Puget Sound Transitional Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jul 1, 2025

  Based on interview and record review, the facility failed to ensure Basic Life Support (BLS) was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) for 1 of 1 resident (Resident 1) reviewed for unexpected death in the facility. This failed practice placed 48 additional residents (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 & 51), who had current physician orders to receive CPR, at serious risk for adverse outcome including death and constituted an Immediate Jeopardy (IJ). […]

• Actual harm, isolatedF559Aug 9, 2021

  Based on interview and record review, the facility failed to provide advanced written notice for room changes, to include the reason for the move, for 2 (Residents 2 and 3) of 3 residents reviewed for room changes. These failures placed the residents at risk for feelings of powerlessness and decreased quality of life. In addition, failure to properly conduct and address continued complaints of a room move, caused Resident 2 psychological harm the night of the room move, and continued physical and mood stressors. Findings included . Review of a 10/20/2017 policy titled Change of Room or Roommate showed the facility would conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or their representative. […]

• Actual harm, isolatedF689Aug 9, 2021

  Based on interview and record review, the facility failed to provide effective supervision for 1 (Resident 1) of 3 residents reviewed for falls. This failure did not protect Resident 1 from additional falls, and resulted in harm when Resident 1 sustained a pelvic fracture. Findings included . Review of a 07/01/2021 Significant Change Minimum Data Set (MDS, an assessment tool) showed Resident 1 was admitted to the facility on [DATE], with multiple diagnoses to include [CONDITION(S)], a stroke, and weakness or paralysis to one side of the body. This MDS showed staff assessed Resident 1 required extensive assist from staff for bed mobility, transfers, and toileting, and had severe cognitive impairment. In addition, this MDS showed Resident 1 had a history of falls since admission. […]

• Actual harm, isolatedF658Jul 22, 2021

  Based on observation, interview and record review, the facility failed to ensure professional standards were met for 9 of 22 (Residents 34, 16, 63, 43, 64, 45, 74, 31, & 137) sampled residents. Facility failure to timely and accurately assess an acute condition (Resident 43); follow and /or clarify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Failure to timely and adequately assess Resident 43's urinary status caused a delay in treatment and required transfer to emergency room for treatment, which constituted harm. Findings included . FAILURE TO ASSESS Resident 43 Resident 43 admitted to the facility on [DATE]. […]

• Actual harm, isolatedF690Jul 22, 2021

  Based on observation, interview and record review, the facility failed to accurately assess and identify a decline in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder and/or bowel function as possible for 3 (Residents 45, 31, & 69) of 4 residents reviewed for indwelling catheters. Failure to identify and assess/determine causative factors requiring catheter use for Residents 69, provide treatment to promote restoration of bladder function, and interventions to prevent injury for Residents 45 & 31, placed residents at risk for continued urinary decline, and decreased quality of life and caused harm to Resident 45 who experienced untreated urinary retention and subsequent infection which required hospitalization . Findings Included . […]