A list of the most recent deficiencies for Puget Sound Transitional Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-05-19 | 2023-07-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-19 | 2023-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-19 | 2023-07-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-19 | 2023-07-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-19 | 2023-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-19 | 2023-07-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-19 | 2023-07-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-19 | 2023-07-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-19 | 2023-07-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-19 | 2023-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-19 | 2023-07-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-19 | 2023-07-14 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-05-19 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-19 | 2023-07-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-19 | 2023-07-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-05-19 | 2023-07-14 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-19 | 2023-07-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-05-16 | 2023-06-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-16 | 2023-05-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-16 | 2023-05-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-16 | 2023-05-29 | N |
| Meet other general requirements. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-23 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-23 | 2022-09-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-08 | 2022-09-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-08 | 2022-09-06 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-30 | 2022-08-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-11 | 2022-08-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-11 | 2022-08-11 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-02-15 | 2022-03-09 | Y |
| Report COVID19 data to residents and families. | Health | 2022-01-10 | 2022-01-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-27 | 2021-11-19 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-10-27 | 2021-11-19 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-22 | 2021-09-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-22 | 2021-09-17 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-07-22 | 2021-09-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-22 | 2021-09-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-22 | 2021-09-17 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-22 | 2021-09-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-22 | 2021-09-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-22 | 2021-09-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-22 | 2021-09-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-22 | 2021-09-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-22 | 2021-09-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-22 | 2021-09-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-22 | 2021-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-07-22 | 2021-09-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-22 | 2021-09-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-22 | 2021-09-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-07-22 | 2021-09-17 | N |
| Provide or obtain dental services for each resident. | Health | 2021-07-22 | 2021-09-17 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-22 | 2021-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-22 | 2021-09-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-22 | 2021-09-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-22 | 2021-09-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-22 | 2021-09-17 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-22 | 2021-09-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-22 | 2021-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-22 | 2021-09-17 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-07-22 | 2021-09-17 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2021-08-09 | 2021-09-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-09 | 2021-09-17 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-14 | 2021-08-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-07-14 | 2021-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-17 | 2021-04-09 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-03-07 | 2019-04-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-07 | 2019-04-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-03-07 | 2019-04-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-07 | 2019-04-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-07 | 2019-04-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-07 | 2019-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-07 | 2019-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-07 | 2019-04-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-07 | 2019-04-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-07 | 2019-04-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-03-07 | 2019-04-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-03-07 | 2019-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-07 | 2019-04-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-07 | 2019-04-16 | N |
| Provide or obtain dental services for each resident. | Health | 2019-03-07 | 2019-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-07 | 2019-04-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-07 | 2019-04-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-07 | 2019-04-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-07 | 2019-04-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-27 | 2019-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-27 | 2019-03-15 | N |
