Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Puget Sound Care during CMS and state inspections, most recent first.
Failure to report an allegation of neglect for a resident who was found in a urine-soaked bed with soaked pillows and bedding. The resident had moderate cognitive impairment, was incontinent of bowel and bladder, and required 2-person assist with all ADLs. A NAC notified the nurse and DON about the condition and later filed a mandatory report, but the Administrator and DON did not log or report the concern as neglect because they did not consider it an allegation.
Failure to follow bowel, PICC, insulin, and weight monitoring orders. The facility did not initiate bowel interventions for three residents with extended gaps between documented BMs, did not document required PICC dressing change measurements and completion for a resident with a PICC, did not follow ordered low blood sugar treatment when a resident’s CBG was 67 on two occasions, and did not obtain weekly weights after admission for that resident. Staff review of the records confirmed missing documentation and unmet physician order requirements.
A resident’s trust account was not conveyed within the required timeframe after the resident expired. The account showed a small remaining balance and was not closed until 53 days later, even though the BOM stated trust accounts were supposed to be conveyed within 30 days of discharge or death.
Missing Care Plans for Bed Rail Use: Two residents with moderate cognitive impairment were observed with quarter-length bed rails on their beds, but their comprehensive care plans did not include any Focus, Goal, or Intervention for bed rail use. An LPN and the DON both confirmed the bed rails were not addressed in the residents' care plans, despite the rails being present during multiple observations.
A resident with DM had physician orders for diabetic nail care by the nurse, but the ADL care plan and Kardex still directed the CNA to clean and trim nails. Staff stated CNAs did not perform diabetic nail care and acknowledged the care plan should have been updated to reflect nurse-provided nail care.
Failure to provide ordered oxygen humidification for a resident with malignant pleural effusion and respiratory failure with hypoxia. The physician ordered O2 at 2 L via NC with humidification, but surveyors observed the resident receiving oxygen from a concentrator without a humidifier connected. An LPN later confirmed the concentrator should have had humidification per the order.
Bed rails were observed on two residents with moderate cognitive impairment, but their EHRs did not show the required physician’s orders, evaluations, or informed consents for the bed rail use. An LPN and the DON both confirmed the missing documentation and stated it should have been completed before the bed rails were used.
Unsecured Medications at Bedside: A resident who was alert and oriented was found with three medication bottles on the bedside table, including Azo Cranberry, Centrum Women's, and Azo Urinary Defense. The resident said she had been taking them for some time and kept them there, while the record showed no self-administration assessment or MD order. An RN and an LPN both stated resident medications should not be kept at bedside without proper review and orders.
A RN allowed a resident to swallow a pill that had fallen on the floor during a medication pass, then placed the pill back on the counter instead of discarding it. Staff also entered a room on Contact Enteric Precaution with a lunch tray without donning a gown and gloves, despite the posted sign requiring hand hygiene and PPE. The aide later used hand sanitizer when leaving the room, while the IP/LPN stated staff were expected to wear PPE and wash with soap and water on exit.
Surveyors observed unsanitary conditions in the kitchen, including food debris on equipment, unclean floors, improper food storage, and the presence of a personal beverage in the food serving area. Staff interviews confirmed that required cleaning between meals was not performed and that food was improperly stored on the floor, in violation of facility policy.
A facility failed to properly disinfect a food thermometer in the kitchen, risking cross-contamination and foodborne illness. A cook was observed using a kitchen cloth instead of alcohol wipes to clean the thermometer between temperature checks of different foods. The Dietary Manager and DON confirmed the expectation to use alcohol wipes for cleaning.
A resident with obstructive sleep apnea and a CPAP machine did not have a comprehensive care plan addressing their respiratory care needs. Despite the presence of the CPAP machine at the bedside, staff confirmed the absence of a care plan, which is required for residents using such equipment.
A resident requiring extensive assistance with personal hygiene did not receive help with shaving, despite expressing discomfort with facial hair. Observations confirmed the presence of unshaved facial hair, and staff interviews revealed an expectation for daily assistance, which was not met.
The facility failed to initiate bowel interventions for three residents, leading to extended periods without bowel movements, contrary to the facility's bowel management policy. A resident went over 138 hours without a bowel movement, another experienced over 141 hours without a bowel movement, and a third went six days without a bowel movement, with no bowel protocol initiated. Staff interviews revealed a lack of documentation and initiation of the bowel protocol as per facility policy.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect for one resident who was reviewed for neglect. The resident was admitted for LTC services, had a 5-day MDS showing moderate cognitive impairment, and was care planned as incontinent of bowel and bladder and requiring 2-person assist with all ADLs. Facility policy stated that alleged violations meeting the definition of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property must be reported immediately, but the facility’s incident/accident logs for March and April 2026 contained no entry for the concern involving this resident. A NAC reported finding the resident’s bed saturated with urine, with urine pooled underneath the resident and two urine-soaked pillows that had to be replaced, along with bedding that had to be changed. The NAC said she notified the nurse, was told to notify the DON, texted the DON about the condition, and was asked to write a statement; she later filed an online mandatory report because she was concerned the facility would not investigate the potential neglect. In a joint interview, the Administrator and DON said they heard a concern about care after shift change, but did not consider it neglect, did not log it as an allegation, and said they did not treat it as neglect because the NAC did not use that terminology.
Failure to follow bowel, PICC, insulin, and weight monitoring orders
Penalty
Summary
The facility failed to ensure bowel interventions were initiated for three residents reviewed for constipation. Resident 8, who was moderately cognitively impaired, had a documented bowel movement on 01/03/2026 and then no further documented bowel movement until 01/09/2026, a gap of over 139 hours. Resident 4, who was alert and oriented, had a documented bowel movement on 12/28/2025 and then no further documented bowel movement until 01/01/2026, a gap of over 95 hours. Resident 25, who was alert and oriented, had a documented bowel movement on 01/09/2026 and then no further documented bowel movement until 01/15/2026, a gap of over 151 hours. For each resident, the MAR did not show bowel interventions during the periods without documented bowel movements, and staff stated the missing documentation may have reflected either absent follow-up documentation or unrecorded bowel movements. The facility also failed to follow physician's orders for Resident 36, who had Type 2 diabetes, congestive heart failure, and was moderately cognitively impaired. Resident 36 had a physician's order for a PICC line dressing change every Sunday, with measurement of upper arm circumference and external catheter length on admission and with each dressing change. The EHR did not show documentation of left upper extremity measurements or external catheter length on admission or with the documented dressing change on 01/11/2026, and it did not show documentation that the scheduled dressing change for 01/18/2026 was completed. Staff reviewed the record and could not find the required PICC documentation. For Resident 36, the facility also did not document implementation of the ordered low blood sugar protocol when CBG readings were 67 on 01/14/2026 and again on 01/15/2026. The physician's orders required treatment for blood glucose below 70, rechecks every 15 minutes until 90 or above, and notification of the MD, but the record did not show those interventions. In addition, the facility did not obtain weekly weights for Resident 36 after admission as required by policy; only one weight was documented on 01/08/2026, and no additional weights were found in the EHR during the review.
Failure to Timely Convey Resident Trust Funds After Death
Penalty
Summary
The facility failed to convey the trust account for Resident 107 after the resident expired. Resident 107 had a trust account while residing in the facility, and the Resident Statement Landscape showed a balance of .03 cents from the relevant period. The account was not closed until 53 days after the resident expired. During interview, the Business Office Manager stated that trust accounts were supposed to be conveyed no later than 30 days after discharge or death and said she had just recently closed out Resident 107's account.
Missing Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents who had quarter-length bed rails on their beds. Resident 36 was admitted to the facility and was assessed on the admission MDS as moderately cognitively impaired. During observations on 01/20/2026 and 01/21/2026, Resident 36's bed was seen with quarter-length bed rails on the upper left and right sides. Review of Resident 36's comprehensive care plan, initiated 01/06/2026, did not show a Focus, Goal, or Intervention documenting the use of bed rails. Resident 78 was also admitted to the facility and was assessed on the admission MDS as moderately cognitively impaired. During observations on 01/20/2026 and 01/21/2026, Resident 78's bed was seen with quarter-length bed rails on the upper left and right sides, and later only on the upper left and right side of the bed. Review of Resident 78's comprehensive care plan, initiated 01/06/2026, did not show a Focus, Goal, or Intervention documenting the use of bed rails. Staff F, Unit Manager/LPN, reviewed both residents' electronic health records and stated that both residents did not have care plans for bed rails and should have had them. Staff B, DON/RN, also stated that the bed rails on both residents' beds should have been addressed in their respective care plans.
Care Plan Did Not Match Diabetic Nail Care Needs
Penalty
Summary
The facility failed to revise Resident 11’s care plan so it accurately reflected the resident’s nail care needs. Resident 11 was admitted with multiple diagnoses including diabetes mellitus and was documented on the quarterly MDS as cognitively intact with diabetes mellitus. The physician’s orders directed diabetic nail care every day shift every Saturday for the licensed nurse to perform nail care. Resident 11’s ADL care plan, revised on 02/20/2025, listed the intervention, “Bathing: Clean and trim nails on bath day and as necessary. Trimming to be done by CNA.” The same instruction also appeared in the resident’s Kardex dated 01/22/2026. Staff E, a CNA, stated that care needs such as bathing and ADLs were obtained from the Kardex. Staff D, the Unit Manager/LPN, stated CNAs did not do nail care for diabetic residents and nurses only did diabetic nail care, and after reviewing the care plan said it should have been updated for the nurse to do nail care. Staff B, the DON/RN, stated the care plan populated the Kardex and said the resident’s care plan should not have assigned nail care to the CNA; it should have been the nurse.
Failure to Provide Ordered Oxygen Humidification
Penalty
Summary
The facility failed to provide oxygen humidification for Resident 78, who was admitted with diagnoses including malignant pleural effusion and had an admission MDS showing moderate cognitive impairment. The physician’s order dated 01/09/2026 directed oxygen at 2 liters via nasal cannula with humidification to keep oxygen saturation above 90% and/or for shortness of breath/comfort every shift for respiratory failure with hypoxia. Although the January 2026 electronic treatment record documented that licensed nurses administered oxygen with humidification, survey observations on 01/20/2026 and 01/21/2026 found the resident lying in bed receiving oxygen via nasal cannula from an oxygen concentrator that did not have a humidifier connected. During interview, the Unit Manager/LPN reviewed the oxygen orders and stated the concentrator should have had humidification per the physician’s order.
Bed Rails Used Without Required Order, Evaluation, or Consent
Penalty
Summary
The facility failed to obtain a physician’s order, evaluation, and informed consent for the use of bed rails for two sampled residents, Resident 36 and Resident 78. The facility policy titled, Safety Device Application, revised 04/07/2023, required a safety device data collection and evaluation, a physician’s order, and review of the evaluation and information with the resident or resident representative before use of a safety device. Resident 36, admitted to the facility and assessed by the admission MDS on 01/10/2026 as moderately cognitively impaired, was observed on 01/20/2026 and 01/21/2026 with quarter-length bed rails on the upper left and right sides of the bed. Resident 78, also admitted to the facility and assessed by the admission MDS as moderately cognitively impaired, was observed on 01/20/2026 and 01/21/2026 with quarter-length bed rails on the upper left and right sides of the bed. Review of both residents’ EHRs did not show a physician’s order, evaluation, or consent for bed rail use. Staff F, the Unit Manager/LPN, reviewed both records and stated that both residents did not have the required orders, evaluations, or consents completed and that they should have been. Staff B, the DON/RN, stated it was her expectation that both residents had bed rail evaluations, consents, and physician’s orders prior to bed rails being used.
Unsecured Medications at Bedside
Penalty
Summary
The facility failed to secure medications in one resident's room. Resident 41 was admitted with a diagnosis that included urinary tract infection and was documented on the admission MDS as alert and oriented. During an observation and interview, the resident was found in bed with three medication bottles on the bedside table: Azo Cranberry, Centrum Women's, and Azo Urinary Defense. The resident stated she had been taking the medications for some time and indicated she kept them on the bedside table, adding that staff would know because she kept them there. Record review did not show that a medication self-administration assessment had been completed or that there was a physician's order for self-administration. A registered nurse observed the bottles at the bedside and stated that resident medications would normally be stored in the nurses' medication cart after provider review and an order, and that resident-owned medications would need a pharmacy-printed label and be administered per physician's order. A unit manager/LPN stated residents should not have medication at bedside unless a self-medication assessment was completed and the MD reviewed the medications and gave an order.
Infection Control Failures During Medication Pass and Room Entry
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices when Staff G, an RN, observed a resident taking medications at the A wing nurse’s station. During the medication pass, one white pill dropped onto the floor. Staff G picked up the pill from the floor and placed it back on the counter beside the cup of pills, and the resident then picked up the pill and swallowed it. When asked about the procedure for a medication that falls on the floor, Staff G stated it should be put in the sharps container. Staff D, the Unit Manager/LPN, stated that a medication that falls on the floor should be destroyed and replaced, and the DON stated she expected a medication that fell on the floor to be thrown away. The facility also failed to ensure staff properly donned PPE for a room under Contact Enteric Precaution. A Restorative Aide/NA entered room B33 with a lunch tray without putting on a gown and gloves, despite the precaution sign posted outside the room directing staff to wash or gel hands before entry and to wear a gown and gloves. The aide then left the room and used hand sanitizer. The aide stated he only had to wear PPE if providing care and only had to sanitize his hands when leaving because no care was provided. The Infection Preventionist/LPN stated staff entering rooms with Contact Enteric Precaution signs were expected to perform hand hygiene and don PPE, and to wash hands with soap and water when exiting.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a sanitary manner, as evidenced by multiple observations of unsanitary conditions in the kitchen. During a general tour after the morning meal, surveyors observed food crumbs and dried food on the steam table, serving bowls, and lids. The stove area had leftover breakfast debris, and the steam table was prepped for lunch service with visible remnants from the previous meal. Kitchen carts used for food transport were found with crumbs, dried food, and liquid spillage, including a dried brown fluid on a plastic cover. The floor in front of the stove and steam table was littered with smashed food and debris. In the food storage room, a box of potatoes was sitting directly on the floor with holes in the box, exposing the potatoes to the floor surface. Further observations revealed that food debris from previous meals remained on serving equipment, and a personal soda bottle was found in the food serving area. Interviews with the Dietary Manager and Cook confirmed that the kitchen was supposed to be cleaned between meals and that food should not be stored on the floor. The staff acknowledged that the required cleaning had not been performed and that personal beverages should not be present in the food service area. These findings demonstrate a failure to follow the facility's sanitation policy and professional standards for food safety.
Improper Disinfection of Food Thermometer in Kitchen
Penalty
Summary
The facility failed to ensure proper disinfecting of the food thermometer when taking food temperatures in the kitchen, which placed residents at risk of cross-contamination and foodborne illness. During an observation, a cook was seen testing the temperature of food on the tray line with a kitchen thermometer. After checking the temperature of pureed chicken, the cook wiped the thermometer with a kitchen cloth instead of using a sterilizer or alcohol wipes, as expected by the facility. The cook then used the same thermometer to test another entree without proper disinfection. When questioned, the cook acknowledged using a cloth for cleaning but noted that the facility preferred alcohol wipes. The Dietary Manager confirmed that the expectation was to use alcohol wipes for cleaning thermometers. The Director of Nursing Services also stated that staff were expected to follow proper cleaning practices to prevent foodborne illness.
Failure to Address CPAP Use in Care Plan
Penalty
Summary
The facility failed to ensure that respiratory care was addressed in the comprehensive care plan for a resident diagnosed with obstructive sleep apnea who was using a CPAP machine. The resident was admitted to the facility and was noted to be alert and oriented. Despite the presence of a CPAP machine on the resident's nightstand, the comprehensive care plan did not include a focus area, goal, or intervention related to the CPAP machine. Observations over several days confirmed the presence of the CPAP machine at the resident's bedside, and the resident acknowledged that staff would fill it with water, although she did not use it every night. Staff members, including the Unit Manager and the Director of Nursing Services, confirmed that residents with a CPAP machine should have a care plan in place, but none was found for this resident. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to provide assistance with shaving for a resident who required extensive help with personal hygiene, as documented in their care plan and Kardex. The resident, who was alert and oriented, expressed that the presence of chin hair was bothersome and noted that staff did not offer to shave her, even during bath times. Observations over several days confirmed the presence of dark facial hair on the resident's chin, which was not addressed by the staff. Interviews with staff members revealed that they were aware of the resident's need for assistance with activities of daily living, including shaving. The Unit Manager and Director of Nursing Services both acknowledged that residents should be offered assistance with shaving daily. Despite this expectation, the resident's personal hygiene task record showed no documented support for shaving during the specified periods, indicating a lapse in care provision.
Failure to Initiate Bowel Protocol for Residents
Penalty
Summary
The facility failed to initiate bowel interventions for three residents, leading to extended periods without bowel movements, contrary to the facility's bowel management policy. Resident 14, who was alert and oriented, went over 138 hours without a bowel movement, and the bowel protocol was not initiated during this period. Similarly, Resident 58, who was moderately cognitively impaired, experienced over 141 hours without a bowel movement, with no bowel protocol initiated. Resident 37, who was severely cognitively impaired and required total assistance, went six days without a bowel movement, and the bowel protocol was not initiated during this time. Staff interviews revealed a lack of documentation and initiation of the bowel protocol as per facility policy. Staff F, a Unit Manager and LPN, was unable to explain why Resident 37 did not alert for no bowel movement, and Staff J, another LPN, admitted to not documenting the initiation of the bowel protocol for Residents 14 and 58. Staff C, another Unit Manager and LPN, confirmed the need for documentation and initiation of the bowel protocol after three days without a bowel movement. The Director of Nursing Services acknowledged the issue, attributing it to documentation lapses.
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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.
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Nursing homes near Olympia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Olympia Rehabilitation And Nursing Center | 3.4 mi | ★★★★★ | 15 | 0 |
| Woodard Creek Health & Rehabilitation | 5.2 mi | ★★★★★ | 45 | 1 |
| Olympia Transitional Care And Rehabilitation | 5.2 mi | ★★★★★ | 19 | 0 |
| Panorama City Conv & Rehab Ctr | 5.7 mi | ★★★★★ | 6 | 0 |
| Lacey Post Acute & Rehabilitation | 6.3 mi | ★★★★★ | 11 | 0 |
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