Bremerton Trails Post Acute

In the surveyor’s words

From the most serious findings on record at Bremerton Trails Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Dec 6, 2023

  Based on observation, interview, and record review, the facility failed to implement Infection Control (IC) and Infection Prevention (IP) practices and outbreak management interventions to prevent transmission of COVID-19 (a highly transmissible respiratory virus), ensure Transmission Based Precautions (TBP) were in place, and the proper Personal Protective Equipment (PPE) was donned (put on) and doffed (removed) according to acceptable IC/IP standards for 16 of 16 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) who tested positive for COVID-19) and in 3 of 6 hallways (Olympic, Mount View, and Bayshore). […]

• Immediate jeopardy, isolatedF678Jan 4, 2024

  Based on interview and record review the facility failed to ensure staff performed timely Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician's order and had express the with for CPR. This failure to train staff on the facility's expectation on how to respond to a resident requiring CPR resulted in Resident 1 not receiving immediate staff action. […]

• Actual harm, isolatedF600Aug 7, 2026

  Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when they were punched and grabbed around the neck, causing bruising and abrasions by a resident with a known history of physical abuse. The facility's failure placed residents at risk of physical injury, fear, intimidation and a decreased quality of life.Findings included.Resident 1 was admitted on [DATE] with diagnoses including severe dementia and dysarthria (slurred and/or slowed speech) following a cerebral vascular accident (interruption of blood supply to the brain causing brain tissue damage). […]

• Actual harm, isolatedF686Jul 15, 2026

  Based on interview and record review, the facility failed to provide enter post hospital discharge wound care orders and provide consistent wound care treatments for pressure ulcers for 1 of 3 residents (Resident 1) reviewed for wounds. Resident 1 experienced harm when the sacral pressure ulcer (injury to the skin and underlying tissue over the tailbone), present on hospital discharge and readmission to the facility, worsened became infected and required surgical incision and drainage of the wound. The facility's failure placed residents at risk of worsening wounds, clinical complications and pain.Findings included.Resident 1 was readmitted to the facility on [DATE] with diagnoses of diabetes and kidney disease. […]

• Actual harm, isolatedF686Nov 18, 2025

  .Based on observations, interviews and record review, the facility failed to evaluate the effectiveness of current pressure offloading treatment plan, document weekly wound assessment and measurements, consistently re-position the resident as care planned every two to three hours and follow physician wound treatment interventions as ordered to prevent development or worsening of pressure ulcers (PU) for 1 of 1 sampled resident (Resident 2) reviewed for PU. Resident 2 experienced harm when their previously healed chronic PU re-developed and worsened from Stage II (a shallow, open sore that has broken through the top two layers of skin, the epidermis and dermis) to Stage III (a deep wound that has gone through the top two layers of skin and into the fatty tissue underneath), and caused an… […]