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Lakeland Village Nursing Facility

State Highway 902 & Salnave Road, Medical Lake, WA 99022 · Government - State · 93 certified beds · (509) 299-1800 Medicaid only — no Medicare

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Flagged for abuse1 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
731 N Stanley St · (509) 299-6900 · Call to confirm hours
Pharmacy
701 Hospital Loop · (509) 247-5567 · Call to confirm hours
Grocery
215 E Highway 902 · (509) 299-3251 · Call to confirm hours
Park
Seattle Ave @ W Castle St · Typically dawn to dusk
Place of worship
864 N Graham Ln · (509) 862-9699

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 4 of 5
Long-stay residentspeople who live here 4 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 fell from 5 to 4 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 rating4★
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 increased7.9%14.2%15.4%better
Long-stay residents who lose too much weight1.7%5.5%5.4%better
Long-stay residents with a catheter left in their bladder2.6%1.0%0.9%worse
Long-stay residents with a urinary tract infection13.0%1.6%2.0%worse
Long-stay residents with depressive symptoms0.0%17.7%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained10.3%0.1%0.1%worse
Long-stay residents with falls causing major injury0.3%2.6%3.3%better
Long-stay residents whose ability to walk worsened7.7%17.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.0%12.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%93.8%95.3%typical
Long-stay residents with pressure ulcers0.5%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control7.4%22.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table21.2%15.1%17.1%worse
Long-stay hospitalizations per 1,000 resident days1.671.331.67typical
Long-stay outpatient ER visits per 1,000 resident days0.861.521.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

Staffing

2.17
RN hours/ resident / day
0.32
LPN hours/ resident / day
8.64
Aide hours/ resident / day
11.12
Total nurse hours/ resident / day
1.75
RN hoursweekends
32.6%
Total nursing turnover
26.7%
RN turnover

How full it usually is: this home is certified for 93 beds and averages 74.2 residents a day — about 80% occupied, or roughly 19 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 11.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 8.64 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.

This home’s total nursing-staff turnover of 33% 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

4
deficiencies at the latest standard inspection (2025-10-27)
6
at the previous standard inspection (2024-09-27)

Deficiencies are fewer than at the previous inspection — improving. 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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2024-09-27 · 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 test modified fluid consistencies after preparation and before serving to vulnerableresidents at risk for aspiration (inhalation of food, liquid, or other material into the airway or lungs) in accordance with professional standards of practice and resident needs for 3 of 9 sampled residents (Residents 8, 30 and 43), reviewed for food and nutrition services. In addition, the facility failed to ensure that foods were stored and prepared in a safe manner, and dishwasher temperatures met the required standard which placed residents at risk for food borne illness and diminished quality of life for all 75 residents. The failure if the facility to make sure that residents at risk of aspiration received the correct fluid consistency represented an immediate jeopardy (IJ). On 09/23/2024 at 8:01 PM, the facility was notified an IJ was identified related to F812 CFR §483.60 Food Procurement/Store/Serve/Sanitary. The facility removed the immediacy on 09/24/2024 with an onsite verification by surveyors ensuring 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 a resident remained free from verbal and physical abuse for 1 of 3 sample residents (Resident 1). This failure placed the residents at risk for physical and psychological harm.Findings included. Review of Resident 1's electronic medical record, on 05/04/2026 at 11:42 AM, showed they had been admitted to the facility on [DATE], and had moved to the nursing facility area on 10/28/2020, with diagnoses of ataxia (unsteady gait), severe intellectual disability (marked impairments in cognitive abilities and practical life skills that affect an individual's ability to perform everyday tasks independently), and a history of psychological trauma. Review of Resident 1's care plan, dated 02/07/2022 to present, showed they used a wheelchair for locomotion related to their unsteady gait, and had no safety awareness. Resident 1's care plan also showed they were verbal, could express their personal preferences and many of their wants/needs, and were most…

    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 before2025-12-15 · 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

    Based on observation, interview, and record review, the facility failed to consistently implement interventions to prevent a resident from ingesting an exam glove for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure placed residents at risk for medical complications and decreased quality of life.Findings included .Review of Resident 1's care plan, dated as effective 02/04/2022 to present, showed they had diagnoses which included profound intellectual disability and PICA (an abnormal desire to eat substances not normally eaten), with the following detail, [Resident 1] has severe PICA and can be very sly and will obtain items of [their] choice and they often are not digestible. [Resident 1] has a 1:1 staff to ensure that [they] do not ingest anything that [they] shouldn't. The care plan also showed that Resident 1 had severely impaired cognition and required limited assistance with mobility while in their wheelchair.Review of a facility investigation, dated 12/06/2025, showed that Resident 1 had an ileostomy (an opening in the abdomen that bypasses…

    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 before2025-10-27 · 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

    Based on interview and record review, the facility failed to follow professional standards of practice to prevent a medication error for 1 of 5 sampled residents (11), reviewed for unnecessary medications. Specifically, Resident 11 received a dose of an antibiotic that was on their list of allergies. This failure placed the resident at risk for health complications and possible anaphylaxis (a serious and potentially fatal allergic reaction).Findings included.The website www.nurseslabs.com (an online nursing resource site), documented the Five Rights of Medication Administration (right patient, right drug, right dose, right route and right time) was a foundational framework in nursing, that ensured patient safety and minimized medication errors. A part of ensuring that a patient was given the right medication was to routinely check on previous allergic reactions to medications. Additionally, the staff should always verify any uncertainty about the medication with the prescriber, prior to administration.According to the quarterly assessment, dated 08/04/2025, Resident 11 had 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 maintain respiratory equipment in a clean manner for 2 of 3 sampled residents (Residents 1 and 69) reviewed for respiratory care. This failure placed the residents at risk for illness and decreased quality of life.Findings included .<Resident 1>The 09/07/2025 quarterly assessment documented Resident 1 had diagnoses including sleep apnea (when your breathing stops and restarts during sleep, preventing the body from getting enough oxygen) and pneumonia. The resident had severe cognitive impairments, and oxygen was not coded on the assessment. In an observation on 10/20/2025 at 10:42 AM, Resident 1 was sitting in their room in their wheelchair. The resident had an oxygen concentrator (a machine that delivers oxygen) in their room that was covered in thick dust debris over the area where the filter was, and the machine was unclean with dust and white splatter. The resident's oxygen tubing and nasal cannula were lying on the floor.The 01/28/2025 sleep apnea care plan instructed nursing staff to apply oxygen when…

    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 before2025-10-27 · 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

    Based on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 1 of 4 medication administration observations. Additionally, the facility failed to ensure PPE (personal protective equipment, gowns and gloves) and incontinence pads were disposed of properly and a hoyer lift (a lift used to transfer residents) was sanitized between resident transfers to prevent the spread of bacteria.Findings included.In an observation on 10/22/2025 at 10:52 AM, Staff F, Attendant Counselor, came out of Resident 2's room carrying unclean incontinence pads that were not contained and carried them down the hall and discarded them in a garbage can. At 10:53 AM, Staff F brought the Hoyer lift out of Resident 2's room into the hall and took it into Resident 10's room without sanitizing it in between transferring the residents. In an observation on 10/22/2025 at 11:22 AM, Staff J, Registered Nurse, entered Resident 69's room to hang a new bag of tube feeding formula. Staff J put on a pair of gloves, removed the old bag of tube feeding formula, and left…

    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 · D2025-10-27 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure chemicals and tools were secured in 2 of 3 rooms observed and 1 of 1 supply cabinets. In addition, the facility failed to ensure wheelchairs, seatbelts and foot troughs (a device used to hold a resident's lower extremities in place) were maintained in a clean manner for three residents (Residents 1, 10, 69), a fan for one resident (Resident 1) and a tube feeding pole for one resident (Resident 69) reviewed for physical environment. In addition, the facility failed to maintain clean refrigerators and a freezer on 1 of 6 cottages. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.Findings included .<Chemicals/Tools>During an observation on 10/20/2024 at 10:05 AM, the supply cabinet near the shower room was unlocked and contained a chemical cleaner on the bottom shelf. The cleaners label stated to call poison control center if ingested. There were no residents wandering near the area or the vicinity of the supply cabinet.In an interview on 10/20/2025…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the residents' right to be free from neglect for 1 of 3 residents (Resident 2). The failure to provide medical care, as ordered by the facility medical provider, resulted in a possible diminished quality of life. Findings include: Record review showed Resident 1 was admitted to the facility in August of 2023 with diagnoses of Moderate Intellectual Disability (characterized by an average mental age of 6 to 9 years old, with adaptive, social and cognitive skills at that level) and dementia (a loss of thinking, remembering and reasoning skills). Review of Resident 2's medical record showed that on 06/02/2025 at 1:34 PM Staff H, Registered Nurse, notified the facility physician, Staff F, that Resident 2's right great toe was discolored and tender to touch. Staff C then wrote in a progress note that they had received a verbal order from Staff F to start Epsom salt soaks for 15 minutes, two times per day, for three days. Further review of Resident 2's medical record showed that on 06/04/2025 at 11:20 AM Staff F, assessed…

    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 before2025-07-07 · 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

    Based on interview and record review, the facility failed to ensure timely reporting of an allegation of neglect for 1 of 1 resident (Resident 1). This failure resulted in potential harm and decreased quality of life for the resident. Findings included: Based on the 04/01/2025 assessment, Resident 1 was cognitively impaired and had diagnoses including moderate intellectual disabilities and schizoaffective disorder. They required maximum assistance for activities of daily living such as transferring in and out of bed and wheelchair, standing, toileting, and personal care. In an interview on 06/04/2025 at 1:00PM, Staff B, Attendant Counselor 1 (AC1) stated they witnessed Resident 1 fall out of bed onto the floor. Staff B could not remember the date of the occurrence. Staff B then called out to Staff C, AC1 to get the nurse. While waiting for the nurse Staff E, Attendant counselor Manager (ACM) entered the room and Staff B informed them that the resident had fallen. Staff E then proceeded to pick up the resident and put them on the bed and told Staff B to not complete an incident…

    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 before2025-03-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 interviews and record review the facility failed to protect 2 of 5 sampled residents (Resident 1, 2) from abuse. These failures resulted in the potential for physical and psychological harm, and decreased quality of life for all residents. Findings included: <Resident 1> Per record review Resident 1 was cognitively impaired, required assistance for most activities of daily living (ADLs), required one to one direct supervision at all times, and had diagnoses including intellectual disability, and fracture of a finger on the right hand. Per review of a Facility Resident Incident Witness Statement dated 01/15/2025, Staff D, Attendant Counselor (AC) documented they witnessed Staff C, Registered Nurse (RN), on 01/15/2025 at approximately 9:15pm pushing on Resident 1's chest, with their hand, while Resident 1 was lying on their bed, and attempting to put medication into Resident1's mouth. Per review of the Developmental Disabilities Administration 5-Day Investigation Report an interview was documented on…

    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 before2025-01-23 · 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 meet professional standards of practice in provision of providing timely incontinence care for 2 of 3 sampled residents (Resident 1 and 2). This failure placed residents' requiring incontinence care at risk for potential skin injury and decreased quality of life. Findings included: <Resident 1> Per the assessment dated [DATE], Resident 1 had severe cognitive impairment, was dependent on staff for most activities of daily living such as personal hygiene, toileting, and transferring, was incontinent of bowel and bladder, was at risk of skin injury, and had diagnoses including moderate intellectual disability, hypersomnia (excessive sleepiness) with long sleep times, and ataxia (a condition which causes poor muscle control). The care plan dated 11/22/2024 documented staff was to offer Resident 1 the toilet upon awakening, before & after meals, before bedtime, & prn (as needed), and that Resident 1 used bedside commode for toileting. A skin assessment for…

    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
Show the remaining 15 citations
  • Potential for harm · Fcited before2024-09-27 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    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 review policies yearly as required, perform hand hygiene and/or glove changes when indicated, handle, store, and transport laundry in a manner to prevent the spread of infection. In addition, the facility failed to place signage in a conspicuous location outside the residents' room to clearly identify transmission based precautions implemented and appropriate personal protective equipment (PPE) to be used, and implement enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 sampled residents (Resident 14), reviewed for infection control. This failure placed residents at risk of development of a MDROs, communicable diseases, and diminished quality of life. Finding included . POLICIES Review of facility policy titled, Antibiotic Stewardship Program showed the policy was last reviewed 08/24/2022. In an interview on 09/26/2024 at 1:12 PM, Staff Q, Infection Preventionist, stated infection control policies were typically reviewed yearly, and the last review date would…

    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 · E2024-09-27 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review, the facility failed to ensure all staff had food handler's cards (a certification that showed staff had completed training on food safety) to prepare food for facility residents. Specifically, in 6 of 7 cottages, the staff were occasionally preparing and cooking some foods, without food handler's cards. In addition, 1 of 24 dietary staff (C) had an expired food handler's card. This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . <Cottage Staff> On 09/19/2024 at 9:06 AM, two flats of uncooked, pasteurized eggs were observed in the Ponderosa Cottage refrigerator, and at 9:24 AM uncooked, pasteurized eggs were observed in another refrigerator in the Ponderosa Cottage. On 09/23/2024 at 9:24 AM, a flat of uncooked, pasteurized eggs were observed in the Rosewood Cottage refrigerator. During an interview on 09/23/2024 at 4:56 PM, Staff W, Attendant Counselor Manager (ACM), stated that some residents wanted eggs made in 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 sampled residents (72), reviewed for unnecessary medications, was informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the resident and/or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications. Findings included The 07/01/2024 quarterly assessment documented Resident 72 had diagnoses which included psychotic disorder, a severe mental illness that caused a person to lose touch with reality and experience abnormal perceptions and thinking. In addition, the assessment documented the resident had received psychotropic medication. Reviews of the September 2024 Physician Order Sheet and the September 2024 Medication Administration Record documented on 03/27/2024, a psychotropic medication, Duloxetine, had been prescribed and Resident 72 had received the medication daily. Review of Resident 72's record found no documentation and/or an…

    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 · D2024-09-27 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 2 of 3 sampled residents (Residents 12 and 60), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 revised October 2023, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yields information about 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · 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 implement interventions to prevent and heal pressure ulcer/injury for 1 of 1 sampled resident (Resident32). This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs. Findings included . The National Institutes of Health (NIH) website nih.govshowed a pressure injury was localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 pressure injury: intact skin with a localized area of non-blanching erythema [redness that does not disappear when pressure is applied to the area] Stage 2 pressure injury: partial thickness [involving epidermis and/or dermis] loss of skin with exposed dermis. The wound bed is viable, pink or red,…

    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 before2024-09-11 · 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 — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to the State Agency as required, for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk for possible abuse. Findings included . Record review showed that on 08/06/2024 at 7:25 AM, Staff B, Attendant Counselor Manager, received an email from Staff C, Certified Nursing Assistant, that they had overheard Staff D yell at Resident 1 on 08/05/2024 at about 4:30 AM. Further record review found that the facility did not report the incident to the required State Survey Agency until 08/06/2024 at 12:13 PM. In an interview at 12:28 PM on 09/11/2024, Staff A, Director of Nursing, stated that the time frame for reporting abuse allegations to the required State agency is two hours and in this instance, there was a delay in reporting the possible abuse. Reference: (WAC) 388-97-0640 (5)(a)

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · 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

    Based on interview and record review, the facility failed to protect, assess and monitor 1 of 3 sampled residents (Resident 1) after an allegation of verbal abuse. Failure to immediately protect the resident, failure to immediately assess the resident and failure to start monitoring for any potential harm related to the abuse allegation, placed residents at risk for diminished quality of life, and continued possible abuse. Findings included . Record review showed Resident 1 had a diagnosis of Rapid Cycle Type 2 Bipolar Disorder (frequent changes in mood from very active to almost no activity with marked impairment in social and occupational functioning) and Moderate Intellectual Disability (a condition that affects learning, behavior and adaptive skills). According to a facility incident report, dated 08/06/2024 at 12:13 PM, on night shift (started on 08/04/2024 into 08/05/2024) of 08/05/2024 at about 4:30 AM Staff C, Nursing Assistant, overheard Staff D, Licensed Practical Nurse, yell at Resident 1 to wake up and take their medication after which the resident appeared to be upset.…

    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 before2024-06-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 5 residents (Resident 1) reviewed for abuse and/or neglect. The failure to provide incontinence care to a resident who was identified to be incontinent of bladder and required staff assistance for toileting, as well as the failure to provide an adequate morning meal resulted in emotional distress and a diminished quality of life. Findings included . Record review showed Resident 1 had been a long-term resident at the facility and on 03/20/2024 had moved to the nursing facility in response to increased medical and physical needs. Resident 1's diagnoses included moderate intellectual disability (a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning diagnosed in childhood), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and unstable mood) and bipolar disorder with severe manic episodes and psychotic symptoms (a mental disorder characterized by severe mood…

    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 before2024-06-20 · 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

    Based on interview and record review, the facility failed to ensure allegations of potential abuse and/or neglect were reported immediately to the State Survey Agency, as required, for 1 of 5 sample residents (Resident 1). This failure placed residents at risk for abuse and/or neglect. Findings included . Record review showed Resident 1 had been a long-term resident at this facility and on 03/20/2024 had moved to the nursing facility portion of the facility in response to increased medical and physical needs. Resident 1's diagnoses included moderate intellectual disability (a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning diagnosed in childhood), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and unstable mood) and bipolar disorder with severe manic episodes and psychotic symptoms (a mental disorder characterized by severe mood swings, hallucinations, delusions, periods of extreme activity and extreme depression). According to a facility incident report, dated…

    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 before2024-06-20 · 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 into allegations of neglect in a timely manner, for 2 of 5 sample residents (Resident 1 and 2). Failure to recognize allegations as possible neglect, failure to protect the residents and failure to immediately investigate allegations, placed residents at risk for diminished quality of life, and continued possible neglect. Findings include . <Resident 1> Record review showed Resident 1 had been a long-term resident at the facility and on 03/20/2024 had moved to the nursing facility portion of the facility in response to increased medical and physical needs. Resident 1's diagnoses included moderate intellectual disability (a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning diagnosed in childhood), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and unstable mood) and bipolar disorder with severe manic episodes…

    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 before2024-02-22 · 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

    Based on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to administration and the State Agency as required, for 2 of 3 sampled residents (1 and 2) reviewed for abuse. This failure placed residents at risk for possible abuse. Findings included . Record review showed that Staff B, Registered Nurse, wrote a progress note on 12/29/2023 at 9:55 PM that stated they witnessed Resident 3 stand over Resident 1 and then push Resident 1's head down while Resident 1 was shaking their head in the negative and pulling away. Further record review found that Staff B wrote a progress note on 12/30/2023 at 6:00 PM that stated they witnessed Resident 3 stroking Resident 2's lap and later the same evening Resident 3 was witnessed to wrap a shoelace around the wrist of Resident 2. Review of the facility investigation, started on 01/02/2024, stated that the date of discovery of the above-described incidents was 12/29/2023 and 12/30/2023. The dates the incidents were reported to the required State Agency was 12/31/2023. 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 · Ecited before2023-03-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure cleaning supplies were used per manufacturer recommendations in the 3-compartment sink in the main kitchen and on the main kitchen food preparation surfaces, and in 5 of 7 (Harvest, [NAME], Ponderosa, Tamarack and Shamrock) resident cottage kitchen areas inspected. This failure placed residents at risk for food-borne illnesses and potential contamination of food items. Findings included . 3-Compartment Sink Sanitizer The undated 3 Compartment Sink facility policy showed that a sink with at least three compartments must be provided for manually washing, rinsing, and sanitizing equipment and utensils. Per the policy, a chemical sanitizer used in a sanitizing solution for a manual or mechanical operation must be used in accordance with the Environmental Protection Agency (EPA) registered label use instructions. An initial kitchen inspection was conducted on 03/13/2023 at 9:26 AM with Staff G, Food Service Manager, and Staff H,…

    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 · Dcited before2023-03-16 · 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 supervision and safety devices were in place for 1 of 5 sample residents (20), reviewed for falls. This failure placed the resident at risk for falls and serious injuries. Findings included . Review of the record showed Resident 20 had diagnoses including profound intellectual disability, seizures, and stroke. A 12/25/2022 Minimum Data Set (MDS) assessment - a federally mandated process for clinically assessing all residents - showed the resident was severely impaired cognitively, required extensive assistance of 1 staff for bed mobility, and had impaired range of motion to both upper and lower extremities. The Comprehensive Functional Assessment of Physical Therapy dated 12/22/2022 showed Resident 20 was at high risk for falls during and after frequent seizures, and recommended a full-length bed wedge placed between the mattress and bed frame on the right side of the bed. Its purpose was to reduce the risk of injury, and help 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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 serve foods and food groups as directed by the menu for 1 of 2 sample residents (14), reviewed for nutrition. This failure caused the resident to receive less food than what the menu indicated, and placed the resident at risk for unplanned weight loss. Findings included . The 11/28/2017 facility Menu Policy showed the menus must meet the nutritional needs of the resident, in accordance with national guidelines, and be followed. Per the policy, alternatives aligned with individual needs and preferences should be available if the primary menu or immediate selections for a particular meal were not to a resident's liking. A review of records showed Resident 14 had diagnoses including profound intellectual disability. The 01/08/2023quarterly Minimum Data Set assessment - a federally mandated clinical assessment to be completed on all residents - showed the resident required limited assistance from one staff for eating and had not had 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    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 the sanitizer dispenser for 1 of 1 three-compartment sinks inspected in the kitchen was repaired timely. This failure placed residents at risk of food-borne illnesses. Findings included . A kitchen inspection was conducted on 03/13/2023 from 9:26 AM through 10:18 AM with Staff G, Food Service Manager and Staff H, Registered Dietitian. Staff G used a test strip and checked the level of sanitizer solution in the third sink of the manual dishwashing system for concentration of quaternary ammonia sanitizer (a type of chemical that is used to kill bacteria, viruses, and mold). The test strip did not change color to indicate sanitizer was present in the solution. Staff G stated the dispenser for the sanitizer had been broken and a work order submitted in 11/2022, but it had not been repaired yet. During an interview on 03/16/2023 at 8:48 AM, Staff H stated they were aware the dispenser was not operational, and stated there was a pending work order to get the dispenser for the sanitizer in 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.

    Environmental 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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in WA

Paying with Medicaid

CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 50A263. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-27, 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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