Inspection Reports for
Life Care Center of Port Townsend
751 Kearney St, Port Townsend, WA 98368, United States, WA, 98368
Back to Facility Profile5 CMS Surveys
Inspection Report — Apr 11, 2025
Routine
Date: Apr 11, 2025
Visit Reason
The inspection was a routine 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, inadequate medication management including failure to document non-pharmacological interventions and inappropriate medication administration, improper medication storage and labeling, failure to maintain dishwasher sanitization temperatures, lapses in infection prevention practices including improper oxygen equipment storage, failure to perform hand hygiene, and inadequate laundry handling procedures. These deficiencies placed residents at risk for harm and diminished quality of life.
Deficiencies (9)
F 0604 - The facility failed to ensure physical restraints such as beds against walls and mobility bars were properly assessed, care planned, and documented for 3 residents. This placed residents at risk for unidentified risks and diminished quality of life.
F 0644 - The facility failed to obtain updated preadmission screening and resident review (PASRR) referrals for 2 residents with serious mental illness indicators, risking unmet care needs and decreased quality of life.
F 0656 - The facility failed to develop and implement comprehensive, individualized care plans for 5 residents, omitting key interventions such as oral hygiene, chronic diarrhea, edema management, and bed positioning, risking inappropriate and inadequate care.
F 0658 - The facility failed to meet professional standards in medication management for 5 residents, including missed daily weights, inaccurate documentation of medication side effects, failure to follow hospice recommendations, and inadequate monitoring after status changes.
F 0677 - The facility failed to provide adequate oral care assistance to 2 dependent residents, placing them at risk for poor oral hygiene and diminished quality of life.
F 0757 - The facility failed to ensure residents' drug regimens were free from unnecessary drugs by not documenting non-pharmacological interventions, administering opioids below pain thresholds, and not monitoring blood pressure parameters for antihypertensive and diuretic medications in 3 residents.
F 0761 - The facility failed to ensure proper storage and labeling of medications, including an undated insulin pen and missing refrigerator temperature logs, and allowed food on medication carts, risking ineffective treatment and contamination.
F 0812 - The facility failed to maintain dishwasher temperatures within required sanitization ranges repeatedly over several months and failed to ensure kitchen staff wore required hair restraints, risking foodborne illness and unsanitary conditions.
F 0880 - The facility failed to properly store oxygen equipment, perform hand hygiene during dining service, use PPE for residents on enhanced barrier precautions, and handle linens appropriately, risking facility-acquired infections and spread of multidrug-resistant organisms.
Report Facts
Missed daily weights: 11
Low dishwasher temperatures: 50
Missed hand hygiene opportunities: 9
Low blood pressure readings: 3
Inspection Report — Aug 12, 2024
Date: Aug 12, 2024
Visit Reason
The inspection was conducted to verify that nurse aides have been properly trained and screened through the nurse aide registry prior to providing care to residents.
Findings
The facility failed to ensure nursing assistants were screened through the nurse aide registry prior to providing care for 1 of 2 staff reviewed. This failure placed residents at risk for abuse and unmet care needs.
Deficiencies (1)
WAC 388-97-1660(3)(c) - The facility failed to ensure nursing assistants were screened through the nurse aide registry prior to providing care for 1 of 2 staff reviewed. This failure placed residents at risk for abuse and unmet care needs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in finding for failure to be screened through the nurse aide registry prior to providing care. |
| Staff A | Administrator | Provided statements regarding lack of verification from the nurse aide registry for Staff B. |
Inspection Report — Feb 23, 2024
Routine
Date: Feb 23, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, dental services, food safety, infection prevention, and mental health treatment plan implementation at the Life Care Center of Port Townsend.
Findings
The facility was found deficient in coordinating and implementing Pre-admission Screening and Resident Review (PASRR) Level II treatment recommendations for one resident, providing timely dental services for another resident, maintaining refrigerator temperature logs, and ensuring proper infection prevention practices including PPE usage and signage. All deficiencies were cited with minimal harm or potential for harm to residents.
Deficiencies (4)
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. The facility failed to ensure PASRR Level II evaluation treatment recommendations were incorporated into a resident's plan of care for 1 of 3 residents reviewed, placing residents at risk for unmet mental health and psychosocial needs.
F 0791 Provide or obtain dental services for each resident. The facility failed to ensure dental services were provided for 1 of 2 Medicaid residents reviewed, resulting in delayed follow-up on dental referrals and extended use of ill-fitting dentures, placing residents at risk for difficulty chewing, oral pain, and diminished quality of life.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The facility failed to maintain and document refrigerator temperatures for 1 of 3 refrigerators reviewed, with multiple missing entries in February 2024, placing residents at risk of food-borne illness and unsanitary conditions.
F 0880 Provide and implement an infection prevention and control program. The facility failed to ensure appropriate PPE was doffed properly for 1 of 4 sampled rooms and failed to ensure proper signage was placed on resident room doors for 2 of 4 days, placing residents at risk for facility-acquired infections and related complications.
Report Facts
Missing refrigerator temperature log entries: 10
Residents affected: 1
Residents affected: 1
Rooms sampled for infection prevention: 4
Inspection Report — Oct 4, 2023
Complaint Investigation
Date: Oct 4, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall and care planning concerns at Life Care Center of Port Townsend.
Complaint Details
The complaint investigation focused on Resident 1 who fell on 09/06/2023 during toileting assistance. Staff statements and records showed conflicting care plan instructions and that one staff assisted the resident instead of two, leading to the fall and injuries. The investigation confirmed the allegations of inadequate care planning and supervision.
Findings
The facility failed to ensure accurate and consistent care planning and proper assistance levels for Resident 1, resulting in a fall during toileting assistance that caused three rib fractures and pleural effusion. The care plans were inconsistent regarding the level of assistance required, and staff did not always follow the two-person assist plan, leading to actual harm.
Deficiencies (2)
F 0656 - The facility failed to develop and implement a complete care plan that accurately reflected Resident 1's needs, causing risk for inconsistent or inadequate care. The care plan showed conflicting information about the level of assistance required for transfers and toileting.
F 0689 - The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision, resulting in Resident 1 being assisted by one staff instead of two during toileting transfer, causing a fall with three rib fractures, pleural effusion, pain, and bruising.
Report Facts
Rib fractures: 3
Pain rating: 8
Pain rating: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Initiated facility investigation and documented Resident 1's fall and care plan details. |
| Staff F | Nursing Assistant (NA) | Provided toileting assistance alone during Resident 1's fall and gave a witness statement. |
| Staff C | Licensed Practical Nurse (LPN), Resident Care Manager | Described care plan update process and staff knowledge of assistance levels. |
| Staff B | Registered Nurse and Director of Nursing | Responsible for updating care plans and commented on assistance levels and in-service needs. |
| Staff E | Nursing Assistant (NA) | Reported staff knowledge of assistance levels and described circumstances of the fall. |
| Staff A | Administrator | Commented on staff knowledge of assistance levels and Resident 1's abilities. |
| Staff G | Physical Therapy Assistant | Explained therapy evaluation and communication process for assistance level changes. |
Inspection Report — Mar 8, 2023
Routine
Date: Mar 8, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with nursing home regulations including resident care, medication administration, infection control, and facility safety.
Findings
The facility was found to have multiple deficiencies including failure to obtain physician orders for restraints, inadequate bed-hold notifications, inaccurate resident assessments, incomplete care plans, failure to monitor skin impairments, unsafe hot water temperatures, inadequate nutrition monitoring and interventions, inaccurate nurse staffing postings, lack of hospital transfer agreements, medication administration errors, unsecured medication carts, and failure to properly track and offer COVID-19 vaccinations. Some deficiencies posed minimal harm while others caused actual harm or immediate jeopardy but were addressed during the survey.
Deficiencies (16)
F 0604 - The facility failed to obtain physician orders, consents, and care plans for physical restraints for 2 sampled residents, placing them at risk for injury and diminished quality of life.
F 0625 - The facility failed to provide written bed-hold notices to a resident or representative at hospital transfer, risking uninformed bed-hold rights.
F 0641 - The facility failed to accurately assess a resident's use of restraints in the Minimum Data Set, risking inaccurate records and unmet care needs.
F 0645 - The facility failed to complete PASARR assessments reflecting mental health diagnoses for 3 sampled residents, risking unmet mental health service needs.
F 0656 - The facility failed to develop and implement a comprehensive person-centered care plan meeting a resident's preferences for activities of daily living, risking unmet care needs and decreased quality of life.
F 0684 - The facility failed to monitor multiple non-pressure skin impairments for a resident, failing to notify the physician or update care plans, risking infection and worsening conditions.
F 0689 - The facility failed to maintain safe hot water temperatures in 4 resident rooms, causing immediate jeopardy for serious burns; the issue was corrected during the survey.
F 0692 - The facility failed to accurately monitor meal intake and resident weights and failed to implement effective weight loss interventions for 2 residents, causing actual harm including significant weight loss and fatigue.
F 0732 - The facility failed to post accurate nurse staffing hours and update postings for each shift on 5 of 30 days, risking uninformed residents and visitors.
F 0742 - The facility failed to monitor and address behavior/emotional health issues including suicide risk for a resident, lacking personalized interventions and care plan updates.
F 0759 - The facility had a medication error rate of 56% due to omitted doses, false documentation, pre-pouring, and leaving medications with residents, risking unmet medication needs.
F 0760 - The facility failed to administer PRN blood pressure medication per physician order for 1 resident, risking medical complications.
F 0761 - The facility failed to secure a medication cart, leaving it unlocked and accessible to residents and visitors.
F 0843 - The facility failed to have a written transfer agreement with at least one Medicare/Medicaid certified hospital, risking delayed hospital transfers.
F 0880 - The facility failed to maintain infection control during medication administration by allowing staff to handle multi-use medications with bare hands and not sanitizing, risking contamination.
F 0887 - The facility failed to track COVID-19 vaccination status and offer the vaccine with education to 3 residents, risking unmet vaccination needs and potential infection.
Report Facts
Medication error rate: 56
Weight loss: 30
Weight loss: 34
Hot water temperature: 130
Hot water temperature: 124.5
Hot water temperature: 129.9
Days with inaccurate nurse staffing postings: 5
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