Inspection Reports for Puget Health Care Center
4001 Capital Mall Dr SW, Olympia, WA 98502, United States, WA, 98502
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 3
Date: Jul 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food storage, preparation, and serving standards in the kitchen area.
Findings
The facility failed to ensure food was stored, prepared, and served in a sanitary manner in the kitchen, with observations of food debris, improper storage, and personal beverages in the food serving area, placing residents at risk of foodborne illness.
Deficiencies (3)
Food crumbs and dried food were visible on the steam table and serving bowls; stove area had leftover debris; food storage room had potatoes stored directly on the floor.
Personal soda bottle found in the food serving area.
Kitchen staff failed to clean the stove, floors, and steam table between meals as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Manager | Interviewed regarding kitchen cleaning practices and food storage. |
| Staff D | Cook | Interviewed about responsibility for cleaning kitchen areas between meals. |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities of daily living assistance, bowel management, and food safety in the facility.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for respiratory care (CPAP use), failure to provide assistance with shaving for residents needing help with activities of daily living, failure to initiate bowel interventions per facility protocol for residents with prolonged absence of bowel movements, and failure to properly disinfect food thermometers during food temperature checks.
Deficiencies (4)
Failure to ensure respiratory care was addressed on the comprehensive care plan for a resident with a CPAP machine.
Failure to provide assistance with shaving for a resident requiring extensive assistance with activities of daily living.
Failure to initiate bowel interventions for residents with prolonged absence of bowel movements according to facility bowel management policy.
Failure to ensure proper disinfecting of the food thermometer when taking food temperatures, risking cross-contamination and food borne illness.
Report Facts
Hours without bowel movement: 138
Hours without bowel movement: 141
Days between bowel movements: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Unit Manager and Licensed Practical Nurse | Mentioned in relation to CPAP care plan deficiency and shaving assistance deficiency. |
| Staff B | Director of Nursing Services and Registered Nurse | Mentioned in relation to CPAP care plan deficiency, shaving assistance deficiency, bowel protocol expectations, and food thermometer cleaning practices. |
| Staff D | Certified Nursing Assistant | Mentioned in relation to knowledge of resident care needs and shaving assistance. |
| Staff F | Unit Manager and Licensed Practical Nurse | Mentioned in relation to bowel management and failure to identify residents needing bowel protocol. |
| Staff J | Licensed Practical Nurse | Mentioned in relation to bowel protocol initiation and documentation. |
| Staff I | Cook | Mentioned in relation to improper cleaning of food thermometer. |
| Staff G | Dietary Manager | Mentioned in relation to expectations for cleaning food thermometer. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors involving Resident 1, where medication orders were incorrectly transcribed, not reconciled, and incorrectly administered, causing harm and hospitalization.
Complaint Details
The complaint investigation found that Resident 1 received medications ordered for a non-facility resident and the admission medications were not verified by two nursing staff as required. The medication errors were discovered after Resident 1's change in condition on 02/11/2024, leading to hospitalization. The facility confirmed the errors and took corrective actions.
Findings
The facility failed to ensure residents were free from significant medication errors, resulting in Resident 1 receiving medications prescribed for another resident and omission of ordered medications. This caused a serious change in condition requiring hospitalization. The facility identified failures in verifying medication orders per protocol and implemented corrective actions including audits and staff education.
Deficiencies (1)
Medication orders were incorrectly transcribed, not reconciled, and incorrectly administered for Resident 1, causing harm and hospitalization.
Report Facts
Medications ordered for Resident 1 not started on admission: 10
Medications erroneously documented from non-facility resident: 20
Days medications omitted: 2
Doses of Cipro administered: 3
Audit duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Resident Care Manager | Reported that medication orders were uploaded offsite and not verified by two nursing staff per protocol |
| Staff B | Licensed Nurse | Discovered medication errors during medication pass and reported Resident 1's change in condition |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 5, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Puget Sound Care.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, medication management, meal service, infection control, and other quality of care aspects at Puget Sound Care nursing home.
Findings
The facility was found deficient in multiple areas including delayed meal service causing resident distress, failure to accommodate resident meal preferences in care plans, inadequate implementation of rehabilitation and diet-related recommendations, failure to monitor therapeutic levels of psychotropic medications, improper medication storage and labeling, and failure to ensure proper hand hygiene during meal service. These deficiencies placed residents at risk for diminished quality of life, unmet care needs, medical complications, and potential infection.
Deficiencies (6)
Failed to ensure residents were treated with respect and dignity, and provided timely meal service; residents waited 43 and 51 minutes past scheduled meal times.
Failed to reasonably accommodate resident meal preferences; resident eating with hands was not care planned.
Failed to provide appropriate treatment and care according to orders and preferences; issues with splint use and diet texture recommendations not implemented.
Failed to monitor therapeutic levels of psychotropic medication (Depakote) via regular blood testing.
Failed to ensure drugs and biologicals were labeled and stored properly; medication cups with loose and ground medications left uncovered in medication cart.
Failed to ensure staff performed hand hygiene during meal service, increasing risk of infection transmission during COVID-19 outbreak.
Report Facts
Meal wait time: 43
Meal wait time: 51
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Dietary Manager | Mentioned in relation to delayed meal service and diet texture issues |
| Staff N | Registered Dietitian | Mentioned in relation to meal service delays and diet order communication |
| Staff D | Resident Care Manager and Licensed Practical Nurse | Mentioned in relation to meal service delays, diet communication, and medication storage |
| Staff I | Unit Manager and Licensed Practical Nurse | Mentioned in relation to resident meal preferences and rehabilitation care |
| Staff C | Assistant Director of Nursing Services and Registered Nurse | Mentioned in relation to meal preferences, psychotropic medication monitoring, and diet changes |
| Staff B | Director of Nursing Services and Registered Nurse | Mentioned in relation to psychotropic medication monitoring and medication storage |
| Staff L | Director of Rehabilitation | Mentioned in relation to rehabilitation services and splint use |
| Staff J | Restorative Services Coordinator | Mentioned in relation to monitoring splint use |
| Staff K | Restorative Aide | Mentioned in relation to assisting resident with hand exercises |
| Staff G | Infection Preventionist and Registered Nurse | Mentioned in relation to hand hygiene education and monitoring |
| Staff H | Registered Nurse | Mentioned in relation to improper medication storage in medication cart |
| Staff E | Physical Therapy Assistant | Mentioned in relation to failure to perform hand hygiene during meal service |
| Staff F | Nursing Student | Mentioned in relation to hand hygiene expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2023
Visit Reason
The inspection was conducted due to a resident-to-resident incident investigation involving Resident 1, focusing on the facility's failure to comprehensively investigate the incident.
Complaint Details
The visit was complaint-related, focusing on a resident-to-resident incident investigation. The facility did not substantiate the complaint fully due to missing witness statements from Resident 1's roommate and the responding staff member.
Findings
The facility failed to obtain witness statements from Resident 1's roommate and the responding staff member during the investigation of a resident-to-resident incident on 02/23/2023. The investigation lacked comprehensive witness interviews, placing residents at risk of inadequate interventions and potential recurrent incidents.
Deficiencies (1)
Facility failed to comprehensively investigate a resident-to-resident incident by not obtaining witness interviews.
Report Facts
Date of resident-to-resident incident: Feb 23, 2023
Date of interview with Administrator: Mar 13, 2023
Date of interview with Assistant Director of Nursing: Mar 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding resident-to-resident A&I investigations and witness statements |
| Staff B | Assistant Director of Nursing and Registered Nurse | Completed the investigation in absence of the Director of Nursing and discussed investigation process and missing witness statements |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 8, 2022
Visit Reason
The inspection was conducted due to complaints regarding quality of care, medication errors, food safety, and immunization procedures at Puget Sound Care nursing home.
Complaint Details
The visit was complaint-related, triggered by allegations of inadequate bowel management, high medication error rates, improper medication administration, unsafe food handling, and lack of immunization education.
Findings
The facility failed to ensure appropriate bowel management interventions, maintain medication error rates below 5%, properly administer medications via enteral feeding tubes and insulin pens, ensure safe food handling practices, and provide education on pneumococcal vaccination risks and benefits. These failures placed residents at risk of harm including medication errors, foodborne illness, and respiratory complications.
Deficiencies (5)
Failed to ensure bowel management interventions were initiated for 1 of 5 sampled residents, placing residents at risk for discomfort and health complications.
Failed to ensure medication error rate was 5% or less, resulting in an 80% error rate for 2 of 4 sampled residents during medication administration.
Failed to ensure medications were administered as ordered via enteral tube and insulin pen for 2 of 4 sampled residents, risking incomplete medication dosing.
Failed to ensure gloves were worn while handling ready-to-eat food and to dispose of expired food in one dining room and the kitchen, risking foodborne illness.
Failed to provide education on the risk and benefits of the pneumococcal vaccine for one of five sampled residents, increasing risk of respiratory complications.
Report Facts
Medication administrations: 25
Medication error rate: 80
Medication error threshold: 5
Bowel movement interval: 168
Insulin dose: 10
Buttermilk container size: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Assistant Director of Nursing Services | Unable to provide information on bowel protocol initiation |
| Staff B | Director of Nursing Services | Unable to find documentation of bowel movement and reviewed medication administration with Staff J |
| Staff J | Registered Nurse | Observed preparing and administering medications via enteral feeding tube; crushed medications improperly; admitted to mixing medications in water |
| Staff O | Registered Nurse | Observed administering insulin pen without priming, risking incorrect dosing |
| Staff F | Dietary Manager | Acknowledged expired buttermilk and lack of written food handling policies |
| Staff I | Nursing Assistant Registered | Observed handling ready-to-eat food with bare hands without proper training |
| Staff H | Infection Preventionist | Did not provide pneumococcal vaccine risk and benefit education unless requested |
| Staff A | Administrator | Reviewed medication administration with Staff J and concluded no error due to physician orders |
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