Sequim Bay Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jul 31, 2023

  Based on observation, interview and record review, the facility failed to: ensure their infection control and preventions practices were implemented to prevent the transmission of a highly transmissible disease Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria resistant to nearly all antibiotics and difficult to remove from the environment, a multi-drug resistant organism [MDRO]); prevent the spread of CRAB within the facility for 6 of 6 sampled residents (61, 41, 42, 70, 37 & 39) reviewed for infection control prevention; utilize the proper types of disinfectant wipes against the Carbapenem-Resistant Organism (CRO); follow and implement Enhanced Barrier Precautions (EBP is a type of isolation for identified high risk residents to prevent the spread of disease from one person… […]

• Immediate jeopardy, isolatedF689May 7, 2022

  Based on interview, observation and record review, the facility failed to ensure staff provided safe resident transfers using a hoyer (mechanical lift used to transfer residents) and were educated on hoyer use, and failed to implement fall risk interventions for four of five sampled residents (53, 3, 55 & 19) reviewed for accident hazards. This failure placed residents at risk for injury, falls and death. An Immediate Jeopardy was called on 05/03/2022 when the facility failed to ensure the safe use of mechanical lifts and slings when transferring three residents and failed to ensure facility staff had the competencies, skills and training needed for safe operation of Hoyer lifts and slings. […]

• Actual harm, isolatedF686Apr 28, 2026

  Based on observation, interview, and record review, the facility failed to ensure pressure offloading interventions were implemented consistently to prevent the development and worsening of pressure injuries (also known as pressure ulcers, that occur when soft tissues are compressed between bony prominences and external services) and that wound care was provided consistently as ordered to promote wound healing for 1 of 3 residents (1) reviewed for pressure injuries. Resident 1 experienced harm when they developed a stage 2 (partial thickness loss of skin with expose dermal tissue) pressure injury on their right heel worsened to an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within ulcer cannot be confirmed because the wound bed is obscured by… […]

• Actual harm, isolatedF692Jul 31, 2023

  Based on observation, interview and record review, the facility failed to ensure identified weight loss acted upon and interventions developed for 1 of 1 sampled resident (Resident 53) reviewed for nutrition. This caused harm to Resident 53 when the resident experienced a significant weight loss of greater than 5% body weight within a 30-day period and the identified weight loss was not addressed. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/19/2023, showed Resident 53 was severely cognitively impaired. […]

• Actual harm, isolatedF686Dec 7, 2022

  Based on observation, interview and record review, the facility failed to prevent pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development and promote wound healing by implementing and following care interventions for two of four sampled residents (4 & 6) reviewed for pressure wounds. This failure placed residents at risk for wound complications, infection, delayed healing, increased pain, and a decreased quality of life. This caused harm to Resident 6 when a low air loss mattress was physician ordered and not implemented, and the resident developed two Stage 3 pressure injuries. Findings included . 1) Resident 6 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body). […]