PUGET SOUND TRANSITIONAL CARE
PUGET SOUND TRANSITIONAL CARE is a 165-bed nursing home in DES MOINES, Washington. CMS has certified it for Medicare and Medicaid since 2004-02-02. It averages 81.1 residents a day.
What harm was found in the violations cited at PUGET SOUND TRANSITIONAL CARE?
CMS lists 63 health-inspection deficiencies for PUGET SOUND TRANSITIONAL CARE since 2023-05-19, 46 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is J; the most recent health inspection was 2026-04-30.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-04-30 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D |
| 2026-03-05 | F0693 | Ensure 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. | E |
| 2026-03-05 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2025-08-27 | F0628, F0657, F0801, F0812, F0887 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Educate 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. | E |
| 2025-08-27 | F0552, F0578, F0636, F0641, F0644, F0658, F0676, F0677, F0679, F0684, F0690, F0700, F0759, F0761, F0881, F0908 | Ensure that residents are fully informed and understand their health status, care and treatments. / Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. / Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. / Ensure each resident receives an accurate assessment. / Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / Ensure services provided by the nursing facility meet professional standards of quality. / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide activities to meet all resident's needs. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. / Ensure medication error rates are not 5 percent or greater. / Ensure 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. / Implement a program that monitors antibiotic use. / Keep all essential equipment working safely. | D |
| 2025-07-01 | F0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J |
| 2025-07-01 | F0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | E |
| 2025-07-01 | F0609, F0610 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. | D |
| 2024-06-12 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2024-06-12 | F0578, F0657, F0658, F0677, F0698, F0759, F0847 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure services provided by the nursing facility meet professional standards of quality. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Ensure medication error rates are not 5 percent or greater. / Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | E |
| 2024-06-12 | F0584, F0623, F0640, F0641, F0656, F0679, F0684, F0688, F0689, F0880 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. / Ensure each resident receives an accurate assessment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide activities to meet all resident's needs. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide and implement an infection prevention and control program. | D |
| 2023-05-19 | F0812, F0835 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F |
| 2023-05-19 | F0553, F0641, F0645, F0655, F0850 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. / Ensure each resident receives an accurate assessment. / PASARR screening for Mental disorders or Intellectual Disabilities / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Hire a qualified full-time social worker in a facility with more than 120 beds. | E |
| 2023-05-19 | F0567, F0582, F0677, F0684, F0692, F0740, F0756, F0760, F0880, F0881 | Honor the resident's right to manage his or her financial affairs. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide enough food/fluids to maintain a resident's health. / Ensure each resident must receive and the facility must provide necessary behavioral health care and services. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / Ensure that residents are free from significant medication errors. / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. | D |
How is PUGET SOUND TRANSITIONAL CARE staffed relative to the WA average?
| Measure | This facility | WA average |
|---|---|---|
| Total nurse staffing hours per resident per day | 3.84625 | 4.36934 |
| Total nursing staff turnover (%) | 32.4 | 45.1 |
| Average number of residents per day | 81.1 | 76.0 |
Who owns PUGET SOUND TRANSITIONAL CARE, and what chain is it in?
PUGET SOUND TRANSITIONAL CARE is registered with CMS as For profit - Corporation, operates under the legal business name RIVER OTTER HEALTHCARE LLC and belongs to the THE ENSIGN GROUP chain.
| Role | Owner | Association date |
|---|---|---|
| DIRECT OWNERSHIP INTEREST | PENNANT HEALTHCARE LLC | since 11/21/2022 |
| INDIRECT OWNERSHIP INTEREST | THE ENSIGN GROUP INC | since 11/21/2022 |
| MANAGING CONTROL - GOVERNING BODY | BURNAM, SOON, DENOR, JOSEPH, FARNSWORTH, STEPHEN, KEETCH, CHAD | since 03/01/2011 |
| CORPORATE DIRECTOR | PORT, BARRY | since 08/01/2023 |
| OPERATIONAL/MANAGERIAL CONTROL | ACTRIV HEALTHCARE LLC, EASTSIDE HEALTHCARE STAFFING LLC, BURNAM, SOON, JENKINS, TRACY | since 08/01/2023 |
| ADP OF THE SNF | ENSIGN SERVICES INC, SALTWATER HEALTH HOLDINGS LLC, STANDARD BEARER HEALTHCARE OP LP, DENOR, JOSEPH, JENKINS, TRACY | since 06/30/2025 |
Were you or a family member harmed at PUGET SOUND TRANSITIONAL CARE?