Deficiency Records for Avamere Transitional Care of Puget Sound
Updated as of March 01, 2024
A list of the most recent deficiencies for Avamere Transitional Care of Puget Sound. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-16 | 2023-10-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-16 | 2023-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-16 | 2023-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-18 | 2023-09-28 | 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 | 2023-08-18 | 2023-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-18 | 2023-09-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-18 | 2023-09-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-18 | 2023-09-28 | 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 | 2023-08-18 | 2023-09-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-18 | 2023-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-18 | 2023-09-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-18 | 2023-09-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-18 | 2023-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-09-28 | 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 | 2023-08-18 | 2023-09-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-18 | 2023-09-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-18 | 2023-09-28 | 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 | 2023-08-18 | 2023-09-28 | 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 | 2023-08-18 | 2023-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-09-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-08-18 | 2023-09-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-18 | 2023-09-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-18 | 2023-09-28 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-16 | 2023-09-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-12 | 2023-05-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-17 | 2022-11-18 | Y |
| 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 | 2022-04-14 | 2022-05-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-14 | 2022-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-14 | 2022-05-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-14 | 2022-05-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-14 | 2022-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-14 | 2022-05-18 | 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 | 2022-04-14 | 2022-05-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-14 | 2022-05-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-14 | 2022-05-18 | N |
| Provide activities to meet all resident's needs. | Health | 2022-04-14 | 2022-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-14 | 2022-05-18 | 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 | 2022-04-14 | 2022-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-14 | 2022-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-14 | 2022-05-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-14 | 2022-05-18 | N |
| 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 | 2022-04-14 | 2022-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-04-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-11 | 2022-04-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-04-11 | 2022-04-22 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-15 | 2022-03-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-15 | 2019-06-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-15 | 2019-06-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-15 | 2019-06-28 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-05-15 | 2019-06-28 | 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 | 2019-05-15 | 2019-06-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-15 | 2019-06-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-15 | 2019-06-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-15 | 2019-06-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-15 | 2019-06-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-15 | 2019-06-28 | 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 | 2019-05-15 | 2019-06-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-15 | 2019-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-15 | 2019-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-09 | 2019-06-13 | N |
