Avamere Transitional Care of Puget Sound

In the surveyor’s words

From the most serious findings on record at Avamere Transitional Care of Puget Sound, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 19, 2026

  Based on interview and record review, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to prevent the development and/or promote healing of PU/PI (Pressure Ulcers/Pressure Injuries) for 1 of 3 Residents (Resident 1) reviewed for PU/PIs. Resident 1 experienced harm when the facility failed to accurately assess, develop/implement/update a resident-centered care plan (CP) for PU/PIs (that included timely interventions consistent with professional standards of care for PU/PI prevention and care), consistently monitor, and accurately follow physician orders (PO) for wound care and prevention and experienced an avoidable worsening of their two coccyx (tailbone) Stage II PU/PIs (partial-thickness skin loss) to a Stage IV PU/PI… […]

• Actual harm, isolatedF689Oct 17, 2022

  Based on interview and record review, the facility failed to implement interventions to prevent a fall for one of two residents (Resident 1). This failure resulted in harm when Resident 1 fell and sustained two nose fractures, a fracture around the right eye, a large blood blister behind the right eye, and pain to the face and neck. The fall required hospitalization and advanced medical attention. Findings included . According to March 2018 facility policy titled Resident -Centered approaches to managing falls and fall risks showed, 1 Facility staff with the input of the attending physician, will implement a resident- centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or history of falls. […]

• No harm, potential for more than minimal, widespreadF761Nov 25, 2025

  Based on observation and interview, the facility failed to ensure treatment and medication carts were secured/locked when unattended for 4 of 4 treatment carts (Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall) and for 4 of 4 medication carts (Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall) when reviewed for medication storage. This failure placed residents at risk for drug diversion and potential loss of medications/treatments.Findings included. […]

• No harm, potential for more than minimal, widespreadF880Jan 22, 2021

  Based on observation, interview, and record review the facility failed to implement the infection prevention and control program for fit test (to qualitatively or quantitatively evaluate the fit of a respirator on an individual) for the N95 respirators (a mask designated for specific use to prevent transmission of respiratory infections) to provide a safe, sanitary environment to help prevent the transmission and control the spread of COVID-19 (a highly transmissible infectious disease caused by the [DIAGNOSES REDACTED]-CoV-2 virus). This failure had the potential for increased spread of infection throughout the facility due to lack of adequate fit testing for the N95 respirators. […]

• No harm, potential for more than minimal, patternF677Nov 25, 2025

  Based on interview and record review, the facility failed to consistently offer/provide showers and oral care for 3 of 4 sampled residents (Residents 14, 84 and 88) when reviewed for activities of daily living (ADL). These failures placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life.Findings included . Resident 14Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses of failure to thrive, anxiety (feeling of fear, tension or worry) and neuropathy (nerve damage). During an interview on 09/23/2025 at 8:58 AM, Resident 14 stated they had been at the facility for over a week and had not received a shower. […]