Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Transitional Care Of Puget Sound during CMS and state inspections, most recent first.
A resident admitted with coccyx skin breakdown and moderate Braden risk was initially misclassified as having skin tears rather than Stage II PUs, and the skin integrity care plan lacked resident-centered interventions addressing specific risk factors such as repositioning, offloading, and moisture management. Nursing documentation over time was inconsistent, with notes alternately stating there were no wounds and describing excoriation and open areas, while weekly wound audits and evaluations were missed or incomplete. The WCC eventually identified a large unstageable coccyx PU that progressed to Stage IV, but WCC orders for twice-daily wound care, specific cleansers, and pressure-relieving devices were inaccurately transcribed on the TAR and not fully incorporated into the care plan. Weekly wound assessments were not consistently performed, and the care plan failed to document the presence and stage of the coccyx Stage IV PU or a new heel DTI, contributing to ongoing worsening of the resident’s pressure injuries.
A resident’s PU/PI status was inaccurately assessed and documented across multiple tools and time points, including the admission skin integrity database, daily skilled notes, CAA, and several MDS assessments and modifications. Initial documentation described coccyx wounds as skin tears and later MDS coding alternated between no PU/PI, unstageable PU/PI present on admit, and a Stage IV PU/PI not present on admit, without consistent supporting clinical detail such as stage, location, or measurements. The CAA lacked documented rationale for PU/PI-related care planning, and a new DTI on the heel identified by a WCC was not coded on the discharge MDS because the wound tracker form was not available to the MDS coordinator at the time of completion.
Medication and treatment carts were found unlocked and unattended on multiple halls, including carts containing residents’ prescribed meds, medical supplies, medicated creams, ointments, wound cleansers, and dressings. RN staff stated the carts should be locked when unattended and acknowledged they had been left unsecured, and the DON stated the expectation was that the carts be locked or secured when left unattended.
Failure to provide scheduled showers and oral care for 3 residents. A resident with failure to thrive, anxiety, and neuropathy said they had gone over a week without a shower, while two other residents who needed ADL help reported missed showers and, in one case, no oral hygiene despite set-up assistance being required. Staff said one resident’s refusals were not documented, one resident’s oral care was missed due to a therapy appointment, and one resident’s bathing preference had not been care planned.
Delayed Response to Call Lights and Insufficient Nursing Coverage: Residents reported waiting 30 minutes to over an hour for call lights to be answered, including delays for pain medication, repositioning, and help getting into bed. Observations showed staff walking past an unanswered call light and a call light remaining active at the nurse's station for 34 minutes, while staff and the DON stated response times should be much shorter and that the call light system should be audible.
Failure to honor a resident's request for mobility bars. A resident with spinal stenosis, anxiety, insomnia, and a recent fall said they repeatedly asked for mobility bars so they could reposition in bed and reduce worry about falling, but the bed remained high and without bars. The care plan did not include the intervention, and the RCM and DON stated the request should have been addressed more quickly.
Missing Resident and Family Participation in Care Conference: A resident admitted with a hip fracture and CHF was not documented as attending a care conference, and the resident’s adult child said they were not invited. The EHR care conference form was left blank for attendee information, and the SS Director and Administrator stated they could not verify who attended the conference.
A resident wearing a life vest had no provider order or care plan interventions for the device, despite staff confirming the resident readmitted with it and understood its use. Another resident with a left foot wart had no treatment order or care plan interventions, and the ordered cream was not provided even after a relative brought it to the facility.
Two residents received O2 at settings that did not match the ordered therapy. One resident with COPD was observed on 2 L NC when the care plan called for 1 L continuously, and another oxygen-dependent resident was observed on 1.5 L NC when the order called for 2 L continuously. Staff acknowledged the mismatched settings and stated they were expected to follow provider orders.
A resident newly admitted with hepatic encephalopathy, DM, and CKD did not receive a timely pharmacy medication regimen review. The DRR identified clinically significant issues related to drug allergy and other concerns, required provider review, and was not received by the facility until several days after admission, with staff stating the review should have been completed within 12 to 24 hours.
A resident admitted after knee surgery with heart failure and diabetes had PRN oxycodone HCl and acetaminophen orders for pain management, but the acetaminophen order lacked pain level parameters and NPI codes. The MAR showed acetaminophen was given with pain scores from 3 to 7 without documented NPI, and it was often administered at the same time as oxycodone HCl. Staff stated the documentation did not meet expectations and that PRN pain meds should have had pain parameters and documented NPI use.
Failure to Follow Transmission-Based Precautions: Staff did not follow a TBP sign posted on a resident’s door for Covid-19. A CNA entered the room wearing only a surgical mask instead of the required N95, gown, gloves, and eye protection, later exited with soiled linens, and another CNA later entered without PPE. The resident was also observed at the doorway without a surgical mask while staff walked by without N95s or eye protection.
Menu deviations were observed when the lunch served did not match the planned menu: chicken in orange sauce was served instead of parmesan chicken, canned mandarin oranges were served instead of seasonal fresh fruit, and a bread roll was not provided. The RD stated the kitchen should follow the menu and review any changes with them, but they were unaware of the substitutions. The dietary manager and administrator both stated deviations should have been communicated and reviewed.
A resident with multiple medical conditions reported rough care by a CNA, resulting in bruising and distress. The incident was documented as a grievance but not reported as an abuse allegation, and there was no evidence of an investigation or required notifications. Staff interviews revealed inconsistent understanding of abuse reporting protocols, and the DNS could not provide documentation of follow-up actions.
A resident with dysphagia and a prescribed minced & moist texture diet was incorrectly served a regular texture hamburger, leading to coughing and hospital evaluation. Staff failed to verify dietary orders and care plans before serving the meal.
The facility failed to investigate an unexpected death and an abuse allegation. A resident with hypertension died unexpectedly after receiving medication against provider orders, and no investigation was conducted. Another resident reported inappropriate behavior by a staff member, but the incident was not logged or reported. The DON and Administrator acknowledged that such incidents should be investigated, but no actions were taken.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks for unmet care needs. One resident, with heart conditions, reported pain and received medications, but the MDS inaccurately showed no pain or anticoagulant use. Another resident, with a leg contusion, had dressings applied, yet the MDS did not reflect this. Staff interviews confirmed these discrepancies.
The facility failed to create comprehensive care plans for four residents, leading to potential risks. A resident with anxiety related to toileting had no care plan addressing this issue, while another on narcotic pain medication lacked a pain management plan. A third resident had an indwelling catheter without an order or care plan, and a fourth resident's fear of falling during bed mobility was not addressed in their care plan. Staff interviews revealed communication gaps and inconsistencies in understanding residents' needs.
The facility failed to follow provider orders and ensure safe medication administration for several residents, leading to significant deficiencies in care. A resident with hypertension was given amlodipine despite low blood pressure, resulting in an unexpected death. Another resident experienced lightheadedness due to low blood pressure without proper monitoring or provider notification. Additional issues included improper administration of medications outside prescribed parameters and inadequate documentation of adverse effects and bowel care.
The facility failed to provide a working doorbell for handicap residents in the courtyard, leading to potential risks. A resident reported that the courtyard doors were too heavy to open, and the doorbell did not prompt staff response, leaving them stuck until a staff member came by. The Maintenance Director was aware of the issue but unsure of its duration.
The facility failed to provide nonpharmacological interventions (NPI) before administering PRN pain medications to two residents. One resident with hypertension received oxycodone and acetaminophen without NPI being offered, while another resident with a hip fracture received narcotic pain medication multiple times without NPI being documented. Staff interviews confirmed that the expectation to use NPI prior to PRN medications was not met.
The facility failed to properly store medications in both medication rooms and on two medication carts. Lorazepam, a controlled substance, was not secured in locked compartments in the medication rooms, and refrigerator temperatures were frequently out of range. Additionally, insulins on the medication carts lacked open or expiration dates, with one being expired. Staff interviews indicated a lack of awareness regarding proper procedures for securing medications and monitoring temperatures.
The facility failed to maintain an effective infection prevention and control program, lacking analysis of infection data and follow-up activities. Transmission-based precautions were not implemented properly, with staff observed entering rooms without required PPE. Enhanced Barrier Precautions were also not followed during wound care. Interviews confirmed that expected precautions were not consistently implemented.
The facility failed to ensure the infection prevention and control program was managed by a qualified individual. During the absence of the designated infection preventionist, there was confusion about who was responsible for infection control tasks. Staff B and Staff Z had not completed necessary training, and Staff CC, who was expected to cover, was not doing so. This placed residents, family members, and staff at risk.
The facility failed to educate four residents on the benefits and potential side effects of the COVID-19 vaccine before offering it. The residents declined the vaccine, and there was no documentation of education provided. Interviews with staff confirmed the lack of documentation and education, which was expected by the facility's administration.
Failure to Accurately Assess, Care Plan, and Implement Wound Care for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services consistent with professional standards of practice to prevent the development and worsening of pressure ulcers/injuries for a resident admitted with coccyx skin breakdown and at moderate risk for pressure injury. On admission, the resident had two coccyx wounds documented as skin tears without detailed wound characteristics, and the Braden Scale score was 14, indicating moderate risk due to moisture, activity, mobility, and friction/shear issues. The initial skin integrity care plan identified actual skin impairment and included general interventions such as keeping skin clean and dry, using lotion, encouraging nutrition, weekly skin assessments, and monitoring/documenting wounds, but it did not include resident-centered interventions addressing specific Braden risk areas or pressure ulcer prevention measures such as repositioning, offloading, or moisture management tailored to the resident’s condition. In the weeks following admission, nursing documentation about the resident’s skin condition was inconsistent and incomplete. Progress notes alternated between stating that the resident had no wounds and describing a pressure ulcer with drainage and slough, excoriation of the buttocks, and open areas on the coccyx, without consistent measurements or staging. Weekly skin audits at times reported no irregularities despite other notes indicating significant skin issues. The contracted wound care clinician (WCC) did not evaluate the coccyx wounds until 14 days after admission, at which time the resident had a large unstageable coccyx pressure injury with extensive eschar. Although the WCC recommended specific treatments, including twice-daily dressing changes, an air mattress, and turning/repositioning every two hours, the care plan was only minimally updated to add an air mattress and did not document the unstageable pressure injury, pressure offloading, repositioning frequency, or other individualized interventions based on the Braden assessment. Over the subsequent weeks, the facility failed to consistently perform and document weekly wound evaluations and did not accurately transcribe or implement physician and WCC wound care orders. Treatment Administration Records showed that orders for twice-daily wound care were entered as once daily, and instructions to leave an acidic wound cleanser on the wound bed for 10 minutes were omitted. Weekly wound evaluations were missing for multiple weeks, and when the WCC documented worsening of the coccyx wound to Stage IV with increasing size and eschar, the care plan still was not updated to reflect the wound stage, detailed interventions, or additional pressure-relieving devices recommended by the WCC. The resident’s coccyx pressure injury continued to worsen in size and depth, and a new deep tissue injury developed on the right heel, despite WCC orders for heel protectors and offloading. The care plan eventually added general instructions to encourage repositioning and elevate heels with pressure-relieving boots, but it still did not document the presence or stage of the coccyx Stage IV pressure ulcer or the heel DTI. Interviews confirmed that wound orders were incorrectly transcribed, weekly wound evaluations were not routinely completed, and the initial coccyx wounds had been misidentified as skin tears rather than Stage II pressure ulcers, contributing to avoidable worsening of the resident’s pressure injuries.
Inaccurate MDS and Wound Documentation for Pressure Ulcers/Injuries
Penalty
Summary
The facility failed to ensure accurate assessment and documentation of a resident’s pressure ulcers/injuries (PU/PIs) from admission through discharge. On admission, the Nursing Database-Skin Integrity dated 12/04/2025 documented two coccyx wounds as skin tears, while the DON later stated the resident actually admitted with two Stage II PU/PIs on the coccyx, indicating the admission documentation was inaccurate. A daily skilled progress note on 12/08/2025 described a PU/PI with drainage and dead tissue but did not include the anatomical location, stage, or measurements. The 12/10/2025 admission MDS coded the resident as at risk for PU/PIs with no unhealed PU/PIs, and the 12/15/2025 PU/PI CAA did not document the rationale for care plan decisions, including complications, risk factors, or resident-centered care needs. Subsequent MDS assessments and modifications contained inconsistent and incomplete coding of the resident’s PU/PIs. A Significant Change MDS dated 01/22/2026 showed one Stage IV PU/PI present on admission, while a 12/10/2025 admission MDS modification dated 01/27/2026 coded one unstageable PU/PI on admission. A later admission MDS modification dated 02/11/2026, submitted after discharge, indicated one unhealed PU/PI but did not include the number or stage of the wound. The MDS coordinator reported there was no supporting documentation for a PU/PI on admission and that the earlier coding of an unstageable PU/PI present on admission was incorrect; the records were then modified to show a Stage IV PU/PI that was not present on admission and had developed at the facility. Additionally, a Wound Care Consultant form dated 02/05/2026 documented a new DTI on the right heel, but the discharge MDS dated 02/10/2026 did not code this DTI, which the MDS coordinator attributed to the wound tracker form not being available in the clinical record at the time of MDS completion.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure treatment and medication carts were secured when unattended. Observations showed the Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall treatment carts and medication carts left unlocked and unattended during multiple checks. The carts contained residents’ prescribed medications and medical supplies, and the treatment carts contained medicated creams, ointments, wound cleansers, and treatment supplies such as various types of dressings. The facility policy titled Medication Storage stated that only licensed nurses, pharmacy staff, and other authorized staff may access medication carts, and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended. During interviews, RN staff stated the carts should be locked when unattended and acknowledged they had been left unsecured. The DON also stated the expectation was that treatment and medication carts should be locked or secured when left unattended.
Failure to Provide Scheduled Showers and Oral Care
Penalty
Summary
The facility failed to consistently offer or provide showers and oral care for 3 of 4 sampled residents who required assistance with activities of daily living. Resident 14, admitted with failure to thrive, anxiety, and neuropathy, told the surveyor they had been at the facility for over a week and had not received a shower. The shower sheet showed the resident was scheduled for showers twice weekly, and the Residential Care Manager stated the resident had declined showers but that the refusals were not documented and should have been. Resident 84, admitted with a fractured femur and anxiety and requiring staff assistance with ADLs, was observed in bed with greasy unkempt hair and yellow matter on their teeth and stated they had not been offered a shower and staff did not provide or offer oral hygiene. The shower sheet showed twice-weekly showers were scheduled, and the EHR showed the resident required set-up assistance with oral hygiene; a CNA stated oral care was not provided due to a therapy appointment. Resident 88, admitted with COPD and diabetes and requiring staff assistance with bathing, stated they had not had a shower in over a week. The shower sheet showed twice-weekly showers were scheduled, and the RCM stated the resident wanted to be bathed by their caregiver who had not yet visited and that this preference had not been care planned.
Delayed Response to Call Lights and Insufficient Nursing Coverage
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide care in a timely manner and complete activities of daily living for residents on 300 hall. During interviews, Resident 67 stated they had turned on their call light the prior night and waited over an hour, and said they did not see any staff in the hallways when they went out into the hall. Resident 32 stated they waited 30 minutes with the call light on to ask for pain medicine and then another 15 minutes for the nurse to bring it, saying that was a long time when they were hurting. Observation showed Resident 51 in their room with a family member who turned on the call light for help repositioning the resident, while multiple staff walked by without answering it; a nursing staff member responded 35 minutes later. Another observation showed the call light system at the nurse's station lit for Resident 5 for 34 minutes, and the resident later stated staff had turned off the light and said they would return before the resident turned it back on and waited until a CNA arrived, for a total wait of 55 minutes. Resident council minutes also documented Resident 4 reporting that a call light in the bathroom took too long to be answered, leading them to use their walker without assistance.
Failure to Honor Resident Request for Mobility Bars
Penalty
Summary
The facility failed to honor a resident's request for mobility bars for Resident 93, who was admitted with spinal stenosis, anxiety, and insomnia and was able to make needs known. During an interview and observation, the resident stated they had fallen at home before admission and continued to worry about falling from the bed at the facility. The resident said they requested mobility bars so they could reposition themselves in bed, but the request had not been honored. Observation showed the resident's bed was in a high position and did not have mobility bars. The care plan, initiated on 09/15/2025, identified Resident 93 as at high risk for falls with a recent fall, but it did not include an intervention for mobility bars. A Safety Device Evaluation and Consent dated 09/17/2025 documented a history of falls and recommended mobility bars for the resident's bed, and noted that mobility bars were requested to improve bed mobility and independence with positioning. Staff F, the RCM, stated the resident was assessed for mobility bars on 09/17/2025, a provider order was obtained on 09/25/2025, and maintenance was notified, but also stated this did not meet the facility's expectation of timely response. Staff B, the DON, stated mobility bars should be provided as soon as possible and that the resident's mobility bars should have been provided more quickly.
Missing Resident and Family Participation in Care Conference
Penalty
Summary
The facility failed to complete a care conference meeting with Resident 74 or the resident’s responsible party for 1 of 19 sampled residents reviewed for care plans and care planning. Resident 74 was admitted with diagnoses including a broken part of the right hip socket and heart failure, and the resident was able to communicate needs. During an interview, Resident 74 stated they did not recall ever going to a care conference or being asked to attend one, and the resident’s adult child stated they were not invited and would have liked to attend a care conference with their parent. Review of the electronic health record showed a care conference information form dated 09/09/2025 with the section for the resident or responsible party who were present and who attended left blank. There was no documentation showing that Resident 74 or the family attended a care conference. The Social Services Director stated they could not tell from the documentation whether Resident 74 had attended a care conference and stated the resident should have attended care conferences on 09/02/2025 and 09/09/2025. The Administrator stated Social Services were to invite residents and/or responsible parties to care conferences by phone, email, or in person, and that the care conference should be documented in the EHR to include who attended.
Missing Orders and Care Plan Interventions for Life Vest and Foot Wart Treatment
Penalty
Summary
The facility failed to have a provider order and care plan interventions in place for a resident who was readmitted with diagnoses including infection and swelling reaction due to a cardiac device implant and diabetes. The resident was observed in bed wearing a life vest under a tank top and stated they had been wearing it for about two weeks, understood how it worked, and knew who to call if there were problems. Review of the electronic health record showed there was no provider order for the life vest and no interventions in the resident’s plan of care related to its use. Staff confirmed the resident had readmitted with the life vest, acknowledged the resident was informed about it, and stated there should have been both an order and interventions in place. The facility also failed to ensure treatment and services were in place for a resident with a non-pressure skin issue on the left foot. The resident was admitted with diagnoses including a broken hip and muscle weakness, and had a left plantar foot wart documented on admission as 9 cm by 8 cm. The resident and a relative reported that a cream for the left foot had been brought to the facility and given to a nurse, but the foot had not been treated with the medication. Record review showed no medication treatment order for the left foot and no related interventions in the care plan. Staff stated they were not aware the foot was wrapped, could not locate a treatment order, and later confirmed the provider should have been notified because the treatment had not been provided.
Failure to Follow Ordered Oxygen Settings
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents when staff did not follow the ordered oxygen settings. Resident 88 was admitted with diagnoses of chronic obstructive pulmonary disease and diabetes and was able to make needs known. Observations on 09/23/2025, 09/24/2025, and 09/25/2025 showed the resident receiving oxygen at 2 L per minute via nasal cannula, while the care plan dated 09/15/2025 listed oxygen settings at 1 L continuously. An LPN stated the oxygen was set at 2 L but should have been set to 1 L, and the RCM stated staff were expected to follow physician orders. Resident 101 was assessed as oxygen dependent. An observation on 09/26/2025 showed the resident receiving oxygen at 1.5 L per minute via nasal cannula, while the care plan dated 09/22/2025 listed oxygen settings at 2 L continuously. An RN verified the oxygen was set at 1.5 L and stated the provider order was for 2 L, adding that staff were in the process of weaning the resident off oxygen but had not received a new order. The DON stated the expectation was for staff to follow provider orders and document accurate information.
Delayed Medication Regimen Review for New Admission
Penalty
Summary
The facility failed to conduct a timely medication regimen review for one sampled resident newly admitted to the facility. Resident 9 was admitted with diagnoses of hepatic encephalopathy, diabetes, and chronic kidney disease, and was able to make needs known. A Drug Regimen Review for New Admissions and Identification of Potential Clinically Significant Medication Issues form dated 09/03/2025 identified clinically significant medication issues in the areas of Drug Allergy and Other and required provider review. The record showed the document was faxed to the facility on 09/23/2025 and reviewed by the provider on 09/24/2025. During interviews, the Resident Care Manager stated the facility did not receive the medication regimen review until 09/23/2025 and that issues were identified on the report, while the Director of Nursing Services stated newly admitted residents should have a medication regimen review from the pharmacy within 24 hours. The report stated the review did not meet expectations for timeliness.
Inconsistent pain medication documentation and missing NPI use
Penalty
Summary
The facility failed to consistently provide non-pharmacological interventions and to have pain level parameters in place before giving as-needed pain medication for Resident 45. Resident 45 was admitted with diagnoses including aftercare following knee surgery, heart failure, and diabetes, and was able to make needs known. Review of the September 2025 MAR showed an order for oxycodone HCl every four hours as needed for moderate to severe pain that required documentation of pain level and NPI attempted first, and the medication was documented with pain levels ranging from 0 to 7. The same MAR also showed an order for acetaminophen extra strength every four hours as needed for pain with no pain level parameters or NPI codes. Documentation showed acetaminophen was given with pain levels ranging from 3 to 7, with no NPI documented before administration, and it was often given at the same time as oxycodone HCl. Staff O stated the acetaminophen order had no pain level parameters and no NPI were provided when it was given without oxycodone HCl. Staff B stated NPIs were to be provided and documented before giving as-needed pain medication and that pain level parameters should have been written to guide when to give acetaminophen versus oxycodone.
Failure to Follow Transmission-Based Precautions
Penalty
Summary
Provide and implement an infection prevention and control program. The facility failed to implement appropriate transmission-based precautions for 1 of 4 hallways, the North front hallway, when a room had a TBP sign posted instructing staff to wear an N95 mask, eye protection, a gown, and gloves and to keep the door closed. On 09/23/2025 at 6:15 AM, Staff H, a CNA, entered the room wearing only a surgical mask, did not don an N95 mask, gown, or eye protection, remained in the room for eight minutes, and exited with a bag of soiled linens while still wearing the surgical mask. Staff H stated the resident in the room had Covid-19. Later that day, the room door was observed open, the resident was sitting in a wheelchair at the doorway without a surgical mask, multiple staff walked by without an N95 or eye protection, and Staff J, a CNA, entered the room without wearing an N95 mask, eye protection, gloves, or a gown. Staff J stated the room had a TBP sign posted but they did not wear PPE because they thought the resident no longer required TBP. The DON stated it was the expectation that staff followed the precaution signs' instructions when entering resident rooms.
Menu Deviations Not Reviewed With RD
Penalty
Summary
The facility failed to follow the prepared lunch menu and did not ensure menu changes were reviewed with the registered dietician. The menu for lunch listed parmesan chicken, sweet potato, cauliflower, bread roll, and seasonal fresh fruit, but observation showed the cook serving chicken breast in an orange sauce, sweet potato, green beans, and canned mandarin oranges. The observed test lunch tray also contained chicken in a sweet orange sauce, sweet potatoes, green beans, and canned mandarin oranges, and a bread roll was not provided. During interview, the registered dietician stated they oversaw the kitchen, that the kitchen should follow the provided menus when possible, and that any menu changes should be reviewed with them to ensure meals met residents’ nutritional needs. The registered dietician stated they were unaware of the substitutions of orange chicken for parmesan chicken, canned mandarin oranges for seasonal fresh fruit, or the lack of a bread roll, and stated the lunch did not follow the planned menu. The dietary manager stated the kitchen was to follow the facility menus and that any deviation needed to be communicated to and agreed upon by the registered dietician. The administrator stated the menus were provided by the corporate office and that the lack of communication regarding the lunch deviations did not meet expectations.
Failure to Identify and Report Alleged Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving one resident who was admitted for skilled nursing and rehabilitation following a recent hospitalization. The resident, who had a history of stroke, back surgery, and an implanted nerve stimulator, reported that a CNA was rough during personal care, including yanking the resident up and down and not listening to requests to stop. The resident described feeling like a 'rag doll' and reported bruising as a result of the rough care. The incident was reported by the resident to a provider the following morning, and subsequently discussed with the Director of Nursing Services (DNS). Despite the resident's report and a grievance form documenting the allegation of rough care, the facility did not log the incident as an abuse allegation in the incident logs. There was no documentation in the electronic health record of a provider note, skin assessment, or evaluation following the resident's report. The DNS documented that education would be provided to the CNA and updated the resident's care plan, but there was no evidence of an abuse investigation or required notifications to authorities as outlined in facility policy and state guidelines. Interviews with multiple staff members revealed inconsistent understanding and implementation of abuse reporting protocols. Some staff indicated they would notify supervisors or complete grievance forms, but were unclear about the process for suspending staff or notifying authorities. The DNS stated that further information would be gathered before suspending staff or notifying parties, and could not recall the staff member involved or provide documentation of the education provided. The administrator confirmed that either the administrator or DNS would decide next steps upon being notified of such incidents.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure that the correct texture of food was served to a resident with a prescribed therapeutic diet. Resident 1, who was moderately cognitively impaired and had a diagnosis of dysphagia, was admitted to the facility with a physician's order for a minced & moist texture diet. Despite this, the resident was served a regular texture hamburger as an alternative meal, which was not in accordance with the prescribed diet. This incident occurred after the resident had been hospitalized for aspiration pneumonia, highlighting the importance of adhering to dietary orders. The incident report revealed that neither the kitchen staff nor the nursing staff verified the resident's dietary orders and care plan before serving the meal. As a result, the resident began coughing after consuming the hamburger, prompting staff to remove the meal and send the resident to the hospital for further evaluation. The failure to check the dietary orders and care plan led to the serving of an incorrect meal texture, which could have posed significant health risks to the resident.
Failure to Investigate Unexpected Death and Abuse Allegation
Penalty
Summary
The facility failed to investigate an unexpected death and an allegation of abuse, leading to deficiencies in care. Resident 52, who had a diagnosis of essential hypertension, unexpectedly died at the facility. The resident was administered amlodipine despite having a low systolic blood pressure, which was against the provider's orders. The resident's condition deteriorated throughout the day, and despite being monitored, the resident became nonresponsive and died. The Director of Nursing Services and the Administrator acknowledged that unexpected deaths should be investigated to rule out abuse, neglect, or mistreatment, but no further investigation was conducted after reviewing the medical records. Resident 114, who was cognitively intact and admitted with multiple fractures of the pelvis, reported an incident involving a staff member to a Charge Nurse. The resident requested that the staff member not return to their room, but the staff member continued to act inappropriately. The incident was not recorded in the facility's incident log, and the Charge Nurse did not report the incident to anyone else. The Director of Nursing Services and the Administrator stated that allegations of abuse should be reported, investigated, and the alleged perpetrator suspended, but these actions were not taken.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Sets (MDS) accurately reflected the health status and care needs of two residents, leading to potential risks for unidentified and unmet care needs. Resident 107, admitted with congestive heart failure and atrial fibrillation, reported significant pain levels and received both tramadol and heparin sodium during the lookback period. However, the admission MDS inaccurately indicated no pain and no anticoagulant medication. Staff interviews revealed that the MDS Coordinator did not review records for reported pain, and the Director of Nursing Services acknowledged the inaccuracies in the MDS. Similarly, Resident 307, readmitted with heart failure and a leg contusion, was observed with a swollen leg and dressings applied by the facility's nurses. Despite this, the five-day MDS inaccurately showed no dressings. Staff interviews confirmed that the MDS should have reflected the dressing changes. These inaccuracies in the MDS assessments were identified through observations, interviews, and record reviews, highlighting a failure to accurately document residents' conditions.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential risks for these individuals. Resident 113, who was admitted with orthopedic surgery complications, expressed anxiety about being left alone in the bathroom, but this was not documented in their care plan. Despite the resident communicating their anxiety to therapy staff, this information was not relayed to nursing staff, resulting in a lack of appropriate interventions. Similarly, Resident 44, who was prescribed narcotic pain medication, did not have a care plan addressing pain management, contrary to the facility's expectations. Resident 108, admitted for post-surgical care, had an indwelling urinary catheter without a corresponding order or care plan, leaving the resident unaware of the catheter's purpose. Additionally, Resident 306, with diagnoses including anxiety and depression, expressed fear of falling during bed mobility, yet their care plan lacked instructions on managing this fear and the required assistance level. Staff interviews revealed inconsistencies in understanding the resident's needs, highlighting a gap in communication and care planning. These deficiencies indicate a failure to ensure that care plans are updated and communicated effectively among staff.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to provider orders and ensure safe medication administration for several residents, leading to significant deficiencies in care. Resident 52, who had a diagnosis of essential hypertension, was administered amlodipine despite having a systolic blood pressure below the prescribed hold parameter. The resident's low blood pressure was not communicated to the provider in a timely manner, and the resident subsequently died unexpectedly. The Director of Nursing Services acknowledged that the medication should not have been given and that the provider should have been notified immediately of the resident's condition. Resident 8, with a history of chronic respiratory failure and heart conditions, experienced lightheadedness due to low blood pressure, yet there were no hold parameters for their metoprolol medication. Blood pressure readings were not consistently rechecked or documented, and the provider was not informed of low readings. Similarly, Resident 206 received metoprolol despite having a systolic blood pressure below the hold parameter, and Resident 44 was given medications with heart rates below the prescribed limits. These actions were contrary to the facility's expectations and policies. Additional deficiencies were noted with Resident 107, who was on anticoagulant therapy and developed bruising that was not documented or monitored as required. Resident 112, who was receiving morphine, experienced constipation that was not addressed according to the bowel care protocol. The facility failed to document interventions or follow the protocol for residents who had not had a bowel movement for several days. These failures in monitoring and communication placed residents at risk of adverse effects and diminished quality of life.
Non-Functioning Doorbells in Courtyard
Penalty
Summary
The facility failed to provide a working doorbell for handicap residents visiting the courtyard, which was identified as an accident hazard. During an interview, a resident stated that both ends of the courtyard had doors that were too heavy for them to open, and the button intended to call for assistance did not result in a staff response. This left residents stuck in the courtyard until a staff member happened to come by. Observations confirmed that the courtyard doors were heavy and that pressing the doorbells did not prompt a staff response. The Maintenance Director acknowledged awareness of the non-functioning doorbells but was unsure of how long they had been inoperative. This deficiency placed residents at risk for accidents, anxiety, feelings of entrapment, and a diminished quality of life, as the facility did not offer any handicap options for residents in the courtyard.
Failure to Provide Nonpharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to provide nonpharmacological interventions (NPI) before administering as-needed (PRN) pain medications to two residents, leading to a deficiency in medication management. Resident 44, who was admitted with a diagnosis of essential hypertension, had orders for oxycodone and acetaminophen to be administered as needed. However, there were no orders for NPI, and the medication administration record showed that Resident 44 received oxycodone four times and acetaminophen three times without any NPI being offered. Interviews with staff confirmed that the expectation was to use NPI prior to administering PRN pain medications, but this was not done for Resident 44. Similarly, Resident 1, admitted with a diagnosis of a fall with a hip fracture, received narcotic pain medication 33 times over a specified period. Documentation showed that NPI was not offered prior to administration for 22 of these instances. Staff interviews revealed that nursing staff should have offered and documented NPI in the medical record, but this was not included in Resident 1's orders. The Director of Nursing Services confirmed that the expectation was to offer NPI before administering narcotic medications, which was not met in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications in both the north and south medication rooms and on two medication carts. In the south medication room, an emergency kit containing Lorazepam, a controlled substance, was not secured in a locked compartment. Similarly, in the north medication room, the refrigerator containing an emergency kit with Lorazepam was not locked, and the medication was not secured. Additionally, the temperature logs for the south medication room showed that the refrigerator temperatures were frequently out of the required range, with instances of both freezing and excessively high temperatures recorded throughout July 2024. On the medication carts, multiple instances of improper labeling were observed. In the south high medication cart, two multi-dose insulins lacked open or expiration dates. Similarly, the south low medication cart contained two multi-dose insulins without open or expiration dates, and one insulin was expired. Staff interviews revealed a lack of awareness and understanding regarding the proper procedures for securing controlled substances and monitoring refrigerator temperatures, contributing to the deficiencies in medication storage and labeling.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of analysis of infection control data, identification of trends, and follow-up activities for the months of April, May, and June 2024. The facility's policy, revised in October 2018, required the infection prevention and control program to be coordinated by an infection preventionist and to follow guidelines from the CDC. However, the facility did not document any analysis or interventions based on infection surveillance data, nor did they map current organisms or infections. Additionally, the facility did not implement transmission-based precautions (TBP) effectively. Observations revealed that rooms with Aerosol Generating Procedure (AGP) precautions had open doors and lacked necessary personal protective equipment (PPE) such as N95 masks. Staff members were observed entering rooms without wearing the required PPE, despite signs indicating the need for gowns, gloves, and masks. Interviews with staff, including the Resident Care Manager and Director of Nursing Services, confirmed that the expected precautions were not followed. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs). During wound care for a resident, staff did not wear a gown as required by the CDC guidelines. Interviews with the Director of Nursing Services and the Administrator highlighted the expectation for staff to follow posted precautions, but these were not consistently implemented. The infection preventionist's responsibilities, including tracking and mapping infections and ensuring precautions were in place, were not fulfilled, contributing to the deficiencies observed.
Inadequate Infection Control Oversight
Penalty
Summary
The facility failed to ensure that the infection prevention and control program (IPCP) was managed by a qualified individual with the necessary time and training to effectively oversee the program. This deficiency was identified during interviews and record reviews, revealing that the designated infection preventionist, Staff Z, was on vacation, and there was confusion about who was responsible for infection control tasks in their absence. Staff CC, a Registered Nurse/Resident Care Manager, was expected to cover for Staff Z but stated they were not currently doing so. Additionally, Staff B, who was not aware of their responsibility for infection control tasks, was only managing the antibiotic line list. The report highlights that neither Staff B nor Staff Z had completed infection control training, which is crucial for the effective management of the IPCP. The facility's policy required the infection preventionist to track vaccines, conduct rounds, ensure proper isolation precautions, review electronic health records for new infections, and provide staff education, among other duties. The lack of a qualified and trained infection preventionist to oversee these tasks placed residents, family members, and staff at risk of contracting communicable diseases and experiencing a decreased quality of life.
Failure to Educate Residents on COVID-19 Vaccine
Penalty
Summary
The facility failed to provide education on the benefits and potential side effects of the COVID-19 vaccination to four residents before offering the vaccine. This deficiency was identified during a review of the electronic health records (EHR) for Residents 14, 15, 20, and 34, who all declined the COVID-19 vaccine on various dates in 2024. There was no documentation found indicating that these residents or their representatives received the necessary education prior to being offered the vaccine. Interviews with facility staff further confirmed the deficiency. Staff Z, the Interim Infection Preventionist, acknowledged that residents should have been educated on the benefits and potential side effects of the COVID-19 vaccines when they were offered, but was unable to locate documentation for the four residents in question. Additionally, Staff A, the Administrator, stated that it was their expectation that all residents receive education on the risks and benefits when offered the COVID-19 vaccines. This lack of documentation and education placed residents at risk of not being able to make informed decisions regarding their medical care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,127 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tacoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eliseo | 0.5 mi | ★★★★★ | 5 | 0 |
| Park Rose Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Cottesmore Of Life Care | 2.8 mi | ★★★★★ | 18 | 0 |
| Orchard Park Health Care & Rehab Center | 3 mi | ★★★★★ | 45 | 0 |
| Agility Health And Rehabilitation | 3.4 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.