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Washington Soldiers Home

1301 Orting-Kapowsin Hwy E, Orting, WA 98360 · Government - State · 97 certified beds · (360) 893-4515 Medicare & Medicaid certified

Call the home — (360) 893-4515 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2026Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$10,358 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • 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
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,358 in federal fines (most recent 2025-08-29)

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 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
11216 Sunrise Blvd E #3-106 · (253) 848-5951 · Call to confirm hours
Pharmacy
134 Washington Ave S · (360) 893-2117 · Call to confirm hours
Grocery
Safeway1.1 mi
215 Whitesell St NW · (360) 893-0840 · Call to confirm hours
Park
Calistoga St W &, Skinner Way SW · Typically dawn to dusk
Place of worship
1005 Orting Kapowsin Hwy E · (360) 893-6929

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 increased22.8%14.2%15.4%worse
Long-stay residents who lose too much weight8.6%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder1.5%1.0%0.9%worse
Long-stay residents with a urinary tract infection3.2%1.6%2.0%worse
Long-stay residents with depressive symptoms2.6%17.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.0%2.6%3.3%better
Long-stay residents whose ability to walk worsened21.3%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.8%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine95.8%93.8%95.3%typical
Long-stay residents with pressure ulcers7.1%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control16.9%22.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.8%15.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Long-stay hospitalizations per 1,000 resident days1.621.331.67typical
Long-stay outpatient ER visits per 1,000 resident days0.551.521.80better

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

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

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

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

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

0.16U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

0.65
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.77
Aide hours/ resident / day
4.27
Total nurse hours/ resident / day
0.45
RN hoursweekends
40.7%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 97 beds and averages 89.2 residents a day — about 92% occupied, or roughly 8 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 4.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.77 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 3.79 hrs/resident/day on weekends vs 4.47 on weekdays — 15% thinner on weekends. RN hours go from 0.73 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as 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

14
deficiencies at the latest standard inspection (2025-08-29)
12
at the previous standard inspection (2024-07-18)

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.

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.

31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2025-08-29 · 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 interview and record review, the facility failed to address identified risk factors for the development of pressure ulcers and implement preventative interventions timely for 1 of 4 sampled residents (Resident 3) reviewed for pressure related wounds. Resident 3 experienced harm when they developed two facility acquired pressure injuries after identified pressure prevention strategies, air mattress and heel protection boots, were not implemented timely as recommended. This failure placed residents at risk of development for pressure injury, medical complications, and diminished quality of life.Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) describes/defines a suspected deep tissue injury as: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury can result from prolonged pressure and may either resolve or develop into further tissue loss. Review of the facility's policy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-08-29 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 podiatry (the treatment of feet and their ailments) care and services were provided timely to avoid podiatric complications in residents with diabetes (elevated blood sugar) for 1 of 3 sampled residents (Resident 39) reviewed for foot care. Resident 39 experienced harm when they developed an avoidable foot wound and pain due to wearing ill-fitting shoes that prevented the resident from participating in therapy resulting in a decrease in strength from baseline and a slight functional decline when there was a delay in scheduling a podiatric shoe fitting. This failure placed residents at risk of discomfort, reduced ambulation and reduced participation in activities of daily life. Findings included . Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses that included quadriplegia (medical condition characterized by the complete or partial loss of motor function in all four limbs [arms and…

    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 · Ddisputed · IDR2026-05-19 · 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 freedom from abuse, during a resident-to-resident altercation, for 1 of 3 residents (Resident 2) reviewed for resident abuse. This failure placed the residents at risk for injury, psychological harm, diminished feelings of safety and security, and a decreased quality of life. Findings included. Review of the electronic health record on 05/19/2026 showed that Resident 2 admitted to the facility on [DATE], and had diagnoses to include dementia/cognitive decline, stroke with left-sided weakness. Resident 2 was able to make need known, and required minimal to moderate assistance with activities of daily living. Review of the facility incident report dated 05/06/2026 showed that Resident 2 was in the dining room and had moved another resident's (Resident 1) name plate to a different location in the dining room as a joke. When Resident 1 entered the dining room, they sat at the new assigned seat, but staff tried to advocate for Resident 1 and told…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) informed consents accurately completed prior to administering the medication for 1 of 5 sampled residents (Resident 8) reviewed for unnecessary medication use. This failure placed the resident and/or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medications and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 8 readmitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set (MDS, assessment tool) dated 08/06/2025 showed Resident 8 had diagnoses to include schizoaffective disorder (a mental health condition that affects a person's ability to think, feel, and behave clearly), bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, depression, psychotic disorder (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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 personal privacy was protected for 1 of 3 sampled residents (Resident 50) when reviewed for resident rights. This failure placed the resident at risk for embarrassment, a violation of their privacy, and a diminished quality of life.Findings included . Review of the electronic health record (EHR) showed Resident 50 admitted to the facility on [DATE] with diagnoses that included high blood pressure, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 50 was able to make needs known. Observation on 08/22/2025 at 9:27 AM showed a Monitoring in Progress sign on the exterior of Resident 50's room door. Review of Resident 50's EHR showed no documentation of consent to the recording device in their room. During an interview on 08/25/2025 at 10:57 AM, Staff J, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 50's roommate used an [NAME] (a smart device…

    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 · D2025-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 maintain a sanitary and homelike environment for 1 of 4 halls (100 hall) when reviewed for environment. Failure to ensure Resident 19's wheelchair left armrest was in good repair placed the resident at risk for unsanitary conditions and a diminished quality of life.Findings included. Review of the electronic health records (EHR) showed the Resident 19 admitted to the facility on [DATE] with diagnoses to include stroke (blood supply to a part of the brain is suddenly cut off), hemiplegia (total or partial inability to move one side of the body) affecting the right side of the body, and utilized a wheelchair for mobility. Resident 19 was able to make needs known. Multiple observations on 08/21/2025 at 12:27 PM, 08/22/2025 at 12:48 PM, 08/25/2025 at 10:03 AM, 08/26/2025 at 10:56 AM, and 08/27/2025 at 12:54 PM showed Resident 19's wheelchair left armrest's black vinyl covering missing/torn off towards the back of the armrest with exposed…

    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 · D2025-08-29 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 93 and 5) when reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Findings included . Resident 93 Review of the electronic health record (EHR) showed Resident 93 admitted to the facility on [DATE] with diagnoses that included chronic pain, anxiety (emotional state characterized by feelings of fear or worry) and diabetes (too much sugar in the blood). Resident 50 was able to make needs known. Review of Resident 93's EHR showed hospitalization on 06/01/2025 and there was no documentation the resident or resident representative was provided with written copies of the bed hold notice or transfer form. During an interview on 08/26/2025 at 1:30 PM, Staff B, Director of Nursing Services (DNS), stated residents were…

    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 · D2025-08-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the minimum data set (MDS, an assessment tool) accurately reflected the status for 3 of 19 sampled residents (Residents 6, 5, and 1) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs, inaccurate medical record information, and a diminished quality of life. Findings included .Resident 1 Review of the electronic health record (EHR) showed Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis that affects only one side of the body after blood flow to the brain was interrupted), heart failure, dysphagia (difficulty swallowing food or liquids) and dementia (thinking and social symptoms that interferes with daily functioning). Resident 1 was able to communicate their needs. During an observation and interview on 08/21/2025 at 12:24 PM, Resident 1 sat on their bed with an uneaten lunch tray in front of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-29 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to screen for mental health services on admission for 1 of 7 sampled residents (Resident 30) when reviewed for Pre-admission Screening and Resident Review (PASSAR, a mental health services screening tool). This failure placed the resident at risk for lack of mental health support, increase in adverse behaviors, decrease in mood, and diminished quality of life. Findings included.Review of the electronic health record showed Resident 30 admitted to the facility on [DATE] with diagnoses to include anxiety disorder, diabetes, and chronic kidney disease. The resident was able to make needs known. Review of the PASSAR level one, dated 05/09/2025, showed the Resident 30 required a level two PASSAR assessment. Review of the care plan, initiated 04/18/2025, showed Resident 30 had a level one PASSAR and a level two PASSAR was requested on 05/09/2025. During an interview on 08/27/2025 at 11:51 AM, Staff M, Social Worker, stated residents who admitted from the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-29 · 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 observation, interview, and record review, the facility failed to ensure license nurses followed orders for applying a splint (device used to immobilize or stabilize a joint or protected body part) and prevalon boots (boots used to relieve pressure on heels) for 1 of 3 sampled residents (Resident 1) when reviewed for positioning. This failure placed the resident at risk for worsening mobility, medical complications, and diminished quality of life.Finding Included.Review of the EHR showed Resident 1 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction (paralysis that affects only one side of the body after blood flow to the brain was interrupted), heart failure, dysphagia (difficulty swallowing food or liquids) and dementia (thinking and social symptoms that interfered with daily functioning). Resident 1 was able to communicate their needs. Observation on 08/21/2025 at 11:28 AM showed Resident 1 laid in bed with no boots or splint 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 received treatment and services to increase and/or prevent further decline for 1 of 3 sampled residents (Resident 39) reviewed for limited range of motion (ROM). This failure placed residents at risk for a functional decline, increased dependence on staff, and diminished quality of life.Findings included . Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses that included quadriplegia (medical condition characterized by the complete or partial loss of motor function in all four limbs [arms and legs]), diabetes (too much sugar in the blood), and kidney disease (impaired kidney function). Resident 39 was able to make needs known. During an interview on 08/21/2025 at 10:01 AM, Resident 39 stated they had not participated in restorative because they had been waiting for wider shoes to be ordered. Resident 39 stated they felt increased weakness in their legs and could not recall…

    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 · D2025-08-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and accurately document fluid restrictions or failed to follow up on a speech therapy referral for 2 of 6 sampled residents (Residents 2 and 3) when reviewed for nutrition and/or dialysis.These failures placed residents at potential risk for medical complications and a diminished quality of life. Findings included.Resident 2 Review of the electronic health records (EHR) showed Resident 2 readmitted to the facility on [DATE] with diagnoses to include kidney failure with dependence on dialysis (the process of removing waste products and excess fluid from the blood due to kidney failure), diabetes (too much sugar in the blood), and heart failure. Resident 2 was able to make needs known. During an interview and observation on 08/25/2025 at 1:01 PM, Resident 2 stated they used to be on a fluid restriction but was no longer on a fluid restriction. There was a sign on the wall that showed, No Water Pitcher Fluid Restriction and Resident…

    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 19 citations
  • Potential for harm · D2025-08-29 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 act on the consultant pharmacist's medication regimen review (MRR) recommendations and to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Residents 8) when reviewed for unnecessary medication use. This failure placed the resident at potential risk for medical complications and a decreased quality of life.:Findings included . Review of the electronic health record (EHR) showed Resident 8 readmitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), schizoaffective disorder (a mental health condition that affects a person's ability to think, feel, and behave clearly), and depression. Resident 8 was able to make needs known. Review of the form titled, Pharmacist Report of Irregularity, dated 06/09/2025 showed the pharmacist recommended Resident 8 be offered the shingles vaccination (a series of two shots that protects against shingles, a painful rash). The form's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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 schedule a follow up dental appointment and provide prompt dental services for 1 of 3 sampled residents (Resident 19) when reviewed for dental. This failure placed the resident at risk for continued dental problems and a diminished quality of life. Findings included. Review of the electronic health records (EHR) showed the Resident 19 admitted to the facility on [DATE] with diagnoses to include stroke (blood supply to a part of the brain is suddenly cut off), hemiplegia (total or partial inability to move one side of the body) affecting the right side of the body, and diabetes (too much sugar in the blood). Resident 19 was able to make needs known. During an interview and observation on 08/21/2025 at 12:42 PM, Resident 19 stated they had oral pain at times in their left upper back molar and told staff three or four weeks ago that they wanted to see a dentist to have the tooth pulled out. Resident 19 stated they still had not seen 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 · Dcited before2025-04-08 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to identify an allegation of neglect and failed to report the allegation to the state agency with the required timeframe for 1 of 3 sampled residents (Resident 1) reviewed for reporting alleged violations. These failures placed the resident at risk for ongoing abuse/neglect, unmet needs and a decreased quality of life. Findings included . Review of the facility operating procedure titled, Abuse and Neglect, dated December 18, 2024, showed that neglect is an act or omission that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, and can also mean a failure to provide a resident with the goods and services necessary to avoid physical harm. The operating procedure further showed that employees witnessing or having cause to suspect that abuse or neglect has occurred must report the concern to a licensed nurse and report it to the State Agency hotline. Review of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide food at an appetizing temperature for 1 of 1 tray line when reviewed for Kitchen Services. This failure placed residents at risk of lower nutritional intake, potential weight loss, and a diminished quality of life. Findings included . On 07/15/2024 at 12:42 PM, Resident 71 stated Some of the food sucks because the meat is overcooked. On 07/15/2024 at 12:58 PM, Resident 37 stated, The food does not taste good here. On 07/15/2024 at 12:23 PM Resident 78 stated, The food is not very flavorful and could use some improvement. The chicken and other meat are over cooked and dry. Review of the lunch menu for 07/17/2024 showed the Regular diets would receive Italian Meatloaf, Lemon Herb Orzo, Garlic Bread, Roasted Asparagus and Marbled Cheesecake. The protein alternative was Tilapia. Observation on 07/17/2024 at 11:49 AM during lunch tray service showed Staff L, Food Service Worker Lead, plating meatloaf on resident trays and adding gravy to only select trays. Staff L said they were adding gravy to the meatloaf slices that…

    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 · E2024-07-18 · tag F0808 — failed to follow doctor-ordered diets — pattern
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 22 of 90 sampled residents (Residents 2, 8, 13, 14, 18, 23, 30, 34, 37, 40, 48, 59, 60, 62, 64, 71, 73, 74, 82, 85, 86 and 140) received physician ordered therapeutic diets or portion sizes. This failure placed residents at risk for medical complications, nutritional deficits and a decreased quality of life. Findings included . <Therapeutic Diets> Review of lunch menu for 07/17/2024 showed the Regular diets would receive Italian Meatloaf, Lemon Herb Orzo, Garlic Bread, Roasted Asparagus and Marbled Cheesecake. Review of the lunch extension menu showed Easy to Chew, Soft and Bite Sized and Puree diets were to receive a wheat roll instead of garlic bread. Observation of the lunch tray preparation service on 07/17/2024 between 11:13 AM and 11:52 AM showed Staff L, Food Service Worker Lead, serving garlic bread to residents on Easy to chew, Soft and bite sized and Puree diets. Observation of the steam table during tray service showed no wheat rolls. During an interview on 07/17/2024 at 11:49 AM, Staff L said…

    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 · D2024-07-18 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 obtain or offer assistance in formulating or periodically checking if a resident had a healthcare advance directive (AD) for 1 of 17 sampled residents (Residents 78) reviewed for AD. This failure placed the resident at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences. Findings included . An AD is a written instruction, such as a living will or durable power of attorney [DPOA] for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Resident 78 admitted to the facility on [DATE] and was able to make needs known. Review of Resident 78's electronic healthcare record (EHR) on 07/15/2024 showed that the resident had a DPOA for financial; however, there was no documentation of an AD for healthcare. During an interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure an incident of potential abuse, such as misappropriation of personal property, was identified as such and reported to law enforcement and the State Survey Agency as required for 1 of 4 sampled residents (Resident 37) reviewed for abuse. Failure to report allegation/incident of abuse placed the resident at risk for additional abuse and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines titled, The Purple Book, dated October 2015, showed the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility and to other officials in accordance with State law .including to the State survey and certification agency. Resident 37 readmitted to the facility on [DATE] and was able to make needs known. During an interview and observation on 07/17/2024 at 10:12 AM, Resident 37 stated staff were aware that they had…

    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 · D2024-07-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to identify and investigate possible misappropriation of personal property/abuse for 1 of 4 sampled residents (Resident 37) reviewed for abuse. Failure to thoroughly investigate an allegation/incident of abuse placed the resident at risk for additional abuse and a diminished quality of life. Findings included . Resident 37 readmitted to the facility on [DATE] and was able to make needs known. During an interview and observation on 07/17/2024 at 10:12 AM, Resident 37 stated staff were aware that they had personal items stolen before and that was why they had keys for the locks on their nightstand and closet. Resident 37 had six keys hanging from a lanyard around their neck. Review of Resident 37's Grievance form dated 06/10/2024 showed that on 06/08/2024 Resident 37 had a concern that people were stealing their things, and they were extremely upset over not having a lock on their closet door. This was causing them emotional distress to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessment was accurately completed upon or prior to admission for 1 of 7 residents (Resident 71) reviewed for PASRRs and/or unnecessary medications. This failure placed the resident at risk for unidentified mental health care needs and a poor quality of life. Findings included . Resident 71 admitted to the facility on [DATE] with diagnoses to include depression, adult failure to thrive, post-traumatic stress disorder (PTSD, difficulty recovering after experiencing or witnessing a terrifying event), and was able to make needs known. Review of Resident 71's PASRR assessment dated [DATE], completed by the hospital prior to Resident 71's admission on [DATE], showed no serious mental illness indicators documented in section I on the form. This form showed, No Level II evaluation indicated. During an interview on 07/17/2024 at 11:57 AM, Staff H, Psychiatric Social Worker, stated Resident 71's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 19 sampled residents (Resident 78) reviewed for quality of care. The failure to assess, obtain orders, monitor, and document the use of Resident 78's shrinker (an elastic sock used to control swelling, promote healing and assist in shaping an amputated/surgically removed leg) prior to use, placed the resident at risk for medical complications, unmet needs, and a poor quality of life. Findings included . Resident 78 admitted to the facility on [DATE] with a diagnosis of an amputation (surgical removal of a limb) of the left lower leg and was able to make needs known. Observation and interview on 07/15/2024 at 12:25 PM showed Resident 78 with a left above the knee amputated leg. Resident 78 stated they were waiting for their shrinker to arrive in the mail so they could use it and then eventually get their prosthetic (artificial body part) leg. Resident 78 stated…

    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 · D2024-07-18 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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, interviews, and record review, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident 57) when reviewed for ADL decline. Failure to obtain a wheelchair for Resident 57's use, placed them at risk for avoidable decline and a diminished quality of life. Findings included . Resident 57 admitted to the facility on [DATE] with multiple diagnoses to include severe malnutrition, large sacral (lower back) skin ulcer and diabetes. The resident was able to make needs known and was dependent on staff for transfers in and out of bed. Multiple observations on 07/15/2024 through 07/18/2024 showed Resident 57 laid in bed on his back. During an interview on 07/18/2024 at 8:39 AM, Resident 57 stated they had a wheelchair in [NAME] waiting for pick up. They had talked to therapy about it and the VA social worker. It drives me crazy; I have been in bed since March, I can't go outside and see the dentist or the eye doctor or other people. I get a bed bath and…

    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 before2024-07-18 · 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 observation, interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program when needed for 1 of 1 resident (Resident 28) reviewed for bowel protocol. Additionally, the facility failed to initiate proper positioning, for 2 of 3 residents (Resident 12 and 52) when reviewed for positioning and mobility. These failures placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life. Findings included . <Bowel Monitoring> Review of a document titled, Bowel (Lower Gastrointestinal Tract) Care - Nursing Operating Protocol, dated 02/01/2018 showed that to promote bowel movements in a pattern that was usual for the resident and to prevent complications associated with constipation (a condition in which dry, hard stool that's difficult to pass). The night (NOC) shift Licensed Nurse (LN) was responsible to review resident bowel records and compile a list of residents who had gone 2 days (midnight to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · 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 provide the necessary supervision and safety monitoring for 1 of 4 residents (Resident 28) reviewed for accidents. This failure placed the resident and the facility at risk for possible fire and serious injury related to an inaccurate smoking safety assessment. Findings included . Review of a policy titled, Smoking and Tobacco in WDVA Facilities, dated, 06/26/2023 showed the rights of all individuals was to provide an example of preventive healthy behavior, maintain a clean and healthful environment and ensure health and comfort of individuals whose tolerance for tobacco use was limited. The document also showed that all those who live, work, and visit the facilities would be provided with an environment that limits the risks of fire or exposure to smoke vapor, and other byproducts of tobacco products. Smoking assessments would occur for residents that smoked upon admission, quarterly and when warranted by circumstances as part of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to monitor and manage issues with pain for 1 of 2 residents (Resident 67) reviewed for pain management. Failure to monitor Resident 67's pain levels placed the resident at risk for uncontrolled pain and a decreased quality of life. Findings included . Resident 67 was admitted to the facility on [DATE] with a diagnosis of left toe amputation (surgically removed toe), chronic pain syndrome, and post-traumatic stress disorder. The resident had a provider order dated 05/28/2024 for a narcotic pain medication three times a day. During an interview on 07/16/2024 at 11:47 AM, Resident 67 stated they were taking pain medications every eight hours, but they are never on time, and it was not enough and that the pain was out of control. Review of the electronic health record on 07/17/2024 showed there was no documentation of the resident's pain level to determine if the medications were effective or what the residents pain level was. During 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications (affecting the mind) were limited to 14 days for 1 of 5 sampled residents (Resident 59) when reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary psychotropic medication, avoidable medication side effects, and a diminished quality of life. Findings included . Resident 59 admitted to the facility on [DATE] with multiple diagnoses to include chronic respiratory failure, and anxiety. Resident 59 was able to make needs known. Review of Resident 59's provider's orders showed an order for lorazepam (an antianxiety medication) every four hours PRN which started on 02/21/2024 and had no stop date. Review of Resident 59's monthly pharmacy recommendations showed no recommendation to stop lorazepam PRN after 14 days. Review of Resident 59's medication administration record showed that Resident 59 was administered lorazepam tree times in the month of July 2024,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 5 residents (Resident 66) reviewed for Unnecessary Medication Use. This failure placed the residents at risk for medical complications and a diminished quality of life. Findings included . The Washington State Nurse Practice Act, WAC 246-840-710(2)(d) showed nurses violated standards of practice by, Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards. Review of the May 2023 Medication Administration Record showed that Resident 66 had an order with a start date of 04/04/2023 for Bisoprolol Fumarate (a medication used to treat high blood pressure) that included instructions for the medication to be held if the pulse rate (heart rate) was less than 60. This order showed the medical doctor was to be notified when the medication was held. Further review showed documentation Resident 66 received Bisoprolol Fumarate on 05/16/2023 with a pulse of 57, on 05/20/2023 with a pulse of 55, and on 05/22/2023 with a pulse of 58.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 sufficient services were provided for 1 of 2 residents (Resident 53) reviewed for Indwelling Urinary Catheter (a catheter/tube inserted into the bladder and left in place to drain urine) and Antibiotic Use. Failure to ensure Resident 53's urology (the branch of medicine concerned with the function and disorders of the urinary system) referral was implemented placed the resident as risk for further complications, unmet care needs, and a diminished quality of life. Findings included . Observation on 06/05/2023 showed Resident 66 laid in bed with a catheter bag hanging below the left side of the bed frame. Review of the significant change in condition Minimum Data Set assessment, dated 03/01/2023, showed Resident 66 readmitted to the facility on [DATE] after a brief hospitalization, with diagnoses to include obstructive and reflux uropathy (urine was unable to flow out either partially or completely due to some type of obstruction),…

    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 · D2023-06-07 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 monitor the dialysis access site and follow up on dialysis center recommendations for 1 of 1 resident (Resident 62) reviewed for Dialysis. This failure placed the resident at risk for medical complications and a decreased quality of life. Findings included . Review of the facility protocol titled Dialysis Monitoring, dated 01/26/2018, showed Nursing staff will monitor and document the dialysis site each shift, observing for signs of infection or bleeding. A: auscultate [listen with a stethoscope] the fistula/graft/shunt [connection of a vein and an artery in your arm] site each shift and document the presence or absence of bruit [sound], change in volume, or absence of sound. Palpate [touch] the fistula/graft/shunt site for thrill [pulsing] or pulse present, documenting any absence, changes in intensity i.e. weak or bounding. Follow the Dialysis Center specific Standard orders for the individual resident. During an interview and observation on 06/02/2023 at 10:15 AM, Resident 62 stated the nurses did not check…

    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
  • No harm found · C2025-08-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 post the actual hours worked in the nursing staffing postings for 5 of 5 observed days during the survey period (08/21/2025, 08/22/2025, 08/25/2025, 08/26/2025, and 08/27/2025) when reviewed for nursing staff postings. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility. Findings included . Observations on 08/21/2025 at 9:48 AM, 08/22/2025 at 10:36 AM, 08/25/2025 at 1:47 PM, 08/26/2025 at 2:00 PM, and 08/27/2025 at 9:30 AM of the nursing staffing postings showed, Number of hours; however, did not indicate if those hours were actual or scheduled hours documented for each discipline on each shift. During an interview on 08/27/2025 at 11:09 AM, Staff E, Administrative Assistant 3 (AA3), stated the night nurse made up the nursing staff postings and posted them daily. Staff E stated the postings showed scheduled hours worked for each discipline on each shift and not the actual hours worked. During 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.

    Nursing and Physician Services 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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$10,358 in federal fines across 1 penalty.

  • $10,358 — penalty dated 2025-08-29

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

Who owns this facility

Owner / managerTypeRoleShareSince
WASHINGTON STATE DEPARTMENT OF VETEOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 09/27/2006
GILBERT, SOLOMONIndividualMANAGING CONTROL - GOVERNING BODYsince 05/22/2023
MURRAY, DANIELIndividualMANAGING CONTROL - GOVERNING BODYsince 11/16/2021
PUENTE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2023
BUTTITTA, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2019
SMITH, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
WESTHOFF, TERRANCEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2020

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$13.8M
Net patient revenuemost recent cost report
-34.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 22%Medicare 2%Other / private 76%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$667per resident / day
operating cost
$20,270per month
≈ monthly operating cost
$496per day
avg. revenue, all payers

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

What families pay in WA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505516. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-29, 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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