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Nursing HomeMedicaid Investigative

Puget Sound Transitional Care

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2800 South 224th Street,, Des Moines, WA 98198165 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.7/5

based on 40 Google reviews

Puget Sound Transitional Care Nursing Home in Des Moines, WA — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Above-median deficiencies (25 vs median 14)

Bottom 25% in WA · Meets national RN staffing standard · Low staff turnover (stable workforce) · Below chain average · No penalties on record

Source: Medicare data

What this means for your family

While the facility is praised for its physical therapy and equipment proficiency, the recurring reports of neglect and slow response times are deeply concerning. We strongly recommend that families conduct an unannounced visit during evening or weekend hours to observe staffing levels and response times firsthand before making a decision.

Google Reviews

Google Reviews

40 reviews on Google
Puget Sound Transitional Care receives highly polarized feedback, with many five-star reviews praising the physical therapy team and staff professionalism, while one-star reviews highlight critical failures in basic patient care. Families report concerns regarding neglect, hygiene issues, and slow response times, suggesting a significant inconsistency in the quality of care provided.

Quality Themes

Tap a score for details
Food5.0Staff5.0Clean3.0Activities2.0Meds2.0Memory2.0Comms3.0ValueN/A

Strengths

  • Effective physical therapy programs
  • Proficiency with assistive equipment like Hoyer lifts
  • Compassionate and professional nursing staff
  • Convenient location for medical appointments

Concerns

  • Neglect and slow response to call lights (mentioned by 2 reviewers)
  • Poor hygiene and failure to assist with basic needs like showering (mentioned by 2 reviewers)
  • Poor communication and unprofessional conduct by social workers (mentioned by 2 reviewers)
  • Facility cleanliness and odors (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.52023(2)3.02024(14)3.92025(45)2.62026(5)

Distribution · 66 analyzed

5
42
4
1
3
0
2
4
1
19
10 reviews posted between Apr 16, 2025Apr 17, 2025 · 10 were 5-star

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1We've heard great things about your physical therapy programs; could you show us how a resident typically participates in those sessions?
  • 2How does the nursing team ensure that call lights are answered promptly, especially during busy shift changes?
  • 3What specific protocols are in place to maintain cleanliness and a fresh environment in the resident rooms and common areas?
  • 4Could you tell us more about the daily activities and social events planned to keep residents engaged and active?
  • 5How does the facility manage medication administration to ensure everything is handled accurately and on schedule?
  • 6In the event of a medical emergency after hours, what is the process for communicating with the family and coordinating care?

Personalized based on this facility's data


Key Review Excerpts

He would put on his call light and no one would come for hours. While waiting he decided to use the bathroom on his own, he ended up falling on the bathroom floor, laying there all night.

Long-term resident's family · 2024☆☆☆☆

The nursing staff was lazy, uncaring, my mother didn't receive a shower for almost 2 weeks before I had realized that this was taking place, the food was so bad and always served cold!!

Long-term resident's family · 2026☆☆☆☆

The staff is also highly skilled, especially in using the Hoyer lift, which is essential for my wife’s trips to the Kidney Center. Their proficiency ensures that her dialysis routine is smooth and stress-free.

Long-term resident's family · 2025★★★★★
Source: 40 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.93hrs
OK
Registered nurses for medical care
Total Nursing
3.89hrs
95%
All nurses + aides combined
Staff Turnover
27%
Lower is better (< 30% = good)
RN Turnover
57%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

11

measures

Worse Than Avg

6

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility47.7%
Worse than Avg
Here
47.7%
US
12.1%
WA
17.1%
King
21.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility48.3%
Worse than Avg
Here
48.3%
US
15.3%
WA
18.8%
King
16.2%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility6.5%
Better than Avg
Here
6.5%
US
19.5%
WA
12.2%
King
9.0%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility25.6%
Worse than Avg
Here
25.6%
US
14.4%
WA
15.0%
King
13.9%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility26.2%
Worse than Avg
Here
26.2%
US
19.4%
WA
23.0%
King
21.8%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility89.5%
Worse than Avg
Here
89.5%
US
95.5%
WA
93.8%
King
91.0%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility95.8%
Better than Avg
Here
95.8%
US
79.7%
WA
82.0%
King
80.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility90.6%
Better than Avg
Here
90.6%
US
81.8%
WA
87.9%
King
87.6%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
WA
1.3%
King
1.4%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

27deficiencies
Well above state avg (17.1)
12 complaint-triggered

This facility shows persistent quality-of-care concerns with recent complaints highlighting serious issues with basic life support and reporting suspected abuse or neglect. The most recurring problems involve resident assessment and care planning, medication management, and food safety - with food safety violations appearing across three consecutive surveys from 2023-2025. While all deficiencies have correction dates, families should be aware that complaints from residents or families have triggered multiple investigations.

Mar 5, 2026Complaint
2
0693Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Sep 26, 2025Complaint
2
0211Potential for harm · WidespreadCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Aug 27, 2025Routine
24
0920Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0628Potential for harm · PatternCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0657Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0801Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0887Potential for harm · PatternCorrected

Infection Control Deficiencies

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.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0636Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0908Potential for harm · IsolatedCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0372Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Jul 1, 2025Complaint
4
0678Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

0726Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Jun 12, 2024Routine
27
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0018Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish procedures for tracking staff and patients during an emergency.

0030Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

0036Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0037Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0578Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0657Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0698Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0847Potential for harm · PatternCorrected

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

0355Potential for harm · PatternCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0640Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0372Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0374Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Jun 12, 2024Complaint
2
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Puget Sound Transitional Care

Organization Type

for profit

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 3.2/5 · Rank 240 of 328

Ownership & Management

Owners

The Ensign Group INC

Owner (parent company) · Organization

Pennant Healthcare LLC

Owner · Organization

Key personnel

Burnam, SoonManaging Control - Governing BodyDenor, JosephManaging Control - Governing BodyFarnsworth, StephenManaging Control - Governing BodyKeetch, ChadManaging Control - Governing BodyPort, BarryOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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