Puget Sound Care

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of neglect for 1 of 4 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk for ongoing neglect and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 7 sampled residents (Resident 8, 4 & 25) reviewed for constipation, failed to follow physician's orders for insulin administration and dressing change for a peripherally inserted central catheter (PICC, a flexible tube inserted in the vein, and near the heart for long-term antibiotics administration) for 1 of 1 residents (Resident 25) and failed to obtain weekly weights for 1 of 5 residents (Resident 36) reviewed for quality of care. These failures placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to convey the trust account for 1 of 4 residents (Resident 107) reviewed for trust funds. This failure placed the residents and/or their representatives at risk for loss of funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 2 of 3 sampled residents (Resident 36 & 78) reviewed for bed rails. This failure placed residents at risk for injury and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 11) reviewed for activities of daily living (ADL). This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen humidification (providing warm and moistened oxygen with water vapor preventing dryness, sore throats, and thickened mucus caused by long-term use of dry oxygen) for 1 of 2 residents (Resident 78) reviewed for respiratory care. This failure placed residents at risk of respiratory complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a bed rail physician's order, use of bed rail consent, and evaluation for 2 of 3 sampled residents (Resident 36 & 78) reviewed for accidents. This failure placed residents at risk of injury and a diminished quality of life.

Inspectors wroteBased on observation interview and record review the facility failed to secure medications in 1 of 1 residents' room (Resident 41) reviewed for medication access and storage. This failure placed residents, staff and visitors at risk for accessing unauthorized medication, injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices when a resident ingested a medication that fell on the floor for 1 of 2 staff observed (Staff G) for medication administration; and failed to ensure staff properly donned (putting on) personal protective equipment (PPE) for 1 of 5 sampled resident rooms (Room B33) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life. Findings Included. In an observation and interview on 01/22/2026 at 9:46 AM, Staff G, Registered Nurse (RN), was observed standing at the A wing nurse's station beside the medication cart. A resident was sitting in her wheelchair next to the nurse's station counter. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure food was stored, prepared, and served in a sanitary manner for 1 of 1 kitchen reviewed for kitchen practices. This failure placed residents at risk of foodborne illness, and the potential for experiencing a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper disinfecting of the food thermometer when taking food temperatures in 1 of 1 kitchens reviewed for sanitation and storage. This failure placed residents at risk of cross-contamination and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was addressed on the comprehensive care plan for 1 of 1 sampled resident (244) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with shaving was provided for 1 of 4 sampled residents (224) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 7 sampled residents (14, 58 & 37) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when medication orders were incorrectly transcribed, not reconciled and incorrectly administered for 1 of 3 sampled residents (Resident 1) reviewed for significant medication error. This caused harm to Resident 1 when the resident was administered potent medications not prescribed and had a serious change of condition requiring hospitalization. This failure placed residents at risk of adverse reactions to medications, change in health conditions and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity, and provided a dignified and timely meal service for 2 of 2 meals observed in 1 of 3 dining halls (Hall B) reviewed for resident rights. This failure placed the residents at risk for feelings of institutionalization, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff completed hand hygiene during meal service on 1 of 2 halls (Hall B) reviewed for serving meals in a sanitary manner. This failure placed residents at risk of contracting an infectious disease and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received reasonable accommodations with meals for 1 of 7 sampled residents (41) reviewed for reasonable accommodation and preferences. This failure placed residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents were provided necessary care and services to maintain or improve range of motion and failed to implement diet-related recommendations for 2 of 6 sampled residents (17 & 66) reviewed for quality of care related to rehabilitation services and nutrition. These failures placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for therapeutic medication levels via regular blood testing for 1 of 5 sampled residents (Resident 59) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards in 1 of 2 sampled medication carts (B hall medication cart) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication, receiving wrong medications, and a diminished quality of life.