Puget Sound Care
4001 Capitol Mall Dr Southwest, Olympia, WA 98502 · For profit - Limited Liability company · 108 certified beds · (360) 754-9792 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0569)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,018 in federal fines (most recent 2024-03-28)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 |
| Short-stay residentsrehab / post-hospital | 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.7% | 14.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 13.4% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 4.3% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.9% | 17.7% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.5% | 2.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 7.6% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.2% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.9% | 93.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.4% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.1% | 22.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.0% | 15.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.5% | 82.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.9% | 19.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.3% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.08 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.70 | 1.52 | 1.80 | typical |
§ 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.
55.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 294 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.7% 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 131 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 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.1%CMS range 49.9–60.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.1%CMS range 6.9–11.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 52.7% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 37.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.8% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 4.0–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 108 beds and averages 95.1 residents a day — about 88% occupied, or roughly 13 beds typically open. It runs fairly full. 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.547 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 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 3.38 hrs/resident/day on weekends vs 4.28 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · G2024-03-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 residents were free from significant medication errors when medication orders were incorrectly transcribed, not reconciled and incorrectly administered for 1 of 3 sampled residents (Resident 1) reviewed for significant medication error. This caused harm to Resident 1 when the resident was administered potent medications not prescribed and had a serious change of condition requiring hospitalization. This failure placed residents at risk of adverse reactions to medications, change in health conditions and a diminished quality of life. Findings included . Review of the facility policy, dated 07/2015 and revised 11/2023, showed: admission orders will be obtained/approved through the Provider as soon as possible following or prior to the resident admission/re-admission to the center . Staff will review medication orders and assure standards of practice with orders to include the following: - Right route, dosage, frequency. - Stop dates 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.
- Potential for harm · D2026-05-08 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews and record reviews, the facility failed to report an allegation of neglect for 1 of 4 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk for ongoing neglect and a diminished quality of life.Findings included.Record review of the facility policy titled, Abuse Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation or Resident Property dated August 2025, showed When allegations that meet the definition of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are received, the center shall:(1) Ensure that all alleged violations are reported immediately. Resident 1 was admitted to the facility on [DATE] for long term care services. The 5-day Minimum data set, an assessment tool, dated 03/14/2026 indicated Resident 1 was moderately cognitively impaired.Review of the facility's incident/accident logging records dated 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.
- Potential for harm · Ecited before2026-01-23 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 7 sampled residents (Resident 8, 4 & 25) reviewed for constipation, failed to follow physician's orders for insulin administration and dressing change for a peripherally inserted central catheter (PICC, a flexible tube inserted in the vein, and near the heart for long-term antibiotics administration) for 1 of 1 residents (Resident 25) and failed to obtain weekly weights for 1 of 5 residents (Resident 36) reviewed for quality of care. These failures placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . Constipation Record review of the facility policy, titled, Management of Constipation, updated, November 2023, documented: When a resident is identified with No/small Bowel Movement (BM) documented for 64 hrs [hours], the LN [Licensed Nurse] will assess the resident and determine if the bowel protocol will be initiated. -The Clinical Alert…
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.
- Potential for harm · D2026-01-23 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to convey the trust account for 1 of 4 residents (Resident 107) reviewed for trust funds. This failure placed the residents and/or their representatives at risk for loss of funds. Findings included.Resident 107 admitted to the facility on [DATE]. Resident 107 had a trust account while a resident in the facility. Resident 107 expired on [DATE]. Review of the facility's Resident Statement Landscape, from [DATE] to [DATE], indicated Resident 107 had a balance of .03 cents. The account was closed on [DATE], 53 days after Resident 107 expired.During an interview on [DATE] at 10:50 AM, Staff L, Business Office Manager, said trust accounts were supposed to be conveyed no longer than 30 days after discharge or death. Staff L said she just recently closed out Resident 107's account. Reference WAC 388-97-0340 (5)
- Potential for harm · Dcited before2026-01-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, interview and record review, the facility failed to develop a comprehensive care plan for 2 of 3 sampled residents (Resident 36 & 78) reviewed for bed rails. This failure placed residents at risk for injury and a diminished quality of life.Findings included.Record review of facility policy, titled, Safety Device Application, date revised 04/07/2023, documented, 1. Verify the following: . d. Safety device is documented on the Safety Device Care Plan.Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 01/10/2026, showed Resident 36 was moderately cognitively impaired. In an observation on 01/20/2026 at 9:44 AM, Resident 36's bed was observed with quarter length bed rails on the upper left and right sides of bed. In an observation on 01/21/2026 at 11:04 AM, Resident 36's bed was observed with quarter length bed rails on the upper left and right sides of bed. Record Review of Resident 36's Comprehensive Care Plans, initiation date…
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.
- Potential for harm · D2026-01-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 11) reviewed for activities of daily living (ADL). This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included.Resident 11 was admitted to the facility on [DATE] with multiple diagnosis to include diabetes mellitus (DM, a disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood sugar levels). The Quarterly Minimum Data Set, an assessment tool, dated 11/07/2025, documented Resident 11 was cognitively intact and had diabetes mellitus. Record review of Resident 11's physician orders, dated 08/04/2023, documented, Diabetic Nail Care every day shift every Sat [Saturday] for DM LN [Licensed Nurse] to do nail care.Record review of Resident 11's ADL care plan, revised on 02/20/2025, showed an intervention, Bathing: Clean and trim nails 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.
- Potential for harm · D2026-01-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care 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 provide oxygen humidification (providing warm and moistened oxygen with water vapor preventing dryness, sore throats, and thickened mucus caused by long-term use of dry oxygen) for 1 of 2 residents (Resident 78) reviewed for respiratory care. This failure placed residents at risk of respiratory complications and a diminished quality of life. Findings included.Resident 78 was admitted to the facility on [DATE] with diagnosis including malignant pleural effusion (excessive fluid build up in the lungs caused by cancer cells). The admission Minimum Data Set, an assessment tool, dated 01/11/2026, showed resident 78 was moderately cognitively impaired. Record review of Resident 78's physician's order, dated 01/09/2026, documented, O2 [oxygen] @[at] 2 Liters via Nasal Cannula w[with]/ humidification to keep O2 sats >[greater then] 90%[percent] and/or SOB[shortness of breath]/Comfort every shift for Respiratory failure w/hypoxia [low…
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.
- Potential for harm · D2026-01-23 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 obtain a bed rail physician's order, use of bed rail consent, and evaluation for 2 of 3 sampled residents (Resident 36 & 78) reviewed for accidents. This failure placed residents at risk of injury and a diminished quality of life. Findings included.Record review of facility policy, titled, Safety Device Application, date revised 04/07/2023, documented, 1. Verify the following: a. Safety Device Data Collection completed and evaluated for the need of a safety device.b. Physician's order obtained for safety device.c. Safety Device Data Collection, Evaluation, and Information evaluation completed and reviewed with the resident or resident representative.Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 01/10/2026, showed Resident 36 was moderately cognitively impaired. In an observation on 01/20/2026 at 9:44 AM, Resident 36's bed was observed with quarter length bed rails 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.
- Potential for harm · Dcited before2026-01-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 secure medications in 1 of 1 residents' room (Resident 41) reviewed for medication access and storage. This failure placed residents, staff and visitors at risk for accessing unauthorized medication, injury and a diminished quality of life. Findings included.Resident 41 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection. The admission Minimum Data Set, an assessment tool, dated 12/09/2025, Showed Resident 41 was alert and oriented. In an interview and observation on 01/21/2026 at 9:46 AM, Resident 41 was observed laying in bed. Resident 41 was observed to have three bottles of medication on her bedside table. The labels/names on the on the bottles were Azo Cranberry, Centrum Women's and Azo Urinary Defense. Resident 41 stated she had been taking the medication for some time. When asked Resident 41 if staff knew she had the medications in her room, she stated I keep them there (pointing at her bedside…
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.
- Potential for harm · D2026-01-23 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 implement appropriate infection prevention and control practices when a resident ingested a medication that fell on the floor for 1 of 2 staff observed (Staff G) for medication administration; and failed to ensure staff properly donned (putting on) personal protective equipment (PPE) for 1 of 5 sampled resident rooms (Room B33) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.Findings Included. In an observation and interview on 01/22/2026 at 9:46 AM, Staff G, Registered Nurse (RN), was observed standing at the A wing nurse's station beside the medication cart. A resident was sitting in her wheelchair next to the nurse's station counter. Staff G was observed to set a cup of pills and a cup of water on the counter beside the resident. The resident took pills out of the cup and started to swallow them. One white pill dropped onto the floor when the resident was taking the pills. Staff G…
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.
- Potential for harm · Fcited before2025-07-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 observations, interviews and record review, the facility failed to ensure food was stored, prepared, and served in a sanitary manner for 1 of 1 kitchen reviewed for kitchen practices. This failure placed residents at risk of foodborne illness, and the potential for experiencing a diminished quality of life. Findings included . Record review of the facility policy, titled, Sanitation, dated January 2018, showed, The Nutrition Services team maintains clean and sanitary kitchen centers and equipment. Walls, floors, ceilings, equipment, and utensils are clean and/or sanitized, and in good working order. The Nutrition Services team will practice good infection prevention and control procedures and habits. Employees will be clean and well-groomed and will handle food properly to prevent contamination. In an observation on 06/16/2025 at 10:46 AM, during a general tour of the kitchen area after the morning meal , food crumbs and dried food were visible on the steam table. The serving bowls and lids were covered with unknown food crumbs. The stove cooking area had visible leftover…
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.
Show the remaining 10 citations
- Potential for harm · Fcited before2024-11-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 and interview, the facility failed to ensure proper disinfecting of the food thermometer when taking food temperatures in 1 of 1 kitchens reviewed for sanitation and storage. This failure placed residents at risk of cross-contamination and food borne illness. Findings included . On 11/06/2024 at 11:32 AM, Staff I, Cook, was observed testing the temperature of the food on the tray line with a kitchen thermometer. At 11:34 AM, Staff I was observed placing the thermometer into pan of pureed chicken. After documenting the temperature, Staff I wiped the thermometer with a kitchen cloth. Staff I then placed the same thermometer into another pan to test the temperature of another entree. Staff I did not use a sterilizer after temping the foods with the thermometer. At 11:36 AM, when asked about safe cleaning practices of food preparation equipment, Staff I said, he used a cloth to clean the thermometer, but the facility would prefer if he were to use alcohol wipes. At 11:43 AM, when asked about the expectation to clean the thermometer between checking food…
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.
- Potential for harm · Dcited before2024-11-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, interview, and record review, the facility failed to ensure respiratory care was addressed on the comprehensive care plan for 1 of 1 sampled resident (244) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 244 was admitted to the facility on [DATE]. The Admission/Medicare 5-day Minimum Data Set assessment, dated 07/26/2024, documented Resident 244 was alert and oriented, had a diagnosis of obstructive sleep apnea (a condition that occurs when the throat muscles relax during sleep, partially or completely blocking the airway interrupting breathing), and had a CPAP (continuous positive airway pressure, a machine that helps treat sleep apnea). Review of Resident 244's Electronic Health Record showed the comprehensive care plan did not document a focus area, goal, or intervention for a CPAP machine. On 11/04/2024 at 10:56 AM, a CPAP machine with tubing and mask was observed 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.
- Potential for harm · D2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 assistance with shaving was provided for 1 of 4 sampled residents (224) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life. Findings included . Resident 244 was admitted to the facility on [DATE]. The Admission/Medicare 5-day Minimum Data Set assessment, dated 07/26/2024, documented Resident 244 was alert and oriented. Review of Resident 244's ADLs care plan, revised on 07/30/2024, documented .Will be neat, clean and well groomed daily . PERSONAL HYGIENE: Resident requires extensive assistance. Review of Resident 244's [NAME] (a nursing worksheet tool that includes a summary of patient information used to guide nursing care), dated 11/06/2024, showed PERSONAL HYGIENE: Resident requires extensive assistance. On 11/04/2024 at 10:38 AM, Resident 244 was observed with dark colored facial hair about one quarter inch long…
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.
- Potential for harm · Dcited before2024-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 7 sampled residents (14, 58 & 37) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . Per Facility Bowel Management Policy, entitled Management of Constipation, updated 11/2023: When a resident is identified with No/small Bowel Movement documented for 64 hrs [hours], the LN [Licensed Nurse] will assess the resident and determine if bowel protocol will be initiated. The Clinical Alert will be cleared using the progress note function to document findings and interventions. Standard bowel protocol to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: --Miralax PO after eight shifts of no BM --Compound Laxative, consisting of 17.2 of Senna and of 10 mg Bisacodyl --Bisacodyl suppository rectally, if no results from the compound laxative…
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.
- Potential for harm · E2023-10-13 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 residents were treated with respect and dignity, and provided a dignified and timely meal service for 2 of 2 meals observed in 1 of 3 dining halls (Hall B) reviewed for resident rights. This failure placed the residents at risk for feelings of institutionalization, unmet care needs and a diminished quality of life. Findings included . The facility Meal Services Schedule specified Hall B Dining Room, undated, showed residents were served breakfast daily at 8:00 AM and lunch at 12:00 PM. 1) On 10/09/2023 at 7:30 AM, three residents were observed in the Assisted Hall B Dining Room. More residents were brought into the dining room by staff shortly after. No drinks or meals were brought out and served at this time. At 7:45 AM, seven residents were observed to be seated in the Hall B Dining Room with no drinks or food served. One resident was observed to have left the dining room without a meal. At 8:35 AM, Resident 56 said he was not sure how much longer he would have to wait, and said he did not know what…
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.
- Potential for harm · Ecited before2023-10-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and interview, the facility failed to ensure staff completed hand hygiene during meal service on 1 of 2 halls (Hall B) reviewed for serving meals in a sanitary manner. This failure placed residents at risk of contracting an infectious disease and a decreased quality of life. Findings included . Record review showed on 10/09/2023 the facility was in outbreak status for COVID-19 (a highly infectious virus that can cause severe illness in the elderly population). On 10/09/2023 at 8:32 AM, Staff D, Resident Care Manager and Licensed Practical Nurse, and Staff E, Physical Therapy Assistant, were observed passing out food trays and drinks. Staff D and Staff E did not wash their hands upon entering the Hall B dining room. At 8:40 AM, Staff F, Nursing Student, said staff should clean their hands when leaving a resident's room. At 8:43 AM, Staff E, Physical Therapy Assistant, was observed touching her facemask while holding an empty mug. Staff E then filled the mug with coffee from a communal coffee dispenser and went to deliver it to a resident. Staff E did not clean…
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.
- Potential for harm · D2023-10-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 received reasonable accommodations with meals for 1 of 7 sampled residents (41) reviewed for reasonable accommodation and preferences. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included . Resident 41 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 08/01/2023, showed the resident was severely cognitively impaired and required extensive assistance with eating. Resident 41's care plan, revised 01/27/2020, documented, needs one person assist with meals; she is able to feed self but needs cueing direction to slow down during meals; set up dishes. The care plan did not show the resident was to eat food with bare hands. Resident 41's order indicated she was on a cardiac diet: dysphagia advanced texture [foods that were nearly normal textures with the exception of crunchy, sticky, or hard foods], thin consistency…
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.
- Potential for harm · Dcited before2023-10-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observations, interview and record review, the facility failed to ensure residents were provided necessary care and services to maintain or improve range of motion and failed to implement diet-related recommendations for 2 of 6 sampled residents (17 & 66) reviewed for quality of care related to rehabilitation services and nutrition. These failures placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . <Rehabilitation Services> Resident 17 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 09/01/2023, indicated Resident 17 was moderately cognitively impaired. The Occupational Therapy (OT) Discharge summary, dated [DATE], documented, Patient keeps her L [left] hand in a fisted position, but is able to fully extend L fingers with assistance. On 10/10/2023 at 9:25 AM, Resident 17 was observed lying in bed. The resident's left hand was in a fisted position. Resident 17 said she 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.
- Potential for harm · D2023-10-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for therapeutic medication levels via regular blood testing for 1 of 5 sampled residents (Resident 59) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 59 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and non-Alzheimer's dementia. The significant change Minimum Data Set, an assessment tool, dated 09/09/2023, documented the resident was severely cognitively impaired. A physician's order, dated 03/16/2023, documented the resident was ordered Depakote, an antipsychotic medication. Resident 59's medical record did not show a documentation of a valproic acid level, a test used to determine a therapeutic level of Depakote. 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.
- Potential for harm · Dcited before2023-10-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 drugs and biologicals were labeled and stored in accordance with professional standards in 1 of 2 sampled medication carts (B hall medication cart) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication, receiving wrong medications, and a diminished quality of life. Findings included . The facility policy, Storage of Medication, dated January 2023, documented, The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. On 10/13/2023 at 8:55 AM, Staff D, Residential Care Manager and Licensed Practical Nurse, and the State Agency surveyor observed the B Hall medication cart under the supervision of Staff H, Registered Nurse (RN). The medication cart showed three medication cups in the top drawer, two containing loose…
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.
“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.
- 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.
Fines & penalties
$8,018 in federal fines across 1 penalty.
- $8,018 — penalty dated 2024-03-28
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.
Part of a chain
This home belongs to CALDERA CARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 5 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PNW HEALTHCARE HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/30/2017 |
| CORNERSTONE 18 OPERATIONS AJH LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/07/2021 |
| CORNERSTONE 18 OPERATIONS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/07/2021 |
| HANDLER, ASHER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/07/2021 |
| WOLMARK, CHAIM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/07/2021 |
| OSCHEROWITZ, RAPHAEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/07/2021 |
| CHHEDA, NEEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/07/2021 |
| SHEPARD, ADDISON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/07/2021 |
| 4001 CAPITAL MALL LLC | Organization | ADP OF THE SNF | — | since 05/07/2021 |
| CORNERSTONE 18 LLC | Organization | ADP OF THE SNF | — | since 05/07/2021 |
| KH CC HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/07/2021 |
| STONE 18 AJH LLC | Organization | ADP OF THE SNF | — | since 05/07/2021 |
| STONE 18 HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/07/2021 |
| STONE WA 18 LLC | Organization | ADP OF THE SNF | — | since 05/07/2021 |
CMS files one row per role, so the 24 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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.
This home reported $743K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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
Straight from this home’s Medicare cost report (CMS, FY2023). 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
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.
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 505299. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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.