washcloths left in the shower and under the sink, a full trash can with the lid open, the shower head touching the floor, and black and pink matter on the floor and tile lines. These conditions were observed on multiple dates in both shower rooms. A cognitively intact, medically complex resident reported that during their stay they were concerned about the shower room’s cleanliness, odor, and dirty linen left from previous use, which made them not want to shower again until discharge. Another cognitively intact resident residing on Dungeness Hall stated they did not use the hall’s shower room because it was a mess, the handle had broken off, and the water temperature fluctuated from hot to cold, so they preferred another unit’s shower room. The housekeeping supervisor reported that shower rooms were mopped daily and deep cleaned weekly but stated it was difficult to keep up due to the age and disrepair of the bathrooms and believed the black substance was mildew or mold, possibly colonized behind the walls. The Infection Control Nurse had not inspected the Grey Wolf and Dungeness Hall shower rooms for some time and was unaware of the current black substance, while the DON and Maintenance Director acknowledged staff-reported mold problems, lack of ventilation, and uncertainty about whether the black substance was mold, with no testing having been done. The administrator and maintenance director both conceded the rooms were old and could be better, and that they did not fully represent a clean, homelike environment.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically bathing, for five residents who were dependent on staff for this care. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good hygiene, including bathing. However, records and interviews revealed that several residents did not receive showers as needed. Resident 4, for example, reported receiving only one shower in 15 days, while Resident 5's family member noted the resident had not had a shower in nine days. Similar issues were noted for Residents 6, 7, and 8, who also did not receive showers or bed baths as frequently as required. Staff interviews indicated that the failure to provide showers was attributed to time management issues and the complexity of care required by residents. Nursing assistants and registered nurses acknowledged the difficulty in completing all assigned tasks, including showers, during their shifts. The Director of Nursing Services and other staff members were aware of the grievances related to missed showers and attributed the issue to staff organization and time management. Despite reviewing and adjusting the shower schedule, the facility continued to face challenges in ensuring residents received the necessary bathing assistance.
Failure to Monitor Residents for Psychosocial Harm After Allegations
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for two residents, leading to a deficiency in monitoring for psychosocial harm following allegations against staff members. Resident 1, who had mild cognitive impairment and was medically complex, alleged mistreatment by staff, including being left in bed and not being assisted with toileting. Despite these allegations, there were gaps in the documentation of monitoring for psychosocial harm, as no nursing notes were recorded for several days following the incidents. Similarly, Resident 2, who was cognitively intact and medically complex, reported feeling disrespected and retaliated against by staff, which included being made to receive care in pairs and experiencing delayed call light response times. The facility's investigation revealed that there was no documentation of monitoring for psychosocial harm in the progress notes for several days after the allegations. Staff interviews confirmed that residents should have been placed on alert and monitored with documentation every shift, which did not occur for these residents.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to maintain an effective infection control program by not ensuring that staff had appropriate personal protective equipment (PPE) available and did not properly don PPE for residents on droplet precautions. Observations revealed that staff members were not wearing the required eye protection and did not change masks and gloves between rooms for residents on droplet precautions. Staff members were also observed entering and exiting rooms without the necessary PPE, and PPE carts were found to be inadequately stocked with essential items such as eye protection, gloves, and gowns. Additionally, the facility did not include the Infection Preventionist (IP) on the water management team and failed to implement all control measures of the Legionella Water Management Program. This included not performing routine chlorine testing and not conducting regular inspections and cleaning of resident room faucets. The water management team lacked a clinician with expertise in infection prevention, and the facility did not have the necessary equipment for chlorine testing until after the deficiency was identified. The report highlights specific instances where staff did not adhere to infection control protocols, such as not wearing eye protection or changing PPE between resident rooms. It also notes the absence of the IP from the water management team and the lack of routine testing and inspections as required by the facility's water management program. These deficiencies were observed during a period of an influenza outbreak, further emphasizing the importance of strict adherence to infection control measures.
Deficiency in Restorative Nursing Services Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff to provide restorative nursing services for all 16 residents reviewed for such services. This deficiency was identified through interviews and record reviews, revealing that the facility had stopped providing restorative nursing services six to eight months prior due to staffing issues. The Restorative Nurse had transferred to another position, and the Restorative Aide had left, leading to a lack of restorative staff. Consequently, some restorative programs were transitioned to functional maintenance programs, but no restorative referrals were made during this period due to the absence of restorative staff. Additionally, the Resident Council minutes from June, July, and August 2024, highlighted ongoing resident complaints about staffing issues, including long call light response times and unmet care needs. Call light audits conducted in response to these complaints showed significant delays in response times, with some exceeding 60 minutes. The facility's assessment indicated that restorative aides were responsible for supporting residents' activities of daily living, but the lack of staff led to unmet restorative needs, placing residents at risk for a decline in their physical abilities and quality of life.
Failure to Provide Restorative Nursing Programs Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative nursing programs (RNPs) to maintain or improve range of motion (ROM), strength, and mobility for 16 residents who were assessed to require them. This deficiency occurred when the facility stopped providing restorative services in December 2023 due to staffing issues, as the Restorative Nurse transferred to another position and the Restorative Aide left. The facility attempted to transition some of the restorative programs to functional maintenance programs (FMP) to be performed by floor aides during activities of daily living (ADL) care, but no assessments or evaluations were conducted to support this transition. Furthermore, the facility was unable to provide documentation of the specific restorative programs each resident required or any evaluations indicating that the programs were no longer necessary. Resident 2, who was admitted with a diagnosis of dementia and osteoarthritis, was identified as requiring a restorative range of motion program to manage and prevent contractures. Despite recommendations from physical therapy and a care plan indicating the need for ROM exercises three to five times a week, Resident 2 did not receive the necessary restorative therapy. The facility's failure to provide these services was attributed to the absence of a Restorative Aide until one was hired, and Resident 2 was not included on the new Restorative Aide's list. This lack of restorative care placed residents at risk for a decline in strength, ROM, contracture formation, increased dependence on staff for ADLs, and decreased quality of life.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store drugs and biologicals in accordance with accepted professional principles, affecting two medication carts and one medication room. During an observation of medication room one, a vial of Tuberculin Purified Protein and a vial of Insulin Lispro were found opened without a date, which is against the protocol that requires these medications to be discarded after a specific period post-opening. Additionally, a Fluticasone-Salmeterol Advair Diskus Inhalation medication on the [NAME] medication cart was found to be expired, as it was opened for more than one month. Staff interviews confirmed these medications were not dated or removed as required, which did not meet the facility's expectations. In the Dungeness medication cart, several medications were found either undated or past their discard date, including Fluticasone propionate aerosol inhalers and Humolog insulin. Furthermore, Resident 27 had a bottle of Nystatin Topical Powder left on their dresser without proper authorization for self-administration, as confirmed by staff interviews. The facility's policy requires medications to be kept in a resident's room only if the resident has been assessed and provided with a lock box and key, which was not the case for Resident 27.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents' medical records were complete, accurate, and readily accessible, affecting 16 residents who required restorative services and one resident receiving hospice care. For the resident receiving hospice services, the facility did not maintain current hospice documentation, including the comprehensive assessment and plan of care, which had expired. There was no documentation in the electronic health record (EHR) to indicate hospice staff visits, assessments, or care provided. Despite multiple requests by the Director of Nursing, the hospice visit notes were not provided, leaving the facility without necessary information about the resident's hospice care. Additionally, the facility discontinued restorative nursing services due to staffing changes, affecting 16 residents who had been assessed to require these services. The facility did not maintain documentation of the restorative programs, assessments, or transitions to functional maintenance programs (FMPs). Staff were unable to locate the restorative binders containing specific programs and associated flowsheets for these residents. This lack of documentation resulted in incomplete and inaccurate health records, placing residents at risk for unmet care needs.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for identifying mental health or intellectual disability needs. Resident 25 was admitted with diagnoses of generalized anxiety, major depressive disorder, and bipolar disorder, but the Level I PASRR inaccurately documented a mood disorder without specifying the type and incorrectly included a diagnosis of dementia, which was not present. Staff D, the Social Services Director, acknowledged that the incorrect dementia diagnosis and the omission of anxiety should have been addressed. Staff B, the Director of Nursing Services, indicated that PASRRs were managed by Social Services and agreed that these errors should have been corrected upon admission. Resident 171's PASRR assessment was also inaccurate. The resident, who had diagnoses of dementia and generalized anxiety disorder, was readmitted to the facility with a Level 1 PASRR that did not indicate a serious mental illness, thus not triggering a Level 2 PASRR. The annual MDS noted psychotic disorder and severe cognitive impairment, but these were not reflected in the PASRR. Staff D stated that their process involved reviewing PASRRs within one to two days of admission, and acknowledged that Resident 171 should have been marked as having a mood disorder. Staff B reiterated that Social Services was responsible for correcting PASRR errors.
Deficiency in Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to adequately document and monitor the behaviors and side effects associated with the use of psychotropic medications for several residents. For Resident 25, the Medication Administration Records (MAR) and Treatment Administration Record (TAR) indicated anxiety, depressive, and psychotic behaviors on multiple occasions, yet there were no specific behaviors documented, nor were there progress notes in the Electronic Health Records (EHR) on the dates these behaviors were observed. Staff acknowledged the need for documentation of specific behaviors observed. Resident 62 was prescribed mirtazapine and Seroquel without documented consent or an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary for antipsychotic medications. The behavior monitoring care plan included target behaviors that the resident had not demonstrated, such as hallucinations, raising questions about the appropriateness of the medication use. Staff confirmed that target behaviors should reflect the resident's demonstrated behaviors to evaluate the medication's effectiveness. For Residents 63 and 372, there was a lack of behavior monitoring to ensure the effectiveness and side effects of prescribed psychotropic medications. The MAR and TAR did not document specific behaviors, and there were no progress notes in the EHR. Staff were unable to explain or demonstrate how behavior monitoring was conducted, and there was no system in place to track interventions or their effectiveness. Resident 171 was readmitted without an order for behavior monitoring for an antidepressant, which was acknowledged as not meeting expectations by the staff.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were informed of the risks and benefits associated with proposed psychotropic medication therapy and did not obtain consent from the residents or their representatives before administering the medication. This deficiency was identified for two residents, Resident 62 and Resident 63, who were reviewed for unnecessary medications. Resident 62, who was cognitively intact, had diagnoses of depressive and anxiety disorders and was receiving antidepressant and antianxiety medications. The facility's records showed that Resident 62 was prescribed mirtazapine and Seroquel, but there was no documentation indicating that the resident or their representative was informed about the risks and benefits of these medications or that consent was obtained. Similarly, Resident 63, who was also cognitively intact, had diagnoses including generalized anxiety, major depressive disorder, hallucinations, panic disorder, and hydrocephalus. The facility's records indicated that Resident 63 was prescribed sertraline, but again, there was no documentation showing that the resident or their representative was informed of the risks and benefits or that consent was obtained. Interviews with facility staff confirmed the lack of documentation for both residents, highlighting a failure in the facility's process to ensure informed consent for psychotropic medication therapy.
Failure to Provide Adaptive Equipment for Resident's Needs
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, identified as Resident 63, who had specific physical needs due to arthritis in both hands, malnutrition, and other conditions. The resident was admitted with a comprehensive assessment indicating the need for assistance with eating. Despite being alert and oriented, the resident required help with cutting food due to difficulty gripping utensils. An occupational therapist had previously introduced a pizza cutter as an adaptive tool, which the resident found effective and allowed for greater independence. However, the facility removed the pizza cutter without documented assessment or justification, leaving the resident unable to cut their food independently. Observations revealed that the resident was left with uncut food during meals, leading them to eat with their hands, which was not conducive to their dignity or independence. Interviews with staff indicated a lack of communication and documentation regarding the decision to remove the pizza cutter. The occupational therapy assistant confirmed the resident's ability to use the pizza cutter safely, as documented in a therapy progress note. Despite this, the facility did not provide alternative solutions or document any assessment of the resident's safety with the pizza cutter, resulting in a failure to accommodate the resident's needs and preferences.
Failure to Document Advance Directives for Cognitively Impaired Residents
Penalty
Summary
The facility failed to properly document advance directives (AD) for two residents who were severely cognitively impaired. Resident 2 was admitted to the facility and had a care conference note indicating that ADs were established, but no copy of the AD was found in the electronic health record (EHR). Staff D, the Social Services Director, acknowledged not having a copy and admitted to not asking for it during the care conference. Similarly, Resident 40 was admitted with a care conference note stating that ADs were established, yet no AD copy was present in the EHR. Staff D admitted to not following up with the family to obtain the AD. The Director of Nursing expressed that the expectation was for staff to attempt to obtain and document the AD.
Failure to Properly Handle Resident Grievances
Penalty
Summary
The facility failed to properly handle grievances from residents, as evidenced by the lack of initiation, investigation, and logging of grievances. The facility's grievance policy required that grievances be communicated to the administrator and logged, but this was not consistently done. During Resident Council meetings, several grievances were raised, such as insufficient sandwich options, potential fire hazards from piled leaves, long call light wait times, and staff behavior issues. None of these grievances were logged, indicating a failure to adhere to the facility's grievance policy. Additionally, specific grievances from residents were not appropriately addressed. For instance, Resident 27 expressed dissatisfaction with certain CNAs and requested not to receive care from them. However, this grievance was not formally documented or investigated at the time. Similarly, Resident 63 filed a grievance regarding meal setup and assistance, but the facility did not explore alternatives or document a critical review of the grievance to reach a resolution. The grievance was signed off without evidence of a thorough investigation or resolution. The facility's process for handling grievances was further compromised by the use of Resident Response Forms instead of the designated Grievance Forms. This practice led to grievances not being reviewed by the administrator, as required. Staff members, including the Social Services Director and Activities Director, acknowledged the improper handling of grievances and the failure to log them, which prevented the administrator from reviewing and signing off on them. This systemic issue in grievance management placed residents at risk of having their concerns unaddressed, affecting their quality of life.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report an allegation of abuse and neglect to the state agency for one resident, identified as Resident 46, who was cognitively intact. The resident reported that a night nurse would delay administering pain medication due to personal grievances, stating that the nurse was in control and indifferent to being reported. The resident believed they had informed the Director of Nursing (DNS), Staff B, about the issue, and the nurse in question was no longer employed at the facility. Staff B acknowledged having investigated the allegation in July, treating it as a grievance rather than an abuse allegation, and did not log or report it to the state. It was only after being questioned again that Staff B initiated a formal investigation and reported the incident to the state. This oversight in reporting placed residents at risk for potential abuse and neglect, as the facility did not adhere to its policy of timely reporting such allegations as required by federal regulations.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to properly notify the Office of the State Long-Term Care Ombudsman regarding the transfer of a resident, identified as Resident 40. This deficiency was identified through interviews and record reviews. Resident 40, who was admitted to the facility and assessed as severely cognitively impaired, was transferred on January 1, 2024. However, there was no documentation in the Electronic Health Record indicating that the Ombudsman was notified of this transfer. Staff D, the Social Services Director, confirmed the absence of such documentation, and Staff B, the Director of Nursing, acknowledged that the expectation was for the Ombudsman notification to be documented and completed.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected their health status and care needs for three residents. Resident 11, who had been receiving hospice services since October 2021, was not documented as having a terminal diagnosis on multiple Minimum Data Set (MDS) assessments, despite having a hospice certification and plan of care indicating a terminal illness. This oversight was confirmed by the Assistant Director of Nursing, who acknowledged that the terminal diagnosis should have been coded on the MDS assessments. Resident 2 was incorrectly documented as participating in a restorative nursing program for passive range of motion, despite no evidence in the clinical record supporting this. The MDS coordinator admitted to mistakenly capturing these minutes, and the Director of Nursing Services confirmed that Resident 2 was not on a restorative program. Additionally, Resident 4 was inaccurately coded as being on a prescribed weight loss regimen, although there were no physician or dietitian orders for such a program. Staff, including the Resident Care Manager and Chief Medical Director, confirmed that Resident 4 was not on a weight loss program, and the MDS coding was incorrect.
Failure to Assist Resident with Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for Resident 58, who was dependent on staff for personal hygiene due to limited functional range of motion in both upper extremities and arthritis. Despite being cognitively intact and having natural teeth, Resident 58 reported that staff did not assist with oral care, which led to poor oral hygiene. The resident expressed that they were unable to brush their teeth themselves and had resorted to using their fingernail to remove plaque, which was observed as yellowish/white debris under the fingernail and along the upper gum line. Resident 58, who was admitted to the facility earlier in the year, had an ADL self-care deficit care plan indicating the need for one-to-two-person assistance with personal hygiene. However, the resident reported that only one male nursing aide and one male therapist had assisted with brushing their teeth since admission. The resident expressed a preference for oral care to be provided at least once daily, either after breakfast or dinner. The lack of consistent oral care assistance was reported to the Resident Care Manager, but the issue was not confirmed as oral care had been provided by that time.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for a resident who was at risk for pressure ulcers. The resident, who was severely cognitively impaired and on hospice, had two pressure ulcers, one of which was present upon admission. Despite being at risk, the facility did not have adequate interventions in place to prevent new pressure ulcers. The resident's skin care plan included interventions such as bruise monitoring, encouraging nutrition and hydration, and weekly skin assessments. However, a new unstageable pressure ulcer developed on the resident's right heel, indicating a lapse in preventive measures. The facility's documentation showed inconsistencies and omissions in weekly skin audits, with one audit missing entirely. Staff interviews revealed that typical interventions for pressure ulcer prevention, such as turning, repositioning, and using pressure-relieving devices, were not consistently applied. The Director of Nursing Services acknowledged that there were no interventions in place initially to prevent new pressure ulcers for the resident, and that the weekly skin audits should have documented the new skin issue when it was identified.
Lack of Coordination and Documentation in Hospice Care
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The facility did not maintain a current hospice coordinated plan of care for the resident, as the existing plan was expired and a current one was not obtained. Staff members, including the Assistant Director of Nursing (ADON) and the Medical Records Director, acknowledged the absence of the current plan and indicated that it had not been provided by the hospice. Additionally, the facility's electronic health records lacked documentation of hospice staff visits, including details of who visited, when, and what care was provided. The facility's hospice contract identified a Social Services Director as the hospice liaison, but this individual only made initial referrals and did not engage in ongoing communication or coordination of hospice services. Despite requests for hospice visit notes from the Director of Nursing, the facility did not receive the necessary documentation from the hospice provider. The ADON confirmed that there was no documentation in the resident's electronic health record regarding hospice visits, and staff were unable to provide details about recent hospice visits or the care provided. This lack of documentation and communication placed residents at risk for not receiving necessary care and services.
Failure to Maintain Safe Equipment Conditions
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically concerning the refrigeration units and water temperature controls. In the facility's kitchen, one refrigerator was observed to have a digital thermometer reading of 47 degrees Fahrenheit, with potentially hazardous foods inside measuring temperatures above the safe range. Staff W, the Kitchen Manager, noted that the refrigerator was not cooling properly, and all foods were subsequently removed. Additionally, the nourishment refrigerators at nursing stations were found to have temperatures logged above the safe range, with potentially hazardous foods like yogurt and cheese stored inside. Staff interviews revealed that the temperature logs used were intended for monitoring COVID-19 vaccines, not food safety. The facility also failed to maintain hot water temperatures at safe levels in several resident rooms and dining areas. Water temperatures were recorded above the recommended safe range, with some readings as high as 122.1 degrees Fahrenheit. The Maintenance Director, Staff V, was present during the temperature checks and acknowledged the discrepancies, noting that the boiler was set at 118 degrees Fahrenheit. However, the facility lacked a formal policy for water temperature testing, and the temperature logs were inadequately documented, with no dates indicating when the temperatures were taken. These deficiencies placed residents at risk for foodborne illness and serious burns, as the facility did not ensure that essential equipment was functioning correctly. The lack of proper monitoring and documentation for both refrigeration and water temperatures contributed to the facility's failure to maintain a safe environment for its residents.
Failure to Adhere to Professional Standards of Practice
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, leading to potential risks for medication errors and other health complications. For Resident 62, antihypertensive medications were administered despite the resident's systolic blood pressure being below the threshold specified in the physician's orders. This occurred on multiple occasions, as confirmed by the Assistant Director of Nursing. Resident 30 did not have the ordered compression stockings applied, yet the treatment administration record was signed as if the task had been completed. Similarly, Resident 10's toe separators were not applied as ordered, although the treatment administration record indicated otherwise. Additionally, Resident 42 was fitted with a Wanderguard device without a physician's order, contrary to the facility's expectations. For Resident 54, a wet to dry dressing was applied without a corresponding physician's order when wound vac supplies were unavailable. The Resident Care Manager confirmed that an order should have been obtained for the temporary dressing. These deficiencies highlight a pattern of failing to follow or clarify physician orders and inaccurately documenting care tasks, which could lead to negative health outcomes for the residents involved.
Deficiencies in Resident Care and Service Delivery
Penalty
Summary
The facility failed to provide necessary care and services to four residents according to their comprehensive person-centered care plans. Resident 30, who was admitted without edema, developed pitting edema in both lower extremities. Despite an order for knee-high compression stockings to manage the edema, the resident was found without them, and the compression stockings were not located in the room. The Treatment Administration Record (TAR) inaccurately indicated that the stockings had been applied. Resident 10, with a history of Hallux valgus, had an order for toe spacers to prevent tissue damage. However, the resident reported not wearing the spacers for approximately three months, despite the TAR showing daily application. Resident 62, who was cognitively intact and on antiplatelet medication, had a bruise under the left eye from a fall. The facility did not document assessments or monitoring of the bruise as per their wound management guidelines. Resident 63, with multiple diagnoses including arthritis and malnutrition, required assistance with positioning for meals. Observations showed the resident was frequently slumped in bed with meals out of reach and uncut, contrary to the care plan. Staff acknowledged the resident's dependence on assistance for positioning but failed to ensure proper positioning during meals. The facility's documentation did not reflect any refusals by the resident to get out of bed, and there was a lack of communication between nursing and occupational therapy regarding the resident's positioning needs.
Deficiencies in Nutritional and Fluid Monitoring
Penalty
Summary
The facility failed to accurately document, monitor, and assess the fluid intake and nutritional status of two residents, leading to significant health risks. Resident 4, who was severely cognitively impaired and on hospice care, had a nutritional care plan due to risks associated with COPD and dysphagia. Despite physician orders to obtain weights regularly, the facility did not adhere to the schedule, resulting in missing weight records and a failure to address a significant weight loss of over 20% in 60 days. The facility did not document any follow-up actions or reassessments for this weight loss, and the Registered Dietitian was unavailable for an extended period, leaving nutritional assessments incomplete. Resident 62, who was cognitively intact and had diagnoses of heart failure and kidney disease, was on a fluid restriction of 1800 ml per day. The facility did not reconcile the fluid intake recorded during meals with the intake recorded on the MAR, leading to the resident exceeding the fluid restriction on multiple occasions. There was no documentation indicating that staff identified this non-adherence or provided necessary education to the resident about the risks and benefits of adhering to the fluid restriction. Additionally, there was no evidence of physician notification regarding the resident's fluid intake exceeding the prescribed limit. These deficiencies in monitoring and documentation placed both residents at risk for serious health complications, including fluid volume overload, electrolyte imbalances, and significant weight loss. The facility's failure to implement and evaluate nutritional interventions and fluid restrictions compromised the residents' quality of life and health outcomes.
Failure to Obtain Legal Representation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary social services for a cognitively impaired resident, Resident 171, to assist in obtaining a legal representative. Resident 171, who was admitted with diagnoses of dementia and generalized anxiety disorder, was found to be severely cognitively impaired and unable to recall information. The resident's Health Care Decision Declaration had expired, and there was no advance directive or legal decision-maker in place. Despite the complexity of Resident 171's condition, no efforts had been made to establish guardianship or a power of attorney since the expiration of the previous surrogate decision-maker. Interviews with facility staff revealed a lack of action in addressing the resident's need for a legal representative. The Social Services Director acknowledged that no steps had been taken to pursue guardianship for Resident 171, despite the expiration of the health care declaration form. The Director of Nursing Services confirmed that it was the responsibility of Social Services to obtain a power of attorney or guardian for the resident. This inaction placed Resident 171 at risk of not having someone to make informed decisions on their behalf, potentially affecting their quality of life and care needs.
Medication Order Discrepancy Leads to Incorrect Administration
Penalty
Summary
The facility failed to ensure that medication orders were clarified and accurately entered into the electronic health record (EHR) for a resident, leading to a discrepancy in the administration of a muscle relaxer. The resident, who was cognitively intact and required assistance with activities of daily living, was prescribed cyclobenzaprine 5 mg to be taken by mouth every eight hours as needed. However, the medication was incorrectly entered into the medication administration record (MAR) as being administered routinely three times daily, with scheduled times, rather than as needed. This error persisted from the time the order was received on June 17, 2024, until the resident's admission to the hospital on June 30, 2024. Interviews with facility staff revealed that the order was intended to be administered every eight hours as needed, but was mistakenly entered and confirmed as three times daily. The Director of Nursing acknowledged the discrepancy between the order and the MAR, indicating that there should have been a clarification of the order. Despite multiple reviews of the order by various staff members, including the Resident Care Manager and the Assistant Director of Nursing, the error was not corrected, and the medication continued to be administered incorrectly. The resident's Power of Attorney was informed of the as-needed order, further highlighting the inconsistency in the medication administration.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sequim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequim Bay Post Acute | 0.5 mi | — | 6 | 0 |
| Olympic View Post Acute | 14.5 mi | — | 14 | 0 |
| Life Care Center Of Port Townsend | 15.9 mi | — | 10 | 0 |
| Regency Coupeville Rehab And Nursing Center | 22.2 mi | — | 6 | 0 |
| Martha And Mary Health Service | 31.5 mi | — | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.