Life Care Center of Port Townsend

In the surveyor’s words

From the most serious findings on record at Life Care Center of Port Townsend, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 8, 2023

  Based on observation, interview and record review, the facility failed to maintain hot water temperatures at safe levels in 4 of 18 occupied resident rooms (124, 126, 127 & 128) reviewed for accident hazards. This failure placed residents at risk for serious burns and decreased quality of life. An Immediate Jeopardy was called on 03/05/2023 at 7:20 PM when the facility's hot water temperatures in four occupied resident rooms exceeded temperatures of 110 +/- 10 degrees (124.5 degrees in room [ROOM NUMBER], 129.9 degrees in room [ROOM NUMBER], 130 degrees in room [ROOM NUMBER] and 130 degrees in room [ROOM NUMBER]) affecting 12 residents (8 of which had cognitive decline and 4 of which could access water independently). The immediacy was removed on 03/06/2023. […]

• Actual harm, isolatedF689Oct 4, 2023

  Based on interview and record review, the facility failed to ensure residents were free from accident hazards when staff provided a one-person transfer with toileting assistance instead of the care planned two-person transfer with toileting assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. Resident 1 experienced harm when he was assisted with one staff rather than two and sustained three rib fractures and subsequent pleural effusion (a build-up of excess fluid between the layers of the pleura outside the lungs), pain, and bruising. […]

• Actual harm, isolatedF692Mar 8, 2023

  Based on observation, interview and record review, the facility failed to accurately monitor meal intake and resident weights and failed to implement and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 2 sampled residents (22 & 30) reviewed for nutrition. This caused harm to Resident 22 when the resident felt fatigued and weak after a 11.78 % weight loss in 98 days, just over three months. This failure placed residents at risk for weight loss, inadequate nutrition and diminished quality of life. […]

• Actual harm, isolatedF692Jul 21, 2021

  Based on interview and record review, the facility failed to identify, assess, and intervene to prevent a significant weight loss for two of seven sampled residents (#12 & 48) reviewed for weight loss. This failure placed residents at risk of poor nutrition and a diminished quality of life. This caused harm to Resident #12 who experienced a significant weight loss of 41.5 pounds (19.17% over three and a half months) and Resident #48 who experienced a significant weight loss of 15.3 pounds (16.63% over five months). Findings included . The Facility's Resident At Risk (RAR) Policy, dated 01/22/2019, defined a significant weight loss as either 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. […]

• No harm, potential for more than minimal, widespreadF725Jul 21, 2021

  Based on interview and record review, the facility failed to identify a licensed nurse to be the designated charge nurse on each shift. This failure place resident at risk for unmet care needs and a diminished quality of life. Findings included . No documentation of a charge nurse was visible upon entry into the facility on [DATE]. On 07/21/21 at 10:28 AM, Staff K, Staffing Coordinator, said the facility did not have a charge nurse during the weekdays on night shift. Staff K said the facility used an on-call nurse. At 11:20 AM, Staff A, Executive Director, said the facility did not use charge nurses. Staff A said the Resident Care Manager was available on the weekend. WAC Reference 388-97-1080 (2)(A)