Puget Sound Transitional Care: Resident Choked, Tipped - WA
The dementia patient, identified in inspection records as Resident 1, told staff what had happened: her roommate had started screaming at her, grabbed her by the neck, and tipped her backward out of the wheelchair. The roommate, Resident 2, was eventually removed from the facility by law enforcement.
The date was April 20, 2026. Federal inspectors arrived ten days later.
What they found, documented in a complaint inspection report, was not simply a violent incident between two residents. It was a failure that began at admission and continued, without correction, until a woman with dementia was on the floor with scratch marks on her throat.
Resident 1 had been living at the facility long enough to have an annual assessment on file, dated March 22, 2026. That assessment documented dementia, depression, pain, and wheelchair dependence. Her care plan, written the previous May, directed staff to watch her for signs of increased anger, agitation, and feelings of being threatened by others. She was, by the facility's own documentation, someone who needed protection from exactly the kind of confrontation that unfolded in her room.
Resident 2 arrived with a documented history that should have set off alarms. His admission records showed post-traumatic stress disorder, major depression, and psychoactive substance abuse. A behavior care plan dated April 20, 2026, the same day as the attack, acknowledged that he had the potential for physical and verbal aggression toward others, driven by anger, poor impulse control, his history of PTSD, and drug abuse.
That care plan was dated the day of the incident. Not before it. The same day.
The Director of Nursing, identified in the report as Staff B, told inspectors during an interview on April 30 that the facility typically does not admit residents with uncontrolled behaviors. She said the facility was not aware Resident 2 had behaviors before he was admitted. She acknowledged that no one-on-one monitoring was put in place until after the attack.
"If there were behaviors after admission," she told inspectors, "the facility should have documented and monitored the residents for safety."
The administrator, Staff A, offered a similar account. The facility, she said, had no way to screen incoming residents for behavioral risks if that information was not included in the discharging hospital's paperwork. She said she did not know why Resident 2 had PTSD, and did not know what his triggers were or what staff should have been watching for.
That is a significant gap. PTSD does not appear on an intake form without a history behind it. A facility that places a resident with documented PTSD, major depression, and substance abuse history into a shared room with a wheelchair-dependent dementia patient, and then waits for violence to occur before writing a behavior care plan, has not screened anyone. It has simply waited.
The facility's own abuse prevention policy, revised as recently as April 2025, stated that the facility would identify, assess, and implement care plans for residents whose behaviors might lead to conflict, and would monitor those residents accordingly. The policy existed. The process it described did not happen.
What the inspection report makes clear is that both residents were, in different ways, vulnerable. Resident 1 used a wheelchair and had dementia. She could not easily remove herself from a threatening situation, and her cognitive condition made her dependent on staff to recognize and prevent danger on her behalf. Resident 2 had a documented psychiatric history that the facility admitted it had not fully understood or planned around. Placing them in the same room without any structured safety monitoring was not a neutral decision. It was a choice that left one of them on the floor.
The inspection classified the harm level as minimal, a designation that refers to the severity category under federal survey guidelines rather than a judgment about what the experience meant to the resident. Resident 1 had redness and scratches on her neck. She had been grabbed, tipped backward, and left on the floor while her roommate continued yelling at her. The facility's own investigation documented all of it.
Inspectors cited the deficiency under Washington state regulation WAC 388-97-0640(1), which governs resident rights and protections from abuse in licensed nursing facilities.
The Director of Nursing's statement to inspectors was careful but telling. She said the facility should have documented and monitored residents if behaviors emerged after admission. The word "should" is doing a lot of work in that sentence. The behavior care plan for Resident 2 was dated April 20, 2026. The attack on Resident 1 was also dated April 20, 2026. The sequence is not ambiguous: the documentation followed the violence, not the other way around.
There is no indication in the inspection report that anyone at the facility had raised a concern about the roommate pairing before staff heard yelling from the hallway. No notes flagging tension between the two residents. No interim safety check. No adjustment to Resident 1's care plan acknowledging that her new roommate had a known history of aggression. Her existing care plan told staff to watch her for feelings of being threatened by others. She was threatened, and then she was hurt, and the record suggests no one connected those two facts until it was too late.
Law enforcement removed Resident 2 from the facility after the incident. The inspection report does not describe what happened to him after that, or what became of Resident 1's living situation in the days that followed.
What the report does describe is a woman with dementia who depended on a wheelchair to move through the world, who was placed in a room with someone whose psychiatric history the facility acknowledged it had not investigated, and who ended up on the floor with scratches on her neck while staff were still in the hallway.
Her care plan had been telling staff for nearly a year that she was at risk of feeling threatened by others.
She was right to feel that way.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Puget Sound Transitional 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
PUGET SOUND TRANSITIONAL CARE in DES MOINES, WA was cited for violations during a health inspection on April 30, 2026.
The roommate, Resident 2, was eventually removed from the facility by law enforcement.
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.