Puget Sound Care

In the surveyor’s words

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

• Actual harm, isolatedF760Mar 28, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  Based 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. Findings included . Record review of the facility policy, titled, Sanitation, dated January 2018, showed, The Nutrition Services team maintains clean and sanitary kitchen centers and equipment. Walls, floors, ceilings, equipment, and utensils are clean and/or sanitized, and in good working order. The Nutrition Services team will practice good infection prevention and control procedures and habits. […]

• No harm, potential for more than minimal, widespreadF812Nov 7, 2024

  Based 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. Findings included . On 11/06/2024 at 11:32 AM, Staff I, Cook, was observed testing the temperature of the food on the tray line with a kitchen thermometer. At 11:34 AM, Staff I was observed placing the thermometer into pan of pureed chicken. After documenting the temperature, Staff I wiped the thermometer with a kitchen cloth. Staff I then placed the same thermometer into another pan to test the temperature of another entree. […]

• No harm, potential for more than minimal, patternF684Jan 23, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF550Oct 13, 2023

  Based 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. Findings included . The facility Meal Services Schedule specified Hall B Dining Room, undated, showed residents were served breakfast daily at 8:00 AM and lunch at 12:00 PM. 1) On 10/09/2023 at 7:30 AM, three residents were observed in the Assisted Hall B Dining Room. More residents were brought into the dining room by staff shortly after. […]