Fir Lane Care: Resident Shoved Twice by Peer - WA
The findings came from a complaint inspection completed on April 30, 2026.
The two residents shared a room. According to staff accounts gathered during the inspection, Resident 2 entered the room and found Resident 1 already there. What happened next was described in slightly different terms by different staff members, but the outcome was not in dispute. Staff B told inspectors that Resident 2 had not been pushing Resident 1 out the door, as had apparently been suggested elsewhere. Resident 2 had been pushing Resident 1 down toward the floor.
The administrator, identified in the report as Staff A, confirmed the account. Resident 2, the administrator said, had deliberately shoved Resident 1. Staff A said they did not believe Resident 2 had intended to cause harm, attributing the behavior to dementia. That explanation did not change what the inspection report documented: this was the second time Resident 2 had shoved Resident 1.
The administrator said the facility had put interventions in place after the first incident to keep Resident 1 safe. What those interventions were, the report does not specify. What the report does make clear is that they did not work. Resident 2 shoved Resident 1 again.
Inspectors cited the facility under WAC 388-97-0640(1), Washington State's regulation governing the protection of residents from abuse, neglect, and exploitation. The violation was categorized as causing minimal harm or potential for actual harm, and as affecting few residents.
The "minimal harm" classification is a regulatory designation, not a description of what it feels like to be shoved to the floor by another person. The inspection report does not describe any injury to Resident 1, but it also does not say Resident 1 was uninjured. It says the level of harm was minimal or potential.
What the report does say is that the facility knew. After the first shove, staff were aware that Resident 2 posed a physical risk to Resident 1. The administrator said so directly to inspectors. Interventions were discussed, decisions were made, and Resident 1 was shoved again anyway.
Resident-on-resident incidents involving dementia are among the more difficult situations nursing homes manage. Residents with dementia can become disoriented, frightened, or agitated in ways that lead to physical confrontations, and staff cannot always anticipate when or where those moments will occur. Facilities are expected to assess those risks and take meaningful steps to reduce them, particularly when a specific pattern between specific residents has already been established.
Here, the pattern was not complicated. One resident had shoved another. Staff knew who had done it, who had been shoved, and where it had happened. The administrator acknowledged the facility's awareness and its response. The response did not prevent a second shove.
The inspection was triggered by a complaint, not a routine survey. Someone contacted regulators. The report does not say who.
Fir Lane Care is a nursing facility in Shelton, Washington, in Mason County. The inspection covered two pages and centered on this single cited deficiency. The report does not describe any other violations identified during this visit.
Resident 1 remained at the facility as of the inspection date. So did Resident 2.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fir Lane Care from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
FIR LANE CARE in SHELTON, WA was cited for violations during a health inspection on April 30, 2026.
The findings came from a complaint inspection completed on April 30, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.