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TheVardellReport
Avamere Transitional Care of Puget Sound
Skilled nursing facility and nursing facility
630 South Pearl Street
Tacoma, WA 98465
Report
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The Vardell Report.Avamere Transitional Care of Puget Sound
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Tacoma, WA
- Record Period
- 2023–2026
- Source Documents
- 9
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from August 2023 to August 2026, state surveyors documented 46 findings at Avamere Transitional Care of Puget Sound; 45 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.
- Inspections
- 7
- 2023–2026, complaint and standard
- Findings
- 46
- Deficiencies cited by state inspectors
- Corrected
- 45
- Of 46 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 20 | 0 |
| 2024 | 1 | 10 | 0 |
| 2025 | 3 | 13 | 0 |
| 2026 | 2 | 3 | 1 |
What the Record Shows
- 45 of 46 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $23,319, its payment not published.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, November 25, 2025, recorded 11 findings (most serious: Level F).
What to Ask About
- Accurate Assessments, Cited in Three Inspections
- Quality of Care, Cited in Three Inspections
- Citation F757, Cited in Three Inspections
- Medication Labeling and Storage, Cited in Three Inspections
- Infection Control, Cited in Three Inspections
- Reporting Suspected Abuse, Cited in Two Inspections
- Care Plans, Cited in Two Inspections
- Care Plan Timing and Review, Cited in Two Inspections
- Help With Daily Living, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Pressure Injury Care, No Recorded Correction
Report at a Glance
- Facility
- Avamere Transitional Care of Puget Sound
- Address
- 630 South Pearl Street, Tacoma, WA 98465
- CMS Certification Number
- 505529
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 60
- Ownership
- For profit - Limited Liability company
- Record Window
- August 18, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for morePast Non-Compliance
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
2 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 13, 2026
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 13, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
11 findings
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level FNo actual harm, potential for moreCorrected Oct 30, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Oct 30, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Oct 30, 2025
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 30, 2025
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level CPotential for minimal harmCorrected Oct 30, 2025
Enforcement Action
Civil money penalty, $23,319 imposed March 19, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 25, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 1, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level DNo actual harm, potential for moreCorrected Mar 7, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
10 findings
- F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
20 findings
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Sep 28, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Sep 28, 2023
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Sep 28, 2023
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Sep 28, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accurate Assessments, Cited in Three Inspections
Inspectors cited F641 in August 2023, July 2024 and March 2026. This citation covers whether each resident’s assessment correctly records their condition. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F641 across all 7 inspections, oldest to newest - 2
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in August 2023, July 2024 and November 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F684 across all 7 inspections, oldest to newest - 3
Citation F757, Cited in Three Inspections
Inspectors cited F757 in August 2023, July 2024 and November 2025. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F757 across all 7 inspections, oldest to newest - 4
Medication Labeling and Storage, Cited in Three Inspections
Inspectors cited F761 in August 2023, July 2024 and November 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F761 across all 7 inspections, oldest to newest - 5
Infection Control, Cited in Three Inspections
Inspectors cited F880 in August 2023, July 2024 and November 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F880 across all 7 inspections, oldest to newest - 6
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in August 2023 and September 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F609 across all 7 inspections, oldest to newest - 7
Care Plans, Cited in Two Inspections
Inspectors cited F656 in August 2023 and July 2024. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F656 across all 7 inspections, oldest to newest - 8
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in August 2023 and November 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F657 across all 7 inspections, oldest to newest - 9
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in August 2023 and November 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F677 across all 7 inspections, oldest to newest - 10
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in August 2023 and July 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242525252626F689 across all 7 inspections, oldest to newest - 11
Pressure Injury Care, No Recorded Correction
F686 was cited in August 2023, March 2026 and August 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious was level G (actual harm). The August 2026 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.
23242525252626F686 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in three inspections, most seriously at level E.
- 02
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level E.
- 03
What changed after F757 was cited, and how do you check it now?
Citation F757: cited in three inspections, most seriously at level E.
- 04
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level F.
- 05
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
- 06
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level D.
- 07
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level E.
- 08
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level D.
- 09
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level E.
- 10
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level E.
- 11
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in three inspections, most seriously at level G. The August 12, 2026 citation has no recorded correction date.
- 12
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in November 2025.
- 13
What led to the 2026 fine, and has it been paid?
A $23,319 civil money penalty was imposed March 19, 2026. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Washington state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Aug 18, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Jul 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Mar 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Sep 15, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Nov 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Mar 19, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Washington state survey agency
Inspection Aug 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 505529
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 18, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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