Life Care Center Of Port Townsend
751 Kearney Street, Port Townsend, WA 98368 · For profit - Limited Liability company · 94 certified beds · (360) 385-3555 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)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $34,808 in federal fines (most recent 2023-10-04)
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 10.5% | 14.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.1% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.5% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.5% | 17.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 2.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 11.2% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.8% | 22.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.7% | 15.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.6% | 82.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.5% | 19.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 24.2% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.09 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.05 | 1.52 | 1.80 | worse |
‡ 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.
60.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.2% 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 54 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% 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 | 60.2%CMS range 54.8–67.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 7.0–13.2 | 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 | 72.2% | 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 | 66.7% | 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 | 74.1% | 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 | 98.0% | 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 | not 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 discharge | 97.0% | 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 | 0.0% | 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 | 4.1% | 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 | 6.6%CMS range 3.9–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 94 beds and averages 41.2 residents a day — about 44% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 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 3.55 hrs/resident/day on weekends vs 4.13 on weekdays — 14% thinner on weekends. RN hours go from 1.04 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2023-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview and record review, the facility failed to ensure residents were free from accident hazards when staff provided a one-person transfer with toileting assistance instead of the care planned two-person transfer with toileting assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. Resident 1 experienced harm when he was assisted with one staff rather than two and sustained three rib fractures and subsequent pleural effusion (a build-up of excess fluid between the layers of the pleura outside the lungs), pain, and bruising. Findings included Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 07/26/2023, documented Resident 1 had severe…
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 · E2026-03-13 · tag F0645 — patternPASARR 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 residents for mental health conditions prior to admission for 2 of 5 sampled residents (Resident 12 and 47) residents reviewed for Preadmission Screening and Resident /review (PASRR). This failure placed residents at risk for unidentified mental health conditions, lack of appropriate mental health care and a decreased quality of life. Findings included . Resident 12 was admitted on [DATE]. Resident 12's Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 12 had a diagnosis of anxiety disorder. Resident 12's physician orders, dated 02/03/2026, showed Resident 12 had lorazepam (medication for anxiety) ordered every four hours as needed for anxiety related to anxiety disorder. Resident 12's Level 1 PASRR, dated 01/26/2026, showed Resident 12 was anticipated to be admitted to the facility on [DATE] and had no serious mental illness indicators and anxiety disorder was not documented. On 03/12/2026 at 1:13 PM, Staff C, Social Service…
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 · D2026-03-13 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored for side effects and target behaviors and provided justification for use of the psychotropic medications and non-pharmaceutical interventions were used prior to utilizing psychotropic medications for 3 of 5 sampled residents (Resident 22, 47 & 12) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage, increase in side effects without interventions, and a diminished quality of life.Findings included.Review of the facility policy titled, Psychotropic Medication Use, revised 03/01/2025, showed the facility staff should take a holistic approach to behavior management that involved a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions and psychotropic medications may be used 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.
- Potential for harm · Dcited before2026-03-13 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to coordinate and follow-up on a preadmission screening and resident review (PASRR, a mental health screening tool) level 2 evaluation for residents diagnosed with a significant mental illness for 2 of 5 residents (3 and 4) reviewed for PASRR. This failure placed the residents at risk for unmet care needs and a decreased quality of life.Findings included .Resident 3Resident 3 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 12/05/2025, showed Resident 3 was cognitively intact and needed set up assistance with oral hygiene and partial/moderate assist to dependent with dressing and showering.Resident 3's PASRR, dated 07/03/2025, showed serious mental illness indicators were checked for psychotic disorder (severe mental illnesses characterized by a loss of touch with reality) depressive disorder (mental health condition characterized by persistent low mood, loss of interest, and low energy), delusion…
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 before2026-03-13 · 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 provide the necessary services for a dependent resident for 1 of 2 sampled residents (3) reviewed for activities of daily living (ADL). This failure placed the resident at risk for a decline in health status and a diminished quality of life. Findings included.Resident 3 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 12/05/2025, showed Resident 3 was cognitively intact and needed set up or clean-up assistance with eating.On 03/09/2026 at 1:37 PM, Resident 3 said sometimes they could not reach their call light. Resident 3 was asked what they do when they cannot reach their call light and Resident 3 said, I have to wait.On 03/09/2026 at 1:51 PM, Resident 3 said they needed the staff to help them drink. Resident 3 was asked what they did when they needed a drink, Resident 3 said sometimes I must wait. Resident 3 said, they tell me I am dehydrated and I do want to drink more.On 03/11/2026…
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 · D2026-03-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 prevent facility acquired pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) from developing for 1 of 3 sampled residents (Resident 6) reviewed for pressure ulcers. This failure placed residents at risk for developing pressure ulcers, worsening pressure ulcers, increased pain, and a diminished quality of life.Findings included .Resident 6Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, as assessment tool) dated 01/07/2026, documented Resident 6 was severely cognitively impaired, had communication deficits, was at risk for developing pressure ulcers and had two Stage 2 pressure ulcers. The skin integrity care plan, initiated on 07/10/2025, documented Resident 6 had an air overlay mattress (a medical device designed to prevent and treat pressure ulcers by redistributing pressure across the body. It typically consists of air-filled cells that inflate and deflate in a cyclical…
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 · D2026-03-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 interview and record review, the facility failed to reassess current nutritional interventions and implement new nutritional interventions for 1 of 1 sampled residents (Resident 6) reviewed to weight loss. This failure placed residents at risk for continued weight loss, malnutrition, medical complications and a diminished quality of life. Findings included .Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, as assessment tool) dated 01/07/2026, documented Resident 6 was severely cognitively impaired, had communication deficits, had a 5 % weight loss and was not on a prescribed weight loss regimen.Resident 6's diet order, dated 07/09/2025, was regular diet, regular texture, thin consistency, finger foods/sandwiches when available. The electronic health record (EHR) documented no change in diet type to include nutritionally enhanced meals (NEM), fortified foods or calorie dense meals.On 10/11/2025, Resident 6 weighed 108 pounds (lbs.) On 03/07/2026, Resident 6 weighed…
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 · E2025-04-11 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 that potential restraints were appropriately assessed for safety, care planned, and/or documented on for 3 of 3 residents (Residents 14, 16, & 29) reviewed for physical restraints. This failure placed residents at risk for unidentified risks and care needs, of the potential for restraint, and for a diminished quality of life. Findings included . 1) Resident 14 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 14 was cognitively intact, was not in any therapies, had lower extremity impairment, and was dependent on staff for toileting/dressing. On 04/07/2025 at 10:42 AM, Resident 14 was observed with their bed against the wall. Review of the Electronic Health Record (EHR) showed Resident 14 had not had a physical restraint evaluation done for the bed against the wall. Review of Resident 14's care plans showed there was not a care plan for the bed against…
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 · E2025-04-11 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary 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 interview and record review, the facility failed to provide non-pharmacological interventions (health interventions/approaches used instead of medication), to implement and/or follow parameters for medications, and/or to reassess necessity of medication when vitals were abnormal for 3 of 6 sampled residents (Residents 19, 23 & 16) when reviewed for unnecessary medications and/or pain management. This failure placed the residents at risk for receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . 1) Resident 19 was admitted to the facility on [DATE]. The Annual Minimum Dated Set (MDS, an assessment tool) , dated 02/07/2025, documented Resident 19 was cognitively intact. Resident 19 received an opioid medication for pain. A physician's order, dated 02/02/2023, documented Resident 19 was to be given the opioid medication when the pain level was above 3. Non-pharmacological interventions were to be offered and completed prior 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.
- Potential for harm · Dcited before2025-04-11 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to obtain an updated preadmission screening and resident review (PASRR, a mental health screening tool) when a diagnosis of significant mental illness was identified for 2 of 5 residents (Resident 4 & 1) reviewed for PASRR. This failure placed the residents at risk for unmet care needs and a decreased quality of life. Findings included . 1) Resident 4 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, depression, and bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/21/2025, showed Resident 4 was confused with poor memory recall. Review of Resident 4's Level 1 PASRR, dated 03/07/2025, showed Serious Mental Illness indicators of mood disorders and anxiety disorders had been selected. During an interview on 04/10/2025 at 1:19 PM, when reviewing guidance from the PASRR dear provider…
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 before2025-04-11 · 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 the comprehensive care plan included resident specific interventions for 5 of 12 sampled residents (Residents 42, 14, 16, 26 & 29) reviewed for care plans. This failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individual needs. Findings included . 1) Resident 42 was admitted to the facility on [DATE]. According to the Modification of Admission/Medicare 5-day Minimum Data Set (MDS, and assessment tool), dated 03/08/2025, Resident 42 required supervision or touching assistance for oral hygiene. Resident 42's diagnoses included Malignant Neoplasm of Rectum (cancer of the rectum). Review of Resident 42's physician orders showed three medications prescribed to treat chronic diarrhea. Review of Resident 42's care plan showed Resident 42 had occasional bowel incontinence…
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 11 citations
- Potential for harm · D2025-04-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure services provided met professional standards of practice related to performing daily weights and accurate documentation of side effects for 1 of 5 residents (Resident 23) reviewed for unnecessary medications, failed to follow hospice (end of life care) recommendations for 1 of 1 resident (Resident 28) reviewed for hospice, and failed to monitor after a change in status for 1 of 2 residents (Resident 29) reviewed for hospitalization. These failures placed residents at risk for unmet care needs,the provider not being aware of resident conditions, and potential negative outcomes. Findings included . <Daily weights> Resident 23 admitted to the facility on [DATE]. The admission Medicare 5-day Minimum Data Set (MDS, and assessment tool), dated 04/01/2025, documented Resident 23 was cognitively intact. Resident 23 had diagnoses that included Unspecified Systolic (Congestive) Heart Failure (CHF, a condition where the heart can't pump blood…
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 before2025-04-11 · 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 dependent residents were provided with oral care for 2 of 3 residents (Resident 42 & 14) reviewed for dental care related to activities of daily living. This failure placed residents at risk for poor oral hygiene, worsening dental condition, and a diminished quality of life. Findings included . A facility provided policy titled, Activities of Daily Living (ADLs), reviewed 09/10/2024, documented, the resident would receive assistance as needed to complete ADLs. 1) Resident 42 was admitted to the facility on [DATE]. The Modification of Admission/Medicare 5-day Minimum Data Set (MDS, and assessment tool), dated 03/08/2025, documented Resident 42 required supervision or touching assistance for oral hygiene, and required partial/moderate assistance to transfer from chair/bed-to-chair. On 04/07/2025 at 2:21 PM, Resident 42 said one great deficiency the facility had was dental hygiene. Resident 42 said they had not brushed their teeth in…
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 · D2025-04-11 · 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 proper storage and labeling of medications in 1 of 2 medication carts (B Hall medication cart) and 1 of 1 medication rooms when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, and a diminished quality of life. Findings included . Observation of the medication cart on B hall on 04/09/2025 at 11:05 AM, with Staff O, Registered Nurse (RN), showed an open insulin pen with no date on it. During an interview on 04/09/2025 at 11:05 AM, Staff O, RN, said they had just opened the insulin pen that morning and forgot to date it. During an interview on 04/10/2025 at 8:35 AM, Staff F, Resident Care Manager (RCM), said all insulin should be dated as soon as it is opened. Observation of the medication room on 04/10/2025 at 8:33 AM, with Staff F, RCM, showed the temperature log for March 2025 was missing 11 of 62 opportunities. Review of the refrigerator showed storage of medication and emergency medication supply. 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.
- Potential for harm · Dcited before2025-04-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure dishwasher temperatures were maintained within required ranges for 1 of 1 dishwasher and failed to ensure appropriate personal protective equipment (PPE) was worn for 1 of 4 (Staff I) kitchen staff observed. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . A facility provided policy titled, Associate Conduct and Dress Code, with a revised date of 04/30/2024, documented dietary staff must wear hair restraints (e.g. hairnet, hat, and/or beard restraint) to prevent hair from contacting food. <Failure to wear PPE> On 04/07/2025 at 10:36 AM and at 12:09 PM, Staff I, Dietary Manager, was observed in the kitchen without a hair restraint on. On 04/09/2025 at 8:57 AM, Staff I was observed in the kitchen without a hair restraint on. At 1:23 PM, Staff I said the expectation was for dietary staff to have their hair covered in the kitchen. When asked about the observations without a hair restraint in the kitchen, Staff I 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.
- Potential for harm · Dcited before2025-04-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews and record review, the facility failed to properly store oxygen equipment for 1 of 1 sampled resident (Resident 39) reviewed for oxygen, and to ensure staff performed hand hygiene for 1 of 1 dining room reviewed for dining services. The facility also failed to use personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents on enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs)) for 1 of 3 sampled residents (Resident 26), and 1 of 3 kitchen staff members (Staff I) reviewed for infection control. Additionally, the facility failed to handle, store, and transport linens appropriately for laundry services reviewed for infection control. These failures placed residents at risk for facility acquired infections, spread of organisms and MDROs, contamination, related health complications, and a decreased quality…
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 · D2024-08-12 · tag F0729 — isolatedVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure nursing assistants were screened through the nurse aide registry prior to providing care to residents for 1 of 2 staff (Staff B) reviewed for staff qualifications. This failure placed residents at risk for abuse and unmet care needs. Findings included . Staff B was hired on 07/30/2024 as a Certified Nursing Assistant. Review of Staff B's employee record did not include documentation from the nurse aide registry. On 08/12/2024 at 2:00 PM, Staff A, Administrator, said Staff B was currently working as a nursing assistant providing resident care at the facility. Staff A said the facility had not received verification from the nurse aide registry for Staff B. Staff A said they had sent another email to the registry requesting verification. Reference WAC 388-97-1660(3)(c) .
- Potential for harm · Ecited before2024-02-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview the facility failed to ensure appropriate personal protective equipment (PPE) was doffed (taken off) for 1 of 4 sampled rooms (room [ROOM NUMBER]) observed for Transmission Based Precautions. The facility also failed to ensure proper signage was placed in front of the entry doors to residents' rooms (room [ROOM NUMBER]A, 127B, 112, 103 & 101) for 2 of the 4 days. These failures placed residents at risk for facility acquired or healthcare associated infections and related complications and a diminished quality of life. Findings included . <[NAME] PPE Usage> On 02/20/2024 at 12:15 PM, Staff E, Certified Nursing Assistant (CNA), was observed exiting room [ROOM NUMBER], after doffing gown and gloves. Staff E stepped into the hallway, placed her eye protection on top of her head. Staff E did not clean the eye protection and did not change her mask. Staff E completed hand hygiene with alcohol-based sanitizer and then proceeded to pass out lunch meal trays to other resident rooms.…
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 before2024-02-23 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II evaluation treatment recommendations were incorporated into a resident's plan of care for 1 of 3 residents (Resident 16) who were reviewed for Level II PASRRs. This failure placed residents at risk for unmet mental health and psychosocial needs. Findings included . Resident 16 admitted to the facility on [DATE]. Review of the 09/04/2023 significant change Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of anxiety and depressive disorders, received antipsychotic medication (class of medications used to manage delusions, hallucinations, paranoia or disordered thought), and was determined to have a serious mental illness (SMI) through the Level II PASRR evaluation process. Review of a Level II PASRR Initial Psychiatric Evaluation Summary, dated 05/02/2022, showed the resident had SMIs of major depressive disorder with psychotic…
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 · D2024-02-23 · tag F0791 — failed to provide routine dental services — isolatedProvide 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 interview and record review, the facility failed to ensure dental services were provided for 1 of 2 Medicaid residents (Residents 17) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to use ill-fitting dentures and/or go without dentures. These failures placed residents at risk for difficulty chewing, oral pain, decreased self-image, and diminished quality of life. Findings included . Resident 17 admitted to the facility on [DATE]. Review of the 04/17/2023 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact and had no natural teeth. A dental care plan, initiated 04/25/2023, showed Resident 17 was endentulous (no natural teeth) and had a Denturist referral pending. The care included direction to staff tocoordinate arrangements for dental care, appointments and transportation as needed/as ordered. Review of a dental consult, dated 04/24/2023, showed…
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 before2024-02-23 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interviews, and record review, the facility failed to maintain and document refrigerator temperatures for 1 of 3 facility refrigerators (snack refrigerator) reviewed for food service. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . On 02/22/2024 at 12:30 PM, review of the facility's refrigerator temperature logs, documented the snack refrigerator located behind the nurses' station had multiple missing entries for the month of February 2024, including: 02/04/2024, 02/05/2024, 02/06/2024, 02/11/2024, 02/12/2024, 02/13/2024, 02/18/2024, 02/19/2024, 02/20/2024 & 02/22/2024. On 02/22/2024 at 12:38 PM, Staff D, Food Services Director, said kitchen staff were responsible for maintaining the refrigerator temperature logs. When shown the missing temperature log dates, Staff D, said the missing dates were unacceptable. At 2:38 PM, Staff B, Director of Nursing Services, said the missing refrigerator temperature logs were not acceptable. Reference WAC 388-97-2980 (1) .
- Potential for harm · Dcited before2023-10-04 · 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 interview and record review, the facility failed to ensure residents' comprehensive plans of care were developed, implemented, and/or accurately reflected residents' care needs for 1 of 3 residents (Resident 1) reviewed for care planning. This failure to accurately update the comprehensive care plan and review for discrepancies placed the resident at risk for inconsistent or inadequate care, injury, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 07/26/2023, documented Resident 1 had severe cognitive impairment and required two-person extensive assistance with transfers and toileting. Resident 1's fall risk care plan, initiated on 02/21/2021, documented Resident 1 required assist of one to two…
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
$34,808 in federal fines across 1 penalty.
- $34,808 — penalty dated 2023-10-04
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 LIFE CARE CENTERS OF AMERICA — 194 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 | 5 of 5 | 3.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
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 | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST | since 03/19/1996 |
| PRESTON, FORREST | Individual | DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | since 03/19/1996 |
| BUTNER, NANCY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2018 |
| CERNA, ANGELA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/18/2019 |
| WINTERS, KARLA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 02/04/2025 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 06/01/1996 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| LAY, LISA | Individual | CORPORATE OFFICER | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE OFFICER | since 04/01/2011 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2025 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/19/2004 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| SEKERAMAYI, FLOYD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/11/2025 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
CMS files one row per role, so the 28 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 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 $669K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 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 505306. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.