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Redmond Care And Rehabilitation Center

7900 Willows Road Northeast, Redmond, WA 98052 · For profit - Corporation · 139 certified beds · (425) 885-0808 Medicare & Medicaid certified

Call the home — (425) 885-0808 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 2024
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
15809 Bear Creek Pkwy #100 · (425) 882-6100 · Call to confirm hours
Pharmacy
14729 NE 87th St · (425) 869-2306 · Call to confirm hours
Grocery
QFC0.5 mi
15800 Redmond Way · (425) 885-2311 · Call to confirm hours
Park
8125 160th Ave NE · (425) 881-8442 · Typically dawn to dusk
Place of worship
8671 154th Ave NE · (425) 881-0415

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 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
Long-stay residents whose need for help with daily activities increased17.5%14.2%15.4%worse
Long-stay residents who lose too much weight2.4%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.5%1.0%0.9%better
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms5.6%17.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%2.6%3.3%better
Long-stay residents whose ability to walk worsened20.7%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication9.6%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.8%95.3%typical
Long-stay residents with pressure ulcers0.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control28.5%22.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.0%15.1%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine90.5%82.0%79.4%better
Short-stay residents rehospitalized after admission18.7%19.9%22.6%better
Short-stay residents with an outpatient ER visit11.0%13.4%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.311.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.841.521.80better

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

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

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

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

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

68.9% 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 351 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.9%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
63.7%U.S. median 56.6%
Met the expected recovery
0.70U.S. median 0.31
Therapy hours / resident / day
0.40hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 63.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 179 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 0.70 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF68.9%CMS range 62.6–72.851.5%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 7.4–12.710.7%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 discharge63.7%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 discharge62.0%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 discharge61.5%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 identified100.0%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 setting94.0%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 discharge100.0%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 worsened1.9%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 hospitalization6.6%CMS range 4.6–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 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

0.98
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.67
RN hoursweekends
26.2%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 139 beds and averages 83.1 residents a day — about 60% occupied, or roughly 56 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.37 hrs/resident/day on weekends vs 3.78 on weekdays — 11% thinner on weekends. RN hours go from 1.10 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-06-13)
8
at the previous standard inspection (2024-06-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2026-02-13 · 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 physician orders for pain management and/or post-surgery staple removal were carried out for 2 of 4 Residents (Residents 1 & 2), reviewed for quality of care. These failures placed the residents at risk for discomfort and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication and Treatment Orders, revised in April 2014, showed Orders for medications and treatments will be consistent with principles of safe and effective order writing [giving instructions for patient [resident] care in a way that is clear, complete, and impossible to misunderstand].RESIDENT 1Review of Resident 1's face sheet showed she was admitted to the facility on [DATE] with diagnoses that included orthopedic (related to the bones, joints, and muscles) aftercare and left knee osteoarthritis (a type of arthritis - inflammation or damage in the joints).Review of Resident 1's hospital document titled, After Visit Summary, 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 · Ecited before2025-06-13 · 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 food items were handled appropriately in accordance with professional standards of food safety for 32 of 75 residents (Residents 11, 3, 34, 128, 4, 178, 66, 28, 30, 33, 55, 182, 17, 51, 59, 36, 63, 74, 230, 183, 231, 44, 49, 7, 72, 52, 1, 13, 26, 53, 68 & 61), reviewed for food services. This failure placed the residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Procurement, Storage, and Distribution, revised on 07/08/2022, showed that the facility would store, prepare, distribute, and serve food in accordance with professional standards for food safety. The policy further showed that the facility would follow proper sanitation or food handling practices to prevent the outbreak of foodborne illness. Observation on 06/11/2025 from 11:32 AM to 12:34 PM, showed Staff G, Cook, with gloves on touched the meal cart, meal tickets, and the preparation table area.…

    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 · D2025-06-13 · 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

    Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained for 1 of 3 residents (Resident 14 ), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives and Associated Documentation, revised in April 2025, showed that Prior to, upon, or immediately after admission, a facility staff member shall .inquire whether they [residents] have completed an Advance Directive and if they had they should Obtain [a] copy of the Advance Directive .documents and place in the resident health record. Review of the facility's document titled, Advance…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · 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 DISCHARGE STATUS RESIDENT 76 Review of the nursing progress notes printed on 06/09/2025 showed Resident 76 discharged home on [DATE]. Review of the discharge MDS dated [DATE] showed Resident 76 was admitted to the facility on [DATE] and was discharged on 03/15/2025. Further review of the MDS showed Resident 76 was marked they were discharged to the hospital in Section A2105 (Discharge Status). Section A2105 should have been marked discharge to Home/Community. In an interview and joint record review on 06/11/2025 at 11:09 AM, Staff D stated that they follow the RAI manual for completion of MDS assessments. A joint record review showed Resident 76's MDS dated [DATE] was marked discharged to the hospital. Staff D stated the MDS was marked discharged to the hospital and [Resident 76] did not go there. A joint record review of the progress notes dated 03/15/2025 showed Resident 76 discharged home. Staff D stated that Resident 76's discharge MDS was not accurate and that it should have been marked discharged 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · 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

    Based on observation, interview, and record review, the facility failed to implement a care plan for 1 of 5 residents (Resident 3), reviewed for comprehensive care plans. The failure to implement the care plan for communication placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised in April 2025, showed that the facility will develop and implement a comprehensive person-centered .care plan for each resident that will include resident's needs, goals and desired outcomes. Review of a hearing clinic visit note dated 04/24/2024, showed that hearing instruments [hearing aids] were recommended for Resident 3. An additional visit note dated 05/24/2024, showed that Resident 3's representative reported that when the device is in her ear, she is able to hear him better. Review of the communication care plan printed on 06/08/2025, showed an intervention for left sided hearing [aid] kept in charger at bedside. Needs staff to place and remove. An…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide services to maintain hearing methods to carry out the Activities of Daily Living (ADL) for 1 of 1 resident (Resident 3), reviewed for communication. This failure placed the resident at risk of not being able to hear and/or communicate and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised on 04/03/2025, showed, A resident's abilities in ADL's do not diminish unless circumstances on the individual's clinical condition demonstrate that diminution [decline] was unavoidable. This includes the resident's ability to .use speech, language, or other functional communication systems. Review of Resident 3's quarterly Minimum Data Set (an assessment tool) showed that Resident 3 had minimal difficulty with hearing (difficulty in some environments, for example when a person speaks softly or the setting is noisy). Review of a hearing clinic visit note dated 04/24/2024, showed that hearing instruments [hearing aids] were recommended for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · 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 RESIDENT 14 An observation on [DATE] at 11:27 AM showed an opened bottle of biotin (a vitamin supplement) on Resident 14's nightstand. Resident 14 stated I try to take it [biotin] every day. Additional observations on [DATE] at 9:28 AM, on [DATE] at 9:17 AM, and at 1:12 PM, showed an opened bottle of biotin on Resident 14's nightstand. An interview and joint observation on [DATE] at 12:12 PM, Staff I, RN, stated that supplements were considered medications and that medications should be stored in a locked medication room or medication cart. When asked if medications could be stored at a resident's bedside, Staff I stated, No, [it] has to be in the cart. A joint observation showed an opened bottle of biotin on Resident 14's nightstand. Staff I stated that they were unsure if the opened bottle of biotin should be there. In an interview on [DATE] at 12:17 PM, Staff F, stated that medications should be stored in locked medication carts. Staff F further stated that if a resident was able to self-administer…

    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 before2025-06-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hand hygiene/glove use practices were followed for 1 of 4 staff (Staff J), reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Infection Prevention and Control Program, revised in April 2025, showed that facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection and the facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste. An observation on 06/08/2025 at 9:20 AM, showed Staff J, Certified Nursing Assistant, took soiled material in a plastic bag from room [ROOM NUMBER] to the soiled utility room. It further showed Staff J wearing gloves on both hands while they carried the plastic bag in the hallway and touched the soiled utility room door handle with their…

    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 · Dcited before2025-03-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observation, interview, and record review, the facility failed to ensure showers or bathing were consistently provided for 1 of 4 residents (Resident 1), reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised in July 2015, showed that nursing assistants would provide assistance with ADLs based on the resident's individualized plan of care. Review of the admission Minimum Data Set (an assessment tool) dated 02/05/2025 showed Resident 1 required partial/moderate assistance with showers. Review of the shower schedule updated on 02/24/2025 showed Resident 1 was scheduled for showers on Thursday evenings. Review of the February 2025 bathing task showed that Resident 1 did not get showers on 02/27/2025 and 03/06/2025. The last time the resident had a shower was on 02/17/2025 and again on 03/18/2025 [before lunch], almost a month of not having a shower. On 03/18/2025 at 10:09 AM,…

    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 before2024-06-12 · 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 foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional standards for food safety for 1 of 3 freezers (Kitchen Walk-In Freezer) and 2 of 2 refrigerators (Kitchen Walk-In Refrigerator and Residents' Refrigerator), reviewed for food services. This failure placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Safety, dated 2018, showed, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded, the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared, the discard day or date may not exceed the manufacturer's use-by-date. KITCHEN WALK IN FREEZER Joint observation and interview on 06/03/2024 at 8:44 AM with Staff H, Nutrition Service Manager, showed 10 bags of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2024-06-12 · tag F0850 — failed to provide social-work services — pattern
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 2 of 2 social workers (Staff J & P), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life. Findings included . Review of the facility's document titled, Job Description Social Services Manager, dated November 2021, showed under section Education and/or Experience, an employee, Must have, as a minimum, a bachelor's [a type of undergraduate degree] degree in social work or a bachelor's degree in a human services field including but not limited to sociology [study of social life and change], special education, rehabilitation counseling [focused on helping people with disabilities], and psychology [study of mind and behavior]. The document further showed the employee, Must have, as a minimum, 1 [one] year of experience as a Social Worker, preferably in a hospital, long-term…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · 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 ensure allegation of abuse was reported to the State Agency for 1 of 3 residents (Resident 237), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse Prevention & [and] Investigation, revised in July 2015, showed, It is the policy of the facility that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to State and Federal regulations. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), showed injuries of unknown source means any injury sustained by a resident where the source of the injury was not observed directly by staff, or the resident is not able to report/inform how the injury occurred. It further showed, Substantial injuries of unknown…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · 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 implement care plans for 2 of 18 residents (Residents 5 & 42), reviewed for comprehensive care plans. The failure to implement care plans for restorative care (to maintain a person's highest level of physical, mental, and psychosocial function to prevent decline that impact quality of life) and communication/sensory placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Restorative Care, revised in May 2016, showed, Restorative Care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. RESIDENT 5 Resident 5 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 04/11/2024, showed Resident 5 had Range of Motion (ROM - the amount of movement a joint or body part can make in a specific direction) impairment on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 follow up on hearing services for 1 of 2 residents (Resident 42), reviewed for communication and sensory. This failure placed the resident at risk for ineffective communication, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Rights, revised in 11/23/2016, showed residents have rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center. Review of the facility's policy titled, Hearing Impaired Resident, revised in February 2018, showed staff will assist the resident or representative with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. Resident 42 admitted to the facility on [DATE]. Review of Resident 42's communication care plan initiated on 05/17/2023, showed that Resident 42 was at risk for a communication problem r/t [related to]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for 1 of 3 residents (Resident 76), reviewed for accident hazards. The failure to monitor and assess a sliding door as an exit, and to ensure a fence/gate that led to a parking lot and street was secured/locked, placed the resident at risk for elopement [form of unsupervised wandering that leads to a resident leaving the facility], injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, Elopement/Unsafe Wandering, revised in January 2022, showed, This facility is committed to promoting resident autonomy [ability to make own decisions] by providing an environment that remains as free of accident hazards as possible. The policy further showed the facility would provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Resident 76 admitted to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · 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 maintain, label/date, and properly store oxygen nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 1 of 1 resident (Resident 47), reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications. Findings included . Resident 47 admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (a condition that blocks airflow and makes it difficult to breathe). Review of Resident 47's physician orders showed the following: - Apply oxygen via nasal cannula three liters [a unit of measurement] per minute continuous to keep saturation (amount of oxygen in the blood) above 90 percent every shift dated 5/15/2024. - Change oxygen tubing and humidifier every Sunday on night shift dated 5/19/2024. Observation on 06/03/2024 at 11:14 AM, showed a portable oxygen tank on the back of Resident 47's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed before and after resident care and during meal tray pass for 1 of 13 staff (Staff I) reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Hand Hygiene, revised on 02/21/2022, showed, Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations, before and after direct contact with residents and after contact with objects in the immediate vicinity of the resident. Observation on 06/03/2024 at 12:15 PM, showed Staff I, Certified Nursing Assistant, brought a meal tray into Resident 1's room, touched the fork and knife, and assisted in cutting Resident 1's food. Staff I then left Resident 1's room without performing hand hygiene and went to the kitchen, touched the kitchen door, and left the kitchen with a new fork. Staff I entered Resident 1's room and handed the new fork 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 · Ecited before2023-05-21 · 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 foods stored were properly covered, labeled/dated, discarded after the expiration date, or use by date and ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the following facility provided policies titled: 1. Food Safety, dated 2018, showed, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded, the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared, the discard day or date may not exceed the manufacturer's use-by-date. 2. Safe Food Handling Practices - King County updated in November 2022, showed, to Develop good serving procedures to protect food and customers, avoid touching the food contact…

    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 · D2023-05-21 · tag F0625 — isolated
    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 ensure bed-hold notices were provided at the time of transfer to the hospital for 3 of 4 residents (Residents 29, 124 and 26) reviewed for hospitalizations. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Admission/Discharge/Transfer - Bed Hold, revised in November 2016, showed that a copy of bed hold notification shall be provided to the resident and/or their representative in a language they can understand at the time of admission, transfer to the general acute hospital and start of the resident's therapeutic leave. RESIDENT 29 Resident 29 admitted to the facility on [DATE]. Review of Resident 29's progress notes in the resident's Electronic Health Record (EHR) showed that Resident 29 was sent to the hospital on [DATE]. No bed-hold notice was in Resident 29's EHR. RESIDENT 124 Resident 124 admitted to the facility…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 1 of 4 residents (Resident 71) reviewed for hospitalizations. The failure to ensure accurate assessment regarding discharge status resulted in inaccurate information in the resident's clinical record and placed the resident at risk for unidentified care needs. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, showed: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). Resident 71 admitted to the facility on [DATE]. Review of Resident 71's clinical records showed a nursing note that stated Resident 71 discharged to home on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-21 · 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 a care plan for 2 of 17 residents (Residents 51 and 36) reviewed for refusal of care/services, and 1 of 5 residents (Resident 26) reviewed for unnecessary medication. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised in August 2017, showed that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to the resident's health and safety, the comprehensive care plan will identify care or service decline, the associated risks,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-21 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet professional standards of practice to ensure physician orders were complete regarding the use of Lidocaine patch (a substance used to relieve pain by blocking signals at the nerve endings in skin) for 1 of 4 residents (Resident 13) reviewed for medication administration. The facility also failed to follow and clarify physician orders for 1 of 5 residents (Resident 69) reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, potential negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, Policy/Procedure-Medication Administration, revised in March 2022, showed that Medications will be accurately prepared, administered, and documented per physician order. Additionally, it showed that medications will be administered based on the Ten Rights including, Right dose and Right route. RESIDENT 13 Resident 13 admitted to the facility on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 bathing/shower and personal hygiene were consistently provided per their plan of care for 1 of 1 resident (Resident 124) reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living (ADL's), revised in July 2015, showed, Nursing assistants will provide assistance with ADLs based on the resident's individualized plan of care .ADL support and resident performance will be documented electronically using Point of Care [POC - the facility's computer software/system] .If a resident chooses to decline an intervention in the plan of care, the licensed nurse and social services will be notified. The IDT [Interdisciplinary Team] will review the plan of care with the resident in an effort to find alternative means to address the need. Resident 124 admitted to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-21 · 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 interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the digestive system) was administered in accordance with physician's orders to accurately record the amount of enteral formula administered for 2 of 2 residents (Residents 68 and 69) reviewed for enteral nutrition. This failure placed the residents at risk for inadequate nutrition, hydration, and potential adverse consequences. Findings included . RESIDENT 68 Resident 68 admitted to the facility on [DATE] with a diagnosis that included cerebral infarction (a medical condition in which poor blood flow to the brain causes cell death). Review of Resident 68's Medication Administration Record (MAR) for May 2023 showed the following: -Enteral feed order every shift: Jevity 1.2 (Formula brand) at 65 milliliters (ml) x 20 hour continuously via J-Tube (feeding tube). Total 1300 ml/1560 kilocalories (kcal) daily. Turn on at 1:00 PM and turn off at 9:00 AM. Document how…

    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 before2023-05-21 · 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 ensure proper care of a suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) including the suction tubing and suction canister for 1 of 1 crash cart (a medical device containing necessary equipment and supplies for use during emergencies). Additionally, the facility failed to store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) tubing and mask when not in use for 1 of 1 resident (Resident 13) and failed to ensure oxygen therapy was given according to physician's order for 1 of 1 resident (Resident 11) reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . SUCTION MACHINE During a joint observation and interview with Staff E, Infection Preventionist, on 05/18/2023…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-21 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    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 2 of 2 garbage dumpsters and 1 of 1 recycling dumpster were covered with a lid reviewed for outdoor garbage storage area. This failure placed the facility at risk of attracting bugs, rodents, and other germ carrying organisms (living things such as an animal or bacteria). Findings included . Review of the facility's policy titled, Garbage Waste Containers, revised in May 2012, showed that garbage containers shall be located throughout the facility and treatment areas and must be kept covered at all times. A joint observation and interview with Staff I, Nutrition Service Manager on 05/19/2023 at 10:29 AM, showed that the lids on the two garbage dumpsters were opened, and one recycling dumpster lid was opened and overflowed with cardboard boxes. Staff I stated that the dumpster or garbage bins should be closed and that someone threw out garbage and forgot to close it. Staff I acknowledged that the recycling dumpster was also overflowed and should have been closed. On 05/20/2023 at 1:49 PM, Staff A,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 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 53.2+1.8 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; 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
HOLMES, NATHANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
TALEGHANI, MASOUDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
FARNSWORTH, STEPHENIndividualCORPORATE DIRECTORsince 01/01/2025
BURNAM, SOONIndividualCORPORATE OFFICERsince 02/19/2013
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
SATO, AMIIndividualCORPORATE OFFICERsince 09/09/2024
PORT, BARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
CARETRUST GP LLCOrganizationADP OF THE SNFsince 12/01/2013
CARETRUST REIT INCOrganizationADP OF THE SNFsince 12/01/2013
CTR PARTNERSHIP LPOrganizationADP OF THE SNFsince 12/01/2013
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 04/01/2013
WILLOWS HEALTH HOLDINGS LLCOrganizationADP OF THE SNFsince 12/01/2013

CMS files one row per role, so the 17 rows in the source record cover these 12 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.

5 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.

$13.7M
Net patient revenuemost recent cost report
+14.8%
Operating marginrevenue minus expenses
$1.1M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 29%Other / private 19%

This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$425per resident / day
operating cost
$12,912per month
≈ monthly operating cost
$499per 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

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505181. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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.

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