🔎 Puget Sound Transitional Care
Inspection Results
Inspection Overview
Puget Sound Transitional Care has been cited for a total of 143 deficiencies since we began saving each survey.
In Washington, the average facility has **70.40 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: E
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.
Scope/Severity: D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: E
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
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.
Scope/Severity: E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Honor the resident's right to manage his or her financial affairs.
Scope/Severity: D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Scope/Severity: E
Ensure each resident receives an accurate assessment.
Scope/Severity: E
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Scope/Severity: E
Hire a qualified full-time social worker in a facility with more than 120 beds.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Implement a program that monitors antibiotic use.
Scope/Severity: E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Scope/Severity: E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: D
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.
Scope/Severity: E
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
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.
Scope/Severity: D
Provide or get specialized rehabilitative services as required for a resident.
Scope/Severity: F
Report COVID19 data to residents and families.
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: E
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.
Scope/Severity: G
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity: E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Scope/Severity: D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Scope/Severity: E
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.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: E
Respond appropriately to all alleged violations.
Scope/Severity: D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Scope/Severity: D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Scope/Severity: E
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: G
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
Assist a resident in gaining access to vision and hearing services.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
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.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: G
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: G
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
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.
Scope/Severity: E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Scope/Severity: D
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.
Scope/Severity: D
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: E
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.
Scope/Severity: D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Scope/Severity: E
Provide or obtain dental services for each resident.
Scope/Severity: E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: E
Implement a program that monitors antibiotic use.
Scope/Severity: E
Prepare residents for a safe transfer or discharge from the nursing home.
Scope/Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: H
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Scope/Severity: D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Scope/Severity: D
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.
Scope/Severity: E
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.
Scope/Severity: E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: E
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.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Assist a resident in gaining access to vision and hearing services.
Scope/Severity: E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
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.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: E
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
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.
Scope/Severity: E
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity: D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Scope/Severity: E
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.
Scope/Severity: D
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: D
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.
Scope/Severity: D
Provide or obtain dental services for each resident.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Implement a program that monitors antibiotic use.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: D
Give residents a notice of rights, rules, services and charges.
Scope/Severity: D
Allow residents to self-administer drugs if determined safe.
Scope/Severity: D
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Scope/Severity: E
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
Scope/Severity: D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Scope/Severity: D
Provide housekeeping and maintenance services.
Scope/Severity: L
Maintain comfortable and safe temperature levels.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide necessary care and services to maintain or improve the highest well being of each resident .
Scope/Severity: D
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Scope/Severity: D
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Scope/Severity: D
Give each resident enough fluids to keep them healthy and prevent dehydration.
Scope/Severity: E
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Scope/Severity: D
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Scope/Severity: D
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Scope/Severity: D
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
Scope/Severity: D
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
Scope/Severity: E
Store, cook, and serve food in a safe and clean way.
Scope/Severity: L
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
Scope/Severity: D
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**