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Panorama City Conv & Rehab Ctr

1600 Sleater Kinney Road SE, Lacey, WA 98503 · Non profit - Corporation · 155 certified beds · (360) 456-0111 Medicare & Medicaid certified

Call the home — (360) 456-0111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609, F0610) — most recent Jan 2026Behavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations$42,904 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $42,904 in federal fines (most recent 2026-01-27)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Urgent care / clinic
1315 Ruddell Rd SE · (360) 357-8054 · Call to confirm hours
Pharmacy
4540 Lacey Blvd SE · (360) 438-2353 · Call to confirm hours
Grocery
1107 College St SE · (360) 491-7834 · Call to confirm hours
Park
1313 College St SE · (360) 491-0857 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.6%14.2%15.4%better
Long-stay residents who lose too much weight6.4%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%1.0%0.9%better
Long-stay residents with a urinary tract infection0.5%1.6%2.0%better
Long-stay residents with depressive symptoms67.9%17.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.5%2.6%3.3%worse
Long-stay residents whose ability to walk worsened18.3%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication9.3%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine96.9%93.8%95.3%typical
Long-stay residents with pressure ulcers1.5%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control20.2%22.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.1%15.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine83.7%82.0%79.4%typical
Short-stay residents rehospitalized after admission14.9%19.9%22.6%better
Short-stay residents with an outpatient ER visit11.4%13.4%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.041.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.601.521.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 176 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.2%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
69.8%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 69.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 116 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.2%CMS range 56.6–70.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 5.8–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge63.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified87.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.7–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.91
RN hours/ resident / day
0.94
LPN hours/ resident / day
3.22
Aide hours/ resident / day
5.07
Total nurse hours/ resident / day
0.61
RN hoursweekends
28.9%
Total nursing turnover
21.7%
RN turnover

How full it usually is: this home is certified for 155 beds and averages 116.0 residents a day — about 75% occupied, or roughly 39 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.22 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.19 hrs/resident/day on weekends vs 5.43 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.04 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2026-01-27)
5
at the previous standard inspection (2024-10-15)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2026-01-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor medical devices to prevent pressure related injuries for 2 of 4 residents (Residents 3 and 7) when reviewed for pressure injuries. Resident 3 experienced harm when they developed avoidable pressure ulcers to both heels and their left calf, related to lack of monitoring of a medical device (E-Z boot - plastic splint designed to stabilize the foot and ankle, preventing rotation and contracture with a soft, fleece-lined interior, non-skid base, and hook-and-loop velcro closure - also called a podus Boot). This failure placed residents at further risk for avoidable pressure injuries. Findings included. Review of the facility policy titled Management of Braces and Splints last reviewed 01/06/2026, showed Braces and splints shall be used only with appropriate clinical justification, proper authorization, and ongoing monitoring to prevent complications such as (including but not limited too) skin breakdown. It further showed Orders must…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interviews and record review, the facility failed to provide the two staff person assistance and use of a gait belt for transfers as required according to the plan of care for 1 of 3 sampled residents (Resident 1) reviewed for falls. Resident 1 experienced harm when they fell and sustained a head laceration when staff transferred them without a second staff person to assist and properly support resident with a gait belt. This failure placed residents at risk for falls with injury, pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and kidney disease. The quarterly minimum data set (MDS) an assessment tool, dated 02/26/2025, documented Resident 1 has moderately impaired cognition and was dependent on staff for all activities of daily living (ADLs). The Care Directive, dated 08/13/2024, documented Resident 1 required a sit-to-stand (a device which mechanically assists a resident to stand)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow the resident's individualized care plan fpr safe transfers and the resident sustained a fracture requiring hospitalization. This failure placed residents at risk for injury and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's policy Mechanical Lift Usage, revised 05/08/2017, showed residents that require maximum to total assistance with transfers were not to be lifted without the aid of a mechanical lift. Those residents who did not bear weight or were unable to hold on to the lift bar were to be lifted with Hoyer lifts (lifts that utilize a sling and lift the resident's entire body). The specific lift used by the resident would be written on the resident's care plan and nursing care directives.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the dishwasher was cleaning dishes at required temperatures for 1 of 1 kitchen dishwashers reviewed under kitchen task. This failure created the potential to expose residents to unsanitary conditions and increased risk of foodborne illness. Findings included .On 01/26/2026 at 9:55 AM, during a kitchen observation, review of the Food Services Department Daily Dish Machine Temerature Log documented, Wash Cycle must reach a temperature of 150-160 degrees Fahrenheit. Rinse Cycle must reach a temperature of no less than 180 degrees. Please report temperature outside of the required range to your Supervisor immediately. The flowing days were listed outside the required temperature ranges:01/05/2026 PM Wash 145 degrees01/10/2026 AM Rinse 179 degrees01/11/2026 AM Rinse 172 degrees01/12/2026 AM Rinse 179 degrees01/13/2026 PM Rinse 145 degrees01/14/2026 PM Rinse 145 degrees01/18/2026 AM Rinse 179 degrees01/18/2026 PM Rinse 145 degrees01/19/2026 PM Rinse 145 degrees01/20/2026 AM Wash 142 degrees01/20/2026 PM Rinse 145…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-27 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 3 residents (Residents 3, 5 and 130) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included.Review of the facility policy titled Antibiotic Stewardship last reviewed 01/5/2026, showed The facility practices the core elements of antibiotic stewardship, outlined by the Centers for Disease Control and prevention. The nurse will utilize McGeer constitutional infection criteria protocol to determine if it is necessary to treat with antibiotics and notify the provider of the results of diagnostics to ensure the resident is taking the appropriate antibiotic or if the antibiotic needs to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) were regularly monitored and documented on and gradual dose reduction (GRD, psychotropic medication decrease) had adequate indication for noncompletion for 2 of 5 sampled residents (Resident 40 & 85) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life. Findings included .Resident 40 Resident 40 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 40 was severely cognitively impaired. A physician's order, dated 11/22/2025, for Trazadone (antidepressant) 12.5 milligrams was prescribed for insomnia. A physician's order, dated 01/15/2026, for Trazadone (antidepressant) was increased to 25 milligrams daily for insomnia. The electronic health records (EHR) showed no documentation of side…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure care and services were provided in accordance with professional standards for 1 of 6 residents (Resident 49) when reviewed for bowel management. This failure placed the residents at risk for medical complications, poor clinical outcomes and a decreased quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 49 admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that effects memory) and adult failure to thrive. The resident was able to make needs known.During an interview on 01/23/2026 at 10:06 AM, Resident 49 stated they were given medicine to soften their stools and staff didn't tell them what they were getting. Resident 49 stated they had been having loose stools every day and did not want the medicine.Review of the EHR showed Resident 49 had been documented as having 14 soft stools and eight loose stools over the prior 24 days. Review showed the resident had two extra-large…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of abuse and injuries of unknown origin timely to the State Agency for 2 of 3 residents (Resident 1 & 2) reviewed for abuse and injuries of unknown origin. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect. Findings included .<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (A stroke) and neurological disorder. The Minimum Data Set (MDS), an assessment tool, dated 05/18/2025, documented Resident 1 had moderate cognitive impairment and was dependent on staff with some activities of daily living (ADLs).Progress notes, dated 06/13/2025, documented during a physician's examination, Resident 1 was found with healing fractures of the right second, third, fourth, and fifth ribs. No source of the injury was identified in the progress notes.The facility investigation, dated 06/13/2025, was blank.The facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation to rule out abuse or injuries of unknown origin for 2 of 3 residents (1 & 3) reviewed for abuse or injuries of unknown origin. Failure to conduct a thorough investigation placed the residents at risk for unidentified abuse or neglect, poor clinical outcomes and a decreased quality of life. Findings included .<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (A stroke) and neurological disorder. The Minimum Data Set (MDS), an assessment tool, dated 05/18/2025, documented Resident 1 had moderate cognitive impairment and was dependent on staff with some activities of daily living (ADLs).Right shoulder dislocationThe facility investigation, dated 05/14/2025, documented Resident 1 was found to have an anterior subluxation of the glenohumeral joint (a dislocation of the shoulder). Resident 1 required surgery for the injury. The investigation did not reveal a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-17 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure resident assessments accurately reflected their health status and/or care needs for 1 of 7 sampled residents (Residents 1) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to accurately assess residents with a pressure ulcer (PU, a wound which develops due to prolonged pressure to the body) placed residents at risk for pain and discomfort, diminished quality of life and unidentified and/or unmet care needs. Findings included . Resident 1 admitted to the facility on [DATE] with a left hip fracture. The admission MDS, dated [DATE], showed Resident 1 was admitted without a PU. Hospital Discharge notes, dated 09/19/2024, documented Resident 1 sustained a PU to the hip from a wrap dressing applied to the resident's hips while hospitalized . Skin Evaluation form, dated 09/19/2024, documented Resident 1 had a PU to the hip. On 01/17/2025 at 3:31 PM, Staff C, licensed practical nurse and MDS coordinator, said Resident 1 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include resident specific information for 1 of 7 sampled residents (Residents 1) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs. Findings included . Resident 1 admitted to the facility on [DATE] with a left hip fracture. The admission Minimum Data Set (MDS, an assessment tool), dated 09/25/2024, showed Resident 1 was dependent on staff with some activities of daily living. Skin Evaluation form, dated 09/19/2024, documented an assessment of Resident 1's skin, identifying the resident with a pressure ulcer (PU) to the hip. According to Skin Evaluation Forms on 09/24/2024 and 10/03/2024, Resident 1 continued to have a PU to the hip. The care plan, dated 09/19/2024, document…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-15 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement 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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure person centered side effect and target behavior monitoring was identified for psychotropic medications (drug taken to exert an effect on the chemical makeup of the brain and nervous system) for 4 of 5 sampled residents (Resident 74, 46, 42 & 3) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for receiving unnecessary medications, adverse side effects, falls, injury and a diminished quality of life. Findings included . The facility policy entitled Psychoactive Medication, revised 04/07/2024, documented, POLICY: Specific behaviors are identified for each resident that affect the resident's quality of life. 9. Side effects must be listed on the Medication Treatment Record (TAR) for each group of medications. Side effects are documented daily on the MAR . 10. Care Pal must be developed around the behaviors the resident is currently exhibiting. Identify only the behaviors that can realistically be changed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure food products were labeled with a prepared or use by date, staff performed hand hygiene and glove changes during meal preparation and service, and that the high temperature (Hi-temp.) dishwasher washer met the minimum wash and rinse temperatures required for proper cleaning and sanitization of resident dishware and utensils. This failure placed residents at risk for food borne illnesses. Findings included . <Hi-Temperature Dishwasher Temperature Log> Observation of the facility's Hi-temp. dishwasher on 10/15/2024 at 7:39 AM, showed there was a laminated sign and a dishwasher temperature log where staff were to record the wash and rinse cycle temperatures of the dishwasher three times a day. The October 2024 dishwasher temperature log showed for proper sanitization of dishware/ utensils, the wash cycle must reach 150 - 160 degrees, and the rinse cycle needed to reach 180 degrees Fahrenheit (df). The log contained instruction to staff to PLEASE report temperatures out of the required range to your…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-10-15 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review, the facility failed to ensure services provided met professional standards of practice when physician orders were not followed and the provider was not notified when medications were held for 1 of 5 sampled residents (Resident 40) reviewed for unnecessary medications. This failure placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs. Findings included . Resident 40 was admitted to the facility on [DATE]. Review of their physician orders showed an 08/26/2023 order for Metoprolol (a blood pressure medication) twice daily for high blood pressure, with direction to hold the medication for a systolic blood pressure (SBP) less than 110 or a pulse (P) less than 60. Review of the September 2024 Medication Administration Record (MAR) showed facility nurses administered Resident 40's Metoprolol outside of the physician's ordered parameters on the following occasions: a) 09/22/2024 at 8:00 AM- P=50;…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-15 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice when IV orders did not include routine monitoring of IV insertion sites, weekly changes of IV dressings and needleless injection caps and an initial and then weekly measurements of IV catheters external length and the resident's arm circumferences for 1 of 1 sampled residents (Resident 74) reviewed for IV therapy. This failure placed residents at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . The facility policy entitled Midline Catheter Dressing Change, revised June 2024, documented Guidance 1. Sterile dressing change using transparent dressing is performed: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean dry and intact the admission dressing change may be omitted and scheduled for 7 days from the dated on the dressing label…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure appropriate hand hygiene was used during dining tray pass for 1 of 3 sampled rooms (room [ROOM NUMBER]) reviewed for dining and 1 of 2 sampled residents (Resident 74) reviewed for transmission based precautions. This failure placed residents at risk for facility acquired or healthcare associated infections and related complications and a diminished quality of life. Findings included . <Dining> On 10/09/2024 at 11:46 AM, Staff H, Certified Nursing Assistant (CNA), was observed passing a food tray to an unknown Resident in room [ROOM NUMBER]. Staff H knocked on the door of room [ROOM NUMBER] and put the food tray down on the bedside table, then assisted placing a shirt saver (garment to protect clothing from food spills) on an unknown resident, touching resident clothing in the process. No hand hygiene was observed after placement of shirt saver and before exiting room and getting a new tray for the next resident. At 11:50 AM, Staff H said she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-11 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to follow professional standards of practice during medication administration for 3 of 6 residents (Residents 5, 6 & 7) reviewed for medication administration. This failure to ensure services provided met professional standards of practice placed residents at risk for diversion of medication, medication errors and adverse outcomes. Findings included . <Policy> Review of the facility's policy, Medication Assessment and Documentation, dated 09/10/2015, showed medications were listed on the Medication Administration Record (MAR) and the licensed nurse would initial the MAR after the medication had been administered. <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnoses including an infection related to an orthopedic prosthetic and arthritis. Resident 5's MAR, dated 05/03/2024, showed the following medications were prepared, administered and signed by Licensed Practical Nurse (LPN), Staff F: 1. CoQ-10 100 mg (milligrams)(vitamin like…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 unit refrigerators (A, E, & F-Wing Snack Rooms) reviewed for food service. This failure placed residents at risk of food-borne illness and a diminished quality of life. Findings included . Review of the record log titled, Food Services Department Daily Refrigerator/Freezer Temperature Checks, showed refrigerator temperatures must stay between 35 and 39 degrees Fahrenheit and staff were to report temperatures outside of the required range to their supervisor immediately. Review of the September 2023, October 2023, and November 2023 temperature logs showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates: 1) A-Wing Snack Room September 2023: 7th 43 degrees F. October 2023: 5th 43 degrees F, 10th 42 degrees F, 13th 42 degrees F, 16th 45 degrees F, 17th 42 degrees F, 20th 43 degrees F, 24th 43 degrees F, 27th 43 degrees F, 29th 42 degrees F. November 2023: 1st 45 degrees F, 2nd 45…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-13 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 2 of 2 residents (Resident 8 & 19) reviewed for hospice services. The facility's failure: to designate a member of their inter-disciplinary team (IDT) to be responsible for communication and collaboration with hospice staff; to obtain and maintain a current copy of residents' hospice plans of care; to identify and communicate what services/disciplines (registered nurse, chaplain, certified nursing assistant, massage therapist etc.) hospice would provide each resident and at what frequency; and to obtain hospice staffs' visit notes, detracted from the effective coordination of care and placed residents at risk for not receiving necessary care and services. Findings included . Review of the facility's Nursing Facility Services Agreement contract, reviewed 05/04/2022, showed hospice…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 1 of 1 sampled residents (Resident 18) reviewed for environment. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included . Resident 18 admitted to the facility on [DATE]. The annual Minimum Data Set, an assessment tool, dated 09/06/2023, documented Resident 18 was moderately cognitively impaired. Resident 18 is blind in her right eye. On 11/06/2023 at 12:34 PM, during an interview, Resident 18 said she was blind in her right eye and could not see the call light when it was clipped to the curtain on her right side. The call light was observed clipped on the curtain, at eye level and on the right side of Resident 18's bed. On 11/09/2023 at 9:29 AM, Resident 18's call light was observed clipped on the curtain, at eye level and on the right side of Resident 18's bed. At 3:41 PM, Resident 18's call light was observed clipped on the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to issue the required liability notice for 1 of 3 residents (Resident 65) reviewed for liability and appeal notices. This failure placed residents at risk of not being informed of their appeal rights prior to the end of Medicare covered services and did not uphold the right to make informed choices about further treatment or services as required by the Medicare Program. Findings included . Resident 65 was admitted to the facility on [DATE]. Resident 65's electronic health record showed the last covered day by Medicare part A service was on 06/02/2023. The required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form was not issued to Resident 65 or the resident's representative. On 11/08/2023 at 3:00 PM, Staff F, Social Service Advisor, said it is Social Services' responsibility to issue the SNF ABN form to the resident and/or their representative. Staff F said she was unsure why the form had not been issued to Resident 65…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses for 1 of 5 sampled residents (Resident 8) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental healthcare needs. Findings included . Resident 8's quarterly Minimum Data Set (an assessment tool), dated 09/17/2023, showed the resident was severely cognitively impaired, had a diagnosis of depression, and received antidepressant and antipsychotic medications during the assessment period. Resident 8's physician orders showed the resident had a 07/15/2022 order for an antidepressant daily for major depressive disorder and a 09/13/2023 order for an antipsychotic daily for anxiety and agitation. Review of Resident 8's Level I PASRR, dated 07/05/2022, showed the resident had a diagnosis of depressive disorder. The assessment did not identify Resident 8 had a diagnosis…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure resident care plans were revised and accurately reflected resident care needs for 2 of 21 residents (Resident 19 and 8) reviewed for care plans. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Care Plans-Documentation on Admission, revised 11/25/2016 showed .The care plan will be reviewed and updated at least every 90 days or more often if resident condition changes . 1) Resident 19 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrolled movements, such as shaking, stiffness and difficulty with balance and coordination) and Dementia (a condition that affects the way a person's brain is working). Resident 19's care plan, dated 9/13/2023, showed Resident 19 had a DTI (Deep tissue injury/discolored intact skin or blood filled…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents received the bowel care they were assessed to require for 3 of 7 residents (Residents 8, 48 and 5) reviewed for bowel management. The failure to administer bowel medications in accordance with physician orders (POs) and facility bowel protocol, placed residents at risk for pain/discomfort, nausea, decreased appetite, and diminished quality of life. Findings included . Review of the facility's Nursing Bowel Care Protocol policy, reviewed 04/07/2022, showed licensed staff were required to print bowel flowsheets at the beginning of their shift to identify any need for bowel care and would implement the following: a) If no bowel movement (BM) for three days (nine shifts) administer senna (vegetable laxative) on the 10th shift. b) If no BM on the 11th shift, administer a bisacodyl (a laxative) suppository per rectum. c) If no results from the suppository, administer a Fleets enema and notify the physician. 1) On 11/07/2023 at 10:45 AM, Resident 8 said constipation had been an ongoing problem for him. Review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure 1 of 5 residents (Residents 8) reviewed for unnecessary medications, was free from unnecessary psychotropic drugs (drug taken to exert an effect on the chemical makeup of the brain and nervous system). The failure to identify the target behaviors each psychotropic medication was intended to treat, to ensure behavior monitoring accurately reflected residents' identified target behaviors, and to perform gradual dose reductions when indicated, placed residents at risk for receiving unnecessary medications and associated adverse side effects, falls, injury and a diminished quality of life. Findings included . Resident 8's quarterly Minimum Data Set (an assessment tool), dated 09/17/2023, showed the resident was severely cognitively impaired, had a diagnosis of depression, and received antidepressant and antipsychotic medication during the assessment period. Resident 8's physician's orders showed the resident had a 07/15/2022 order for escitalopram (an antidepressant) daily for major depressive disorder and a 09/13/2023…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$42,904 in federal fines across 2 penalties.

  • $31,714 — penalty dated 2026-01-27
  • $11,190 — penalty dated 2025-05-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
FLEMMING, STANLEYIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2022
WILKERSON, DENNISIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
GAVIN, WILLIAMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2001
GOLDBERG, FREDERICKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 08/01/1990
HEDDEN, DALEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 08/31/2023
JENSEN, DARYLIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 06/01/1999
MADDEN, KATHRYNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2017
MAH, DOUGLASIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/26/2023
MASON, NANCYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 12/01/2009
MURPHY, JUDYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/30/2023
MURRY, MATTHEWIndividualCORPORATE OFFICERsince 08/01/2016
STRADER, CHARLESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/04/2005

CMS files one row per role, so the 25 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$55.7M
Net patient revenuemost recent cost report
+0.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 4%Medicare 8%Other / private 88%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$1,128per resident / day
operating cost
$34,288per month
≈ monthly operating cost
$1,131per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Washington Medicaid page.

Typical monthly cost in Washington
$13,155/mo
Nursing home (semi-private)
$15,969/mo
Nursing home (private)
$7,600/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505059. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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