Inspection Reports for
Puget Health Care Center

The facility failed to maintain sanitary conditions in the kitchen, including food debris on serving equipment and improper food storage. Interviews confirmed staff acknowledged cleaning lapses and improper practices such as personal beverages on the food line.

The investigation focused on multiple allegations including lack of comprehensive care planning for respiratory equipment, failure to assist with shaving, failure to initiate bowel protocols, and improper food thermometer sanitation. All allegations were substantiated with citations issued.

The facility was found deficient in multiple areas including failure to develop a comprehensive care plan for respiratory care for one resident, failure to provide shaving assistance for one resident, failure to initiate bowel interventions for three residents, and failure to properly disinfect food thermometers in the kitchen. All deficiencies were cited with minimal harm and affected few to many residents.

The complaint investigation revealed that Resident 1 received medications prescribed for a non-facility resident due to transcription errors and lack of verification by two nursing staff. The medication errors caused a serious change in condition requiring hospitalization. The facility conducted a full audit and implemented education and monitoring to prevent recurrence.

The facility failed to ensure residents were free from significant medication errors when medication orders were incorrectly transcribed, not reconciled, and incorrectly administered to one resident, causing actual harm and hospitalization. The facility identified the errors, discontinued the incorrect medication list, and implemented corrective actions including staff education and audits.

No health deficiencies were found during this inspection.

The facility was found to have multiple deficiencies including delayed meal service, failure to accommodate resident meal preferences, inadequate rehabilitation and diet-related care, failure to monitor psychotropic medication levels, improper medication storage, and poor hand hygiene during meal service. All deficiencies were cited with minimal harm and some residents affected.

The complaint investigation focused on a resident-to-resident incident on 02/23/2023. The facility's investigation was incomplete as it did not include witness interviews from Resident 1's roommate or the responding staff member. Staff interviews confirmed the lack of witness statements. The allegation was substantiated by the deficiency citation.

The facility failed to conduct a thorough investigation of a resident-to-resident incident by not obtaining witness statements from Resident 1's roommate and the responding staff member. The incident was documented, and interventions were implemented, but the investigation lacked completeness.

The investigation included multiple allegations related to quality of care, medication errors, food safety, and immunization education. Deficiencies were substantiated in all areas reviewed.

The facility was found deficient in multiple areas including failure to initiate bowel management interventions, high medication error rates due to improper medication administration practices, failure to ensure gloves were worn during food handling and disposal of expired food, and failure to provide education on pneumococcal vaccine risks and benefits. All deficiencies were cited with minimal harm or potential for harm to residents.