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Life Care Center Of South Hill

2508 7th St Southeast, Puyallup, WA 98374 · For profit - Corporation · 100 certified beds · (253) 661-5948 Medicare only — no Medicaid

Call the home — (253) 661-5948 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$17,388 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,388 in federal fines (most recent 2025-11-13)
  • about 18% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
102 23rd Ave SE · (253) 200-0300 · Call to confirm hours
Pharmacy
310 31st Ave SE · (253) 770-9889 · Call to confirm hours
Grocery
2910 S Meridian · (253) 445-6800 · Call to confirm hours
Park
7th St SE · Typically dawn to dusk
Place of worship
1818 S Meridian · (253) 203-4264

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
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 4 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.8%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine82.9%82.0%79.4%typical
Short-stay residents rehospitalized after admission23.2%19.9%22.6%typical
Short-stay residents with an outpatient ER visit11.6%13.4%12.0%typical

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.

59.7% 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 1,554 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.7%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
87.3%U.S. median 56.6%
Met the expected recovery
1.54U.S. median 0.31
Therapy hours / resident / day
0.73hours / resident / day
Physical therapy
0.69hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 87.3% 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 644 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 1.54 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF59.7%CMS range 57.1–61.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 8.4–10.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge87.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge87.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge86.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization4.9%CMS range 3.5–5.97.1%Oct 2023–Sep 2024better than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.16
RN hours/ resident / day
1.30
LPN hours/ resident / day
2.34
Aide hours/ resident / day
4.80
Total nurse hours/ resident / day
0.82
RN hoursweekends
40.2%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 97.6 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 4.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 is below 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 3.94 hrs/resident/day on weekends vs 5.14 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.29 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-11-21)
14
at the previous standard inspection (2024-10-31)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2024-10-31 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide an ordered medication, significant to the health of the resident, for 1 of 6 sampled residents (Resident 27) reviewed for medication administration. Resident 27 experienced harm when they developed stroke like symptoms and was emergently transferred to the hospital for a change in condition. The facility has corrected the above deficiency prior to the standard survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of Lippincott Manual of Nursing Practice, Eighth Ed., 2006, showed an anticoagulant (blood thinning) medication can be used to disrupt the blood's natural clotting function, when there is a risk of blood clots forming. Such a risk is present with a diagnosis of atrial fibrillation (A-fib, an abnormal heart…

    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 · Past Non-Compliance
  • Potential for harm · D2025-11-21 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 initiate, investigate, and resolve a grievance for 1 of 2 sampled residents (Resident 142) when reviewed for grievances. This failure placed the residents at risk for lack of comfort and a diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 142 admitted to the facility on [DATE] with diagnoses that included congestive heart failure (condition that happens when your heart is unable to pump blood well enough to give your body a normal supply) and chronic kidney disease (condition where the kidneys are damaged and unable to filter blood). Resident 142 was able to make needs known. During an interview on 11/17/2025 at 3:05 PM, Resident 142 stated they did not have enough room in their bed to turnover comfortably. Resident 142 stated they had requested a larger bed upon admission however they did not get a response.Review of the EHR showed a progress noted dated 10/31/2025, the progress note 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · 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 observation, interview, and record review, the facility failed to implement safety interventions to ensure safety from potential further abuse for 1 of 3 sampled residents (Resident 143) when reviewed for abuse. This failure placed the resident at risk for physical harm, mental anguish, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 143 admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interfere with daily functioning), anxiety (feeling of worried thoughts) and depression (feeling of sadness and/or loss of interest). Resident 143 was able to make needs known. During an interview on 11/18/2025 at 9:42 AM, Resident 143 stated they would like to share a room with their spouse who was also a resident in the facility (Resident 306). Resident 143 stated their Power of Attorney (POA) had also spoken to the facility about the concern; however, Resident 143 did not know 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 before2025-11-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop care plans for 1 of 19 sampled residents (Resident 126) when reviewed for comprehensive care plans. Failure to care plan Resident 126's bowel functions and half a side rail equipment placed the Residents at risk of avoidable injuries, loss of functions and diminished quality of life. Findings included. Resident 126 was admitted to the facility on [DATE] with diagnoses to include malnutrition, diabetes (high blood sugar), anemia (low red blood cells) and depression. Review of the admission minimum data set (MDS) an assessment tool, dated 10/25/2025, showed Resident 126 was able to communicate needs. During an observation and interview on 11/18/2025 at 9:50 AM, Resident 126 stated they had a fall trying to go to the bathroom, and they use the half side rails in bed for mobility. Resident 126 was sitting next to their bed and was pointing towards the rails on the bed. Resident 126 stated they had diarrhea (multiple loose stools) all…

    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 before2025-11-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide ordered bowel medications for constipation per provider's orders for 2 of 5 sampled residents (Residents 136 and 124) when reviewed for quality of care. This failure placed the residents at risk for decreased comfort and a diminished quality of life. Findings included.Resident 136Review of the electronic health record (EHR) showed Resident 136 admitted to the facility on [DATE] with a diagnosis of recent spinal surgery. The resident was able to make needs known. Review of the bowel management documentation showed Resident 136 did not have a bowel movement (BM) from 11/07/2025 through 11/12/2025. Review of the medication administration record (MAR) for November 2025 showed no as needed bowel medications were offered to Resident 136. Resident 124Review of the EHR showed Resident 124 admitted to the facility on [DATE] with a diagnosis of dementia. The resident was unable to make needs known. Review of the bowel management documentation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · 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 implement residents' fluid restrictions for 1 of 2 sampled residents (Resident 132) when reviewed for nutrition. This failure placed residents at risk of fluid overload, discomfort, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 132 admitted to the facility on [DATE] with diagnoses to include end stage renal disease (the kidneys can no longer filter waste and excess fluid from the blood), muscle weakness, and diabetes (too much sugar in the blood). Resident 132 was able to make needs known. During an interview and observation on 11/17/2025 at 12:48 PM, Resident 132 stated they had a fluid restriction, was not sure how much, and facility staff did not monitor their fluid intake. Observation showed Resident 132 had a measured cup with 500 millimeters (ml) of fluid and an empty coffee mug on their overbed table. Review of provider's orders showed an order, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 121) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs and potential negative outcomes. Findings included . Review of the electronic health record (EHR) showed Resident 121 admitted to the facility on [DATE] with diagnoses that included congestive heart failure (condition that happens when your heart is unable to pump blood well enough to give your body a normal supply) and a fractured vertebra (broken bone in the spine). Resident 121 was able to make needs known. Review of Resident 121's care plan, dated 11/13/2025, showed no intervention for oxygen therapy. Observation on 11/17/2025 at 10:40 AM showed Resident 121 received O2 set to 6 liters (L) per minute via a nasal canula (device to deliver O2 through a tube into the nose). Review of a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure proper storage of medications in 1 of 6 halls (700 hall) when reviewed for medication storage. This failure placed residents at risk for medication errors, ineffective treatment, and diminished quality of life. Findings included .Observation on 11/17/2025 at 11:12 AM showed room [ROOM NUMBER] with a medicine cup on the bedside table with three pills. Resident 92 stated one of the pills was an antibiotic but did not know what the others were. During an interview on 11/17/2025 at 11:31 AM, Staff H, Registered Nurse, stated they would leave medications with the resident when they were refusing. During an interview on 11/17/2025 at 11:16 AM, Staff D, Resident Care Manager, stated the medications should not been left at bedside. During an interview on 11/21/2025 at 8:04 AM, Staff J, Licensed Practical Nurse, stated the process for medication administration was when a resident refused, the nurse was to dispose of the medication and reapproach later.…

    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 before2025-11-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed received care and treatment in accordance with professional standards of practice regarding placement of an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). This failure placed residents at risk of unmet care needs, pain, and medical complications Findings included . The facility policy for Indwelling Urinary Catheter (Foley) Management, revised 06/27/2023 and reviewed 09/04/2025, documented the facility would ensure that, for residents admitted with a urinary catheter, staff would adhere to professional standards of practice protocols and infection prevention and control procedures for insertion, ongoing care and catheter removal. The policy referenced [NAME] on Procedural Guidance on Routine care for indwelling urinary catheter (Foley) care and management. According to Lippincott Nursing Procedures (8th ed.) (2019). Wolters Kluwer, after insertion of a urinary…

    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 · Ecited before2024-10-31 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to include all required services in the plan of care for 3 of 20 sampled residents (Residents 40, 42, and 226) when reviewed for comprehensive care plan. This failure placed residents at risk of not receiving required services, staff being unaware of how to assist residents, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses of ankylosing spondylitis (a type of arthritis that affects the spine and other parts of the body) and pneumonia (a lung infection). Review of provider's orders showed Resident 40 had an order for a fluid restriction. Review of Resident 40's care plan, initiated 09/26/2024, showed no information related to a fluid restriction. During an interview on 10/30/2024 at 9:54 AM, Staff R, Licensed Practical Nurse/Resident Care Manager, stated residents on a fluid restriction should have a care focus area for it…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-31 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program as needed for 3 of 4 sampled residents (Residents 177, 176 and 40) reviewed for care and services. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Findings included . Review of a policy document titled, Bowel Protocol, dated 09/16/2024, showed the facility should provide effective interventions for signs and symptoms of constipation that were consistent with current standards of practice. The nursing staff was to record, in the electronic health record (EHR), each time a resident had a bowel movement (BM). In addition, the facility, in coordination with the resident's provider, would implement standing orders to address a lack of a BM. Resident 177 Review of Resident 177's entry minimum data set (MDS), an assessment tool, dated 09/22/2024, showed the resident readmitted on [DATE] with diagnoses to include…

    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 18 citations
  • Potential for harm · Ecited before2024-10-31 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    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 accurately monitor resident fluid intake and/or ensure dietary and supplement orders were obtained/transcribed according to standard of practice for 2 of 2 sampled residents (Residents 40 and 42) reviewed for nutrition. This failure placed residents at risk of fluid overload, swelling, discomfort, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses of chronic heart failure (CHF), ankylosing spondylitis (a type of arthritis that affects the spine and other parts of the body), and pneumonia (a lung infection). Review of provider's orders showed Resident 40 had an order for a 2000 milliliters (ml) fluid restriction related to CHF. Review of the order showed for nursing to provide 480 ml fluid during day, evening, and night and for dietary to provide 200 ml day and 180 ml evening and night. Review of Resident 40's October 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-31 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure 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 implement non-pharmacological interventions (NPI, methods to reduce pain without medication) prior to providing pain medications for 5 of 5 sampled residents (Residents 6, 24, 32, 41 and 226) reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary pain medications and a decreased quality of life. Findings included . Resident 6 Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with a diagnosis of fracture of the left forearm. Review of the EHR showed the resident had a provider order for oxycodone tablet (a narcotic pain medication) every four hours as needed for severe pain which was provided daily from 10/01/2024 through 10/28/2024. Included was a separate provider order to attempt NPI prior to administering the narcotic pain medication. Review of the medication administration record (MAR) from 10/01/2024 through 10/28/2024 showed all day shift…

    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 · E2024-10-31 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to timely initiate monitoring of adverse side effects and target behaviors for 3 of 6 sampled residents (Residents 24, 276 and 226) when reviewed for unnecessary psychotropic (affecting the mind) medications. These failures placed the residents at risk for unidentified mental health needs and a decreased quality of life. Findings included . Resident 24 Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with a diagnosis of depression. Review of the EHR showed a provider order dated 09/23/2024 for nortriptyline (an antidepressant medication) at bedtime for depression. Review of Resident 24's medication administration record (MAR) from 09/23/2024 through 10/28/2024, showed Resident 24 was provided nortriptyline per provider orders; however, the order to monitor targeted behaviors related to the use of an antidepressant was not initiated until 10/28/2024. Resident 276 Review of the EHR showed Resident 276…

    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 · E2024-10-31 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to implement an infection control program that included the application of enhanced barrier precautions (EBP) for 2 of 3 sampled residents (Residents 5 and 226) when reviewed for EBP. Also, the facility failed to track all infectious organisms for 2 of 3 months (August and September 2024) when reviewed for infection control. These failures placed residents at risk of communicable diseases, avoidable side effects, and a diminished quality of life. Findings included . <EBP> Review of the facility policy titled Enhanced Barrier Precautions, dated 06/03/2024, showed the facility should use EBP for residents who had chronic wounds, such as pressure wounds, or indwelling devices, such as urinary catheters. It further showed that EBP included posting a sign outside the resident's door instructing staff on the use of a gown and gloves for all high contact resident care activities. Resident 5 Review of Resident 5's electronic health record (EHR)…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-31 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 1 of 2 sampled residents (Resident 26) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility policy titled Antibiotic Stewardship, revised 05/16/2024, showed the facility would implement antibiotic time-out at 72 hours after antibiotic initiation or first dose in the facility. Each resident should be reassessed for consideration of antibiotic need by reviewing lab results, response to therapy and resident condition. It further showed the facility would design and use a system to identify residents with multidrug resistant organisms (MDRO, infections resistant to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · 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 provide information on formulating an advanced directive for 1 of 3 sampled residents (Resident 36) when reviewed for advanced directives. This failure placed residents at risk of not having an established decision maker, lacking input into care, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 36 admitted to the facility on [DATE]. Review of progress notes showed the social services department called Resident 36's representative on 09/19/2024 to schedule a care conference, which was held on 09/23/2024 (20 days after admitting to the facility). Review of the Social Service Assessment, dated 09/04/2024, showed the advanced directive area left blank. Review of the care plan, dated 09/03/2024, showed no information regarding Resident 36's advanced directive status. During an interview on 10/29/2024 at 1:46 PM, Staff P, Social Service Director, stated Resident 36 was provided information…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · 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 observation, interview, and record review, the facility failed to ensure the minimum data set assessment (MDS), an assessment tool, accurately reflected resident status for 1 of 20 sampled residents (Resident 226) reviewed for accuracy of assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 226 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems) and chronic (long lasting) respiratory failure with hypoxia (low levels of oxygen [O2] in the blood). Resident 226 was able to make needs known. Review of the admission MDS, dated [DATE], showed Resident 226 was not receiving O2 while a resident. Observation on 10/28/2024 at 9:40 AM showed Resident 226 laid in bed receiving O2 set to two liters per minute via nasal cannula (devise to deliver O2 through…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 2 sampled residents (Resident 72) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes. Findings included . Review of Resident 72's admission minimum data set (MDS), an assessment tool, dated 10/15/2024, showed the resident admitted on [DATE] with diagnoses to include stroke, kidney disease, aphasia (a language disorder that affects a person's ability to understand and express language), and muscle weakness. Resident 72's electronic health…

    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 before2024-10-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Residents 226) reviewed for respiratory care. Failure to transcribe/obtain and follow physician orders for oxygen (O2) therapy, care plan, ensure O2 tubing was regularly changed and maintained, placed the resident at risk for unmet needs and potential negative outcomes. Findings included . Resident 226 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems), and chronic (long lasting/ongoing) respiratory failure with hypoxia (low levels of O2 in the blood). Resident 226 was able to make needs known. Observation on 10/28/2024 at 9:40 AM showed Resident 226 laid in bed receiving O2 set to two liters (L) per minute via nasal canula (devise to deliver O2 through a tube into the nose) and the tubing was not dated.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · 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 implement their abuse prohibition policy for 2 of 6 residents (Residents 10 & 11) reviewed for abuse. The failure to properly identify a resident grievance as an alleged violation and report the alleged violation to the State Agency (SA) placed residents at risk for further exposure to potential abuse/neglect, unmet care needs, and diminished quality of life/quality of care. Findings included . <POLICY> Review of the facility's Abuse-Reporting and Response - No Crime Suspected policy, reviewed 06/17/2024, showed all alleged or suspected violations involving mistreatment, abuse, neglect, and injuries of unknown origin would be reported immediately but no later than two hours after the allegation was made, to the appropriate authorities, including the SA (in accordance with State Laws). The reporter of the violation did not have to explicitly characterize the situation as abuse, neglect, mistreatment, or exploitation in order to trigger the facility 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement their abuse prohibition policies and procedures for 2 of 6 residents (Residents 10 & 11) reviewed for abuse. The failure to conduct a thorough investigation of an alleged violation and maintain documentation to show an alleged violation was thoroughly investigated that included immediate interventions implemented to prevent further potential abuse/neglect during (and after) the investigation placed residents at risk for further exposure to potential abuse/neglect, unmet care needs, and diminished quality of life/quality of care. Findings included . <POLICY> Review of the Washington State Department of Social & Health Services Nursing Home Guidelines -The Purple Book, dated October 2015 (guidelines to assist nursing homes with compliance of the State and Federal requirements for the prevention, identification, reporting, and investigating incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, exploitation, and misappropriation of nursing home residents) showed the facility must begin…

    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 · D2024-09-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Resident 3) reviewed for medication administration. The failure to follow, obtain, and/or clarify physician orders, only sign for medications administered placed, and accurately document medication timing requests placed residents at risk for medication errors, delay in treatment, and adverse outcomes. Findings included . <Resident 3> Review of the admission Minimum Data Set (MDS-assessment tool) dated 05/08/2024, showed Resident 3 was admitted to the facility on [DATE], had no cognitive problems, and diagnoses included surgical aftercare following an orthopedic surgery and diabetes. Resident 3 received both scheduled and as needed pain medication. Resident 3 had frequent pain that reached an 8/10 during the five-day observation period. Review of the Pain Care Plan (CP), dated 05/03/2024, directed staff to administer pain medications as they were ordered.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement the personalized discharge plan for a smooth transition to the community for 1 of 3 residents (Resident 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . <POLICY> Review of the facility's Discharge Plan policy, reviewed 09/05/2024, showed the facility would develop and implement an effective discharge planning process for post-discharge care and reduction in factors that led to preventable readmissions. <Resident 2> Review of the admission Minimum Data Set (MDS-assessment tool), dated 04/05/2024, showed Resident 2 had no cognitive problems and diagnoses included a fracture of the pelvis. Resident 2 planned to discharge back to the community, had an active discharge plan, and no referrals were made to Local Contact Agencies (LCA). Review of the Discharge Care Plan, dated 04/02/2024, showed Resident 2's tentative plan was to move in with a family member. An intervention, dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure temperature control and labeling of food items to provide safe, sanitary food storage in 2 of 2 resident food refrigerators (Cascade and Olympic refrigerators) when reviewed for Kitchen. This failure placed residents at risk of consuming expired food items, foodborne illness, and a diminished quality of life. Findings included . Observation on 10/11/2023 at 12:57 PM showed the Cascade resident refrigerator without a temperature log. Observation of the freezer showed thermometer with a completely red line and the temperature could not be read. Observation of the refrigerator showed a thermometer which read 54 Fahrenheit (F). Observation on 10/11/2023 at 1:00 PM showed the Olympic resident refrigerator without a temperature log. Observation of the freezer showed no thermometer, two containers of ice cream without a label with resident name, and one ice cream sandwich unlabeled. Observation of the refrigerator showed a thermometer which read 49 F. During an interview on 10/11/2023 at 1:23 PM, Staff C,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide dialysis care and services to meet the needs of one resident (Resident 14) of one sampled resident reviewed for dialysis. The facility failed to provide consistent monitoring of the dialysis documentation of communication, to the dialysis unit, to inform them of pertinent clinical information. This failure placed the resident at risk for unmet care needs. Findings included . Review of a document titled, Hemodialysis Offsite Policy, dated 08/23/2023, showed, that the facility assured each resident received care and services for the provision of offsite hemodialysis consistent with professional standards of practice to include: ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at the certified dialysis facility; and ongoing communication and collaboration with dialysis facility regarding dialysis care and services. Review of the admission Minimum Data Set (MDS, a required…

    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 · C2024-10-31 · 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 ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 4 of 4 days of the survey period. This failed practice prevented residents, family members and visitors from knowing the facility's actual number of available nursing staff. Findings included . Observations on 10/28/2024 at 3:40 PM, 10/30/2024 at 8:49 AM, and 10/31/2024 at 8:31 AM showed nursing staff postings with no actual nursing staff hours posted (the actual hours worked were left blank on the form). Observation on 10/29/2024 at 8:49 AM showed the nursing staff posting was dated 10/28/2024 (previous day's date) and did not show actual nursing staff hours posted. During an interview on 10/31/2024 at 10:19 AM, Staff N, Staffing Coordinator, stated upon arriving to the facility they would remove the previous day's nursing staff posting form and put out the new nursing staff posting; however, on 10/29/2024 they had removed the posting to update the form and the previous date was left behind in its…

    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
  • No harm found · B2024-10-31 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 properly notify the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) of discharges for 2 of 4 sampled residents (Residents 177 and 42) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who could inform them of their options and rights, and to ensure that the SLTCO was aware of facility practices and activities related to transfers and discharges. Findings included . Resident 177 Review of Resident 177's entry minimum data set (MDS, a required assessment tool), dated 09/22/2024, showed the resident was readmitted on [DATE] after a transfer out to a local medical center with diagnoses to include heart and kidney disease, diabetes, depression and anxiety. The MDS further showed that Resident 177 was able to make needs known. During an interview on 10/28/2024 at 10:19 AM, Resident 177 stated they had been transferred…

    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
  • No harm found · B2024-10-31 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 notices at the time of transfer to the hospital for 4 of 4 sample residents (Residents 177, 27, 42, and 47) reviewed for hospitalization. This failure placed residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital. Resident 177 Review of Resident 177's entry minimum data set (MDS), an assessment tool, dated 09/22/2024, showed the resident readmitted on [DATE] with diagnoses to include heart and kidney disease, diabetes, depression and anxiety. The MDS showed Resident 177 was able to make needs known. During an interview on 10/28/2024 at 10:19 AM, Resident 177 stated they had been transferred to a local medical center for treatment of shingles (a viral infection that causes a painful rash) several weeks ago; however, no bed hold was provided to them at that time. Review of the Resident 177's electronic health records (EHR) showed the resident was transferred out to a local medical…

    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

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

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

Fines & penalties

$17,388 in federal fines across 1 penalty.

  • $17,388 — penalty dated 2025-11-13

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 →

RatingThis homeChain avg
Overall 5 of 53.4+1.6 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

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 / managerTypeRoleSince
DEVELOPERS INVESTMENT COMPANY INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 07/30/2014
PRESTON, FORRESTIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 06/10/2011
BUTNER, NANCYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 09/16/2018
MEDINA, ALEXANDERIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
SUWANEH, ALHAJIIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/18/2023
CROSS, CINDYIndividualCORPORATE OFFICERsince 12/15/2014
HENRY, TERRYIndividualCORPORATE OFFICERsince 08/16/1999
LAY, LISAIndividualCORPORATE OFFICERsince 02/09/2018
SWANKER, RICHARDIndividualCORPORATE OFFICERsince 04/01/2011
THURMOND, JOANIndividualCORPORATE OFFICERsince 07/30/2014
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
SCHMITZ, BRADLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024

CMS files one row per role, so the 23 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.

$20.3M
Net patient revenuemost recent cost report
+11.1%
Operating marginrevenue minus expenses
$3.3M
Related-party expense18% of expenses

This home reported $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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.

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

$600per resident / day
operating cost
$18,240per month
≈ monthly operating cost
$675per day
avg. revenue, all payers

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

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Washington Medicaid page for homes that do.

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 505526. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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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