Inspection Reports for Life Care Center of Port Townsend
751 Kearney St, Port Townsend, WA 98368, United States, WA, 98368
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 9
Apr 11, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to properly assess and document physical restraints, incomplete care plans for residents, failure to obtain updated mental health screenings, inadequate monitoring and documentation of medication administration and side effects, improper medication storage and labeling, failure to maintain dishwasher temperatures, inadequate infection prevention practices including hand hygiene and PPE use, and improper handling and storage of linens.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure potential physical restraints were appropriately assessed, care planned, and documented for residents with beds against the wall and mobility bars. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain updated preadmission screening and resident review (PASRR) for residents with significant mental illness diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive care plans including resident-specific interventions for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure services met professional standards related to daily weights, documentation of medication side effects, hospice recommendations, and monitoring after change in status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide dependent residents with oral care and assistance as needed, resulting in poor oral hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide non-pharmacological interventions prior to medication administration, failure to follow medication parameters, and failure to reassess medication necessity when vital signs were abnormal. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper storage and labeling of medications including undated insulin pen and missing refrigerator temperature logs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain dishwasher temperatures within required sanitization ranges and failure to wear appropriate personal protective equipment in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly store oxygen equipment and tubing, failure to perform hand hygiene during dining services, failure to use PPE during enhanced barrier precautions, and improper handling and storage of linens. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 9
Missed dishwasher temperature logs: 11
Missed weight recordings: 11
Low blood pressure readings: 3
Missed dishwasher temperature out of range: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Resident Care Manager (RCM) | Named in multiple findings including restraint assessments, care planning, medication administration, and oxygen equipment storage |
| Staff B | Director of Nursing Services (DNS) | Named in interviews regarding restraint assessments, care planning, medication administration, oxygen equipment storage, and infection control |
| Staff J | Rehabilitation Director | Named in interviews regarding restraint assessments and care planning |
| Staff H | Social Services Director (SSD) | Named in interviews regarding PASRR referrals |
| Staff S | Certified Nursing Assistant (CNA) | Named in observations and interviews regarding oral care provision |
| Staff G | Certified Nursing Assistant (CNA) | Named in interviews regarding oral care provision and supply availability |
| Staff O | Registered Nurse (RN) | Named in observation and interview regarding insulin pen labeling |
| Staff I | Dietary Manager | Named in observations and interviews regarding PPE use, dishwasher temperatures, and hand hygiene |
| Staff K | Housekeeping | Named in observation and interview regarding oxygen equipment storage |
| Staff L | Activity Assistant | Named in observations regarding missed hand hygiene during dining service |
| Staff M | Certified Nursing Assistant | Named in observation and interview regarding PPE use during catheter care |
| Staff N | Laundry Aide | Named in observation and interview regarding linen cart handling and hand hygiene |
| Staff P | Director of Environmental Services | Named in interview regarding linen cart handling and hand hygiene |
| Staff E | Infection Preventionist (IP) | Named in interview regarding hand hygiene and PPE use |
Inspection Report
Deficiencies: 1
Aug 12, 2024
Visit Reason
The inspection was conducted to verify that nursing assistants were properly screened through the nurse aide registry prior to providing care to residents.
Findings
The facility failed to ensure that nursing assistants were screened through the nurse aide registry prior to providing care for 1 of 2 staff reviewed, placing residents at risk for abuse and unmet care needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure nursing assistants were screened through the nurse aide registry prior to providing care for 1 of 2 staff reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Staff B was not verified through the nurse aide registry prior to providing care. |
| Staff A | Administrator | Reported that verification from the nurse aide registry for Staff B was not received. |
Inspection Report
Routine
Deficiencies: 4
Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dental services, food safety, infection prevention, and implementation of Pre-admission Screening and Resident Review (PASRR) Level II evaluation treatment recommendations.
Findings
The facility failed to incorporate PASRR Level II treatment recommendations into a resident's care plan, ensure dental services and follow-up appointments were provided, maintain refrigerator temperature logs, and properly implement infection prevention and control measures including appropriate PPE use and signage. These failures placed residents at risk for unmet mental health needs, oral health issues, food-borne illness, and healthcare-associated infections.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure PASRR Level II evaluation treatment recommendations were incorporated into a resident's plan of care for 1 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dental services were provided for 1 of 2 Medicaid residents reviewed, including failure to follow up on dental referrals and appointment scheduling. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain and document refrigerator temperatures for 1 of 3 facility refrigerators reviewed for food service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate personal protective equipment was doffed properly and proper signage was placed on resident room doors for Transmission Based Precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missing refrigerator temperature log entries: 10
Residents reviewed for PASRR Level II: 3
Residents reviewed for dental services: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing Services | Mentioned in relation to lack of documentation for PASRR treatment plan implementation and denturist appointment scheduling. |
| Staff G | Social Services Director | Mentioned in relation to lack of documentation for PASRR treatment plan implementation and dental service follow-up. |
| Staff D | Food Services Director | Mentioned regarding responsibility for maintaining refrigerator temperature logs and acknowledging missing entries. |
| Staff E | Certified Nursing Assistant | Observed improperly doffing PPE. |
| Staff F | Licensed Practical Nurse | Observed wearing N95 mask improperly and described doffing procedure. |
| Staff C | Infection Preventionist | Reported having correct signage and initiating staff education on infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 4, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to ensure residents' comprehensive care plans were developed, implemented, and accurately reflected residents' care needs, specifically related to Resident 1's care planning and accident hazards.
Findings
The facility failed to update and implement accurate care plans for Resident 1, leading to inconsistent care and increased risk of injury. Resident 1 was assisted with one-person transfers instead of the care-planned two-person assistance, resulting in a fall that caused three rib fractures, pleural effusion, pain, and bruising.
Complaint Details
The complaint investigation revealed that Resident 1 was assisted with one-person transfers instead of the required two-person assistance, leading to a fall on 09/06/2023. Resident 1 sustained three rib fractures and pleural effusion. The facility investigation and staff interviews confirmed inconsistent care planning and supervision.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and measurable actions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in actual harm to Resident 1. | Level of Harm - Actual harm |
Report Facts
Rib fractures: 3
Pain rating: 8
Pain rating: 3
Pain rating: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Initiated facility investigation report and documented Resident 1's fall and care plan details. |
| Staff F | Nursing Assistant (NA/NAC) | Witnessed and reported the fall incident; involved in transferring Resident 1 during the fall. |
| Staff C | Licensed Practical Nurse (LPN), Resident Care Manager | Provided information about care plan updates and staff knowledge of assistance levels. |
| Staff B | Registered Nurse and Director of Nursing | Responsible for updating care plans and provided statements about staff assistance levels. |
| Staff E | Nursing Assistant (NA/NAC) | Provided statements regarding staff knowledge of assistance levels and fall incident. |
| Staff G | Physical Therapy Assistant | Described therapy evaluation process and assistance levels for Resident 1. |
| Staff A | Administrator | Provided statements about staff knowledge of assistance levels and Resident 1's care plan. |
Inspection Report
Routine
Deficiencies: 15
Mar 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to physical restraints, bed-hold notifications, accurate assessments, PASARR screening, care planning, skin integrity, accident hazards, nutrition, medication administration, mental health services, medication errors, medication security, hospital transfer agreements, infection control, and COVID-19 vaccination status.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders and consents for physical restraints, failure to provide written bed-hold notices, inaccurate resident assessments, incomplete PASARR screenings, inadequate care planning, failure to monitor skin impairments, unsafe hot water temperatures, inadequate nutrition monitoring and interventions, medication administration errors, unsecured medication carts, lack of hospital transfer agreements, improper infection control during medication administration, and failure to track and offer COVID-19 vaccinations to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Potential for minimal harm: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to obtain physician order, consent, and care plan for physical restraints for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written bed-hold notice to resident or representative at time of hospital transfer for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess resident including restraint use for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete PASARR screening to reflect mental health diagnoses for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive person-centered care plan to meet resident needs and preferences for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor multiple non-pressure skin impairments and notify physician or update care plan for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain safe hot water temperatures in 4 resident rooms, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to accurately monitor meal intake and resident weights and evaluate weight loss interventions for 2 residents. | Level of Harm - Actual harm |
| Failed to post accurate nurse staffing hours and update postings for 5 of 30 days reviewed. | Level of Harm - Potential for minimal harm |
| Failed to have medication error rate less than 5% with 17 of 30 medication administration opportunities in error for 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's order for administering PRN blood pressure medication for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication cart was secured, leaving it unlocked and accessible. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper infection control during medication pass; staff used bare hands to handle medications and contaminated multi-use bottles. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a written transfer agreement with at least one Medicare/Medicaid certified hospital. | Level of Harm - Potential for minimal harm |
| Failed to track COVID-19 vaccination status and offer vaccine to eligible residents for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Rooms with unsafe hot water temperatures: 4
Residents affected: 2
Residents affected: 5
Medication administration opportunities: 30
Medication errors: 17
Residents affected: 4
Days with missed PRN medication: 7
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing Services | Named in multiple findings including restraint use, bed-hold notification, assessment, nutrition, medication errors, infection control, and behavioral health |
| Staff C | Licensed Practical Nurse and Resident Care Manager | Named in bed-hold notification, nutrition, behavioral health, and medication error findings |
| Staff D | Social Service Director / Licensed Practical Nurse and Resident Care Manager | Named in PASARR and COVID-19 vaccination findings |
| Staff E | Director of Rehabilitation | Named in nutrition and behavioral health findings |
| Staff F | Maintenance Director | Named in hot water temperature hazard findings |
| Staff G | Registered Dietitian | Named in nutrition findings |
| Staff I | Certified Nursing Assistant | Named in nutrition findings |
| Staff J | Certified Nursing Assistant | Named in nutrition findings |
| Staff K | Certified Nursing Assistant | Named in nutrition findings |
| Staff L | Certified Nursing Assistant | Named in nutrition findings |
| Staff N | Registered Nurse | Named in medication administration and infection control findings |
| Staff A | Administrator | Named in hot water temperature hazard and hospital transfer agreement findings |
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