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Richmond Beach Rehab

19235 - 15th Avenue Northwest, Shoreline, WA 98177 · For profit - Limited Liability company · 131 certified beds · (206) 546-2666 Medicare & Medicaid certified

Call the home — (206) 546-2666 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 20261 actual-harm citation$44,753 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% 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
  • it has 1 actual-harm citation
  • 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
  • the CMS record shows $44,753 in federal fines (most recent 2023-08-23)
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
655 NW Richmond Beach Rd · (206) 542-9688 · Call to confirm hours
Pharmacy
Rite Aid0.7 mi
655 NW Richmond Beach Rd · (206) 542-9688 · Call to confirm hours
Grocery
2002 NW 196th St · (206) 546-1944 · Call to confirm hours
Park
2201 NW 197th St · (206) 801-2600 · Typically dawn to dusk
Place of worship
1512 NW 195th St · (206) 542-7477

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 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.6%14.2%15.4%better
Long-stay residents who lose too much weight5.7%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.7%1.0%0.9%better
Long-stay residents with a urinary tract infection1.5%1.6%2.0%better
Long-stay residents with depressive symptoms59.6%17.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%2.6%3.3%better
Long-stay residents whose ability to walk worsened10.8%17.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.0%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine79.0%93.8%95.3%worse
Long-stay residents with pressure ulcers1.5%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control28.7%22.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.4%15.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.4%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine88.4%82.0%79.4%better
Short-stay residents rehospitalized after admission9.9%19.9%22.6%better
Short-stay residents with an outpatient ER visit8.6%13.4%12.0%better

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.

46.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 153 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.5%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
41.6%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 41.6% 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 89 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% 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 SNF46.5%CMS range 39.7–52.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.9–14.410.7%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 discharge41.6%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 discharge36.0%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 discharge52.8%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%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 worsened2.9%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 hospitalization6.8%CMS range 4.1–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 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

0.65
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.49
Aide hours/ resident / day
4.05
Total nurse hours/ resident / day
0.67
RN hoursweekends
31.0%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 131 beds and averages 98.6 residents a day — about 75% occupied, or roughly 32 beds typically open. It usually has some room. 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 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.57 hrs/resident/day on weekends vs 4.24 on weekdays — 16% thinner on weekends. RN hours go from 0.63 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 31% 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

13
deficiencies at the latest standard inspection (2026-02-25)
9
at the previous standard inspection (2024-11-29)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2023-08-23 · 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 ensure safe transportation was provided for 1 of 3 residents (Resident 45), reviewed for transportation to an appointment in the facility van. This failure caused harm when the wheelchair tipped over causing ongoing pain in Resident 45's left shoulder, arm, and hand. The failure to ensure the straps attached to the floor of the van were securely attached to the wheelchair before/after appointment transportation placed other residents at risk for injury and harm. Findings included . Review of Resident 45's quarterly Minimum Data Set assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident 45 was cognitively intact. Resident 45 was identified as requiring extensive assist of two person for bed mobility, transfers, and toileting, and required a wheelchair for mobility. Review of Resident 45's medical diagnoses included low back pain and chronic pain. The diagnosis of left shoulder…

    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 · D2026-04-21 · 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 report an allegation of sexual abuse for 1 of 5 residents (Resident 1), reviewed for abuse reporting. The failure to report an allegation of sexual abuse to the State Agency placed the residents at risk for repeated incidents and unidentified abuse.Findings included.Review of the facility's policy titled, [Facility] Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated September 2022, showed, It is the policy of this facility that all suspected, alleged, or actual cases of resident abuse.shall be thoroughly and completely investigated and reported according to Federal and/or State regulations. It showed that Sexual abuse means non-consensual sexual contact of any type with a resident. It further showed that Mandated reporters are to immediately report all alleged violations to the Administrator, state agency and all other required agencies.when they have reasonable suspicion of abuse.has occurred.Resident 1…

    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 · F2026-02-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 chlorine test strips (used to measure the concentration of free available chlorine in sanitizing solutions) were not expired in accordance with professional standards for 1 of 1 kitchen, reviewed for dinnerware sanitization and storage. This failure placed the residents at risk for unsanitary dining conditions and a diminished quality of life.Findings included .Review of the facility's policy titled Dishwashing Machine Use, revised in March 2010, showed, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation.During a joint observation and interview on 02/23/2026 at 8:33 AM, Staff R, Culinary Aide, checked the dishwasher temperature and the chemical sanitation Parts Per Million (ppm - unit of measure for concentration) range. Staff R used [Brand name] Chlorine Test Paper. Staff R stated that the test strip results should be between 50 ppm to 100 ppm. 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
  • Potential for harm · E2026-02-25 · tag F0585 — failed to handle grievances — pattern
    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

    Based on observation, interview and record review, the facility failed to develop a system that ensured the right to file grievances anonymously for 5 of 8 residents (Resident 26, 37, 10, 100 & 104), reviewed for grievances. This failure placed the residents at risk for unresolved concerns, unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Grievance Policy, revised in January 2017, showed, Grievance may be filed orally or in writing and with the right to file anonymously. Review of the facility's undated document titled, Resident Grievance/Complaint Procedures, did not show documentation of a system to file grievances anonymously. Review of the facility's undated form titled, Grievance Communication Form, did not show documentation of a system to file grievances anonymously. Observation and record review on 02/19/2026 at 10:24 AM, showed an undated document titled, Grievance/Complaint Procedures, in an enclosed glass bulletin board outside the administrator's office. Review of the undated document showed, [Grievance] Forms…

    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 · Ecited before2026-02-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 properly 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) mask when not in use, administer CPAP as ordered, and monitor oxygen (O2) saturation (the amount of oxygen in the blood) for 3 of 6 residents (Resident 52, 2 &104), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.Findings included . Review of the facility's policy titled, CPAP/BiPAP [Bilevel Positive Airway Support-used to assist breathing by delivering air through a mask that covers the nose, mouth, or both] Support, dated July 2025, showed the purpose of CPAP/BiPAP was to improve O2 levels present in the blood in residents with OSA [Obstructive Sleep Apnea - a sleep disorder that is marked by pauses in breathing of ten seconds or more during sleep and causes unrestful sleep] .…

    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 · E2026-02-25 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 document medication administration in accordance with professional standards for 4 of 6 residents (Residents 46, 90, 29 & 93), reviewed for medication administration. This failure placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication Administration, revised in April 2019, showed, the individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones.RESIDENT 46Review of Resident 46's February 2026 MAR showed they had orders for the following medications:- Cranberry (supplement), 1 (one) tablet- Senna (stool softener), 2 (two) tablets- Lactulose (stool softener) oral solution, 15 milliliters (a unit of measurement)- Excedrin (pain reliever), 2 tablets- Aripiprazole (mood stabilizer), 1 tablet- Lamotrigine (mood stabilizer), 1 tablet- Oxycodone (pain reliever), 1…

    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 · Ecited before2026-02-25 · 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 ensure infection control practices were followed by 4 of 12 staff (Staff W, K, O & P) and for 2 of 2 residents (Residents 29 & 44), reviewed for infection control. The failure to properly transport clean clothes, use Personal Protective Equipment (PPE-face shield/goggles, gowns) before entering a droplet precaution (measure taken to prevent spread of germs transmitted when a person coughs, sneezes, talks or breaths) room and during wound care, disinfect a glucometer (a device used to measure blood sugar level) and pen injector (device used to inject Liraglutide [medication that helps regulate blood sugar levels]), and ensure a urine-filled urinal was not placed next to a resident's meal tray, placed the residents, visitors, and staff at risk for infection and related complications.Findings included. Review of the facility's policy titled, Infection Prevention and Control Program, dated October 2025, showed, An infection prevention and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure an informed consent explaining the risks/benefits for psychotropic medication (alters mood, perception, and behavior) was completed prior to medication administration for 1 of 5 residents (Resident 12), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications prior to administration.Findings included .Review of the facility's policy titled, Psychotropic Medication Use, revised in July 2022, showed, Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The policy further showed, The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.Review of Resident 12's February 2025 Medication Administration Record (MAR) showed an as needed (PRN) order for lorazepam (an antianxiety) medication was administered.Review of Resident 12's January…

    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 · D2026-02-25 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed, and/or a physician order was obtained for safe administration of medication for 2 of 3 residents (Residents 92 & 64), reviewed for self-administration of medication. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication Administration, revised in April 2019, showed, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do safely.RESIDENT 92Review of Resident 92's Electronic Health Records (EHR) under evaluations tab from 01/24/2025 to 02/19/2026 showed no documentation to indicate that Resident 92 had a self-administration of medication evaluation.Review of a physician orders printed on 02/18/2026 showed no documentation 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 dignity was provided during dining observations for 2 of 10 residents (Residents 89 & 47), reviewed for dining. The failure to ensure licensed nurses refrained from administration of medications during resident meals placed the residents at risk for a diminished quality of life.Findings included.Review of the facility's policy titled, Dignity, revised in October 2025, showed, Residents are treated with dignity and respect at all times.RESIDENT 89Observation on 02/17/2026 at 12:54 PM, showed multiple residents were eating their meals in the dining room. Staff K, Licensed Practical Nurse, entered the dining room and mixed Resident 89's medication with yogurt. Resident 89 took their medication in the dining room.An additional observation on 02/19/2026 at 1:03 PM, showed multiple residents were eating their meals in the dining room. Staff K administered Resident 89 their medication in the dining room.RESIDENT 47Observation on 02/17/2026 at 1:04 PM showed Staff K administered Resident 47 their medication in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 6 residents (Resident 107), reviewed for significant change in condition. The failure to complete an SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD - observation period over which the resident's condition or status is captured by the MDS and ends at…

    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
Show the remaining 15 citations
  • Potential for harm · Dcited before2026-02-25 · 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 3 of 24 residents (Residents 68, 13 & 8), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding dialysis (treatment that helps body remove extra fluid and waste products from blood when the kidneys cannot), medication, and smoking placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian…

    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 before2026-02-25 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR or PASRR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was followed up on or sent out for a Level II PASARR referral for 2 of 6 residents (Residents 15 & 12), reviewed for PASARR Screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Findings included.On 02/24/2026 at 9:40 AM, Staff H, Social Service Assistant, stated they would send in a referral for a Level II PASARR for anyone who had a diagnosis of a mental illness. Staff H stated they would send medical records including a face sheet, diagnoses, medication, and progress notes. Staff H stated that they would email this information and expect to follow up within a month. Staff H further…

    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 · D2026-02-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure care plans were revised accurately to reflect changes related to discontinuation of medications for 2 of 22 residents (Residents 13 & 12), reviewed for care planning. This failure placed residents at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated July 2025, showed, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. RESIDENT 13 Review of the Behavior Monitor care plan printed on 02/22/2026 showed Resident 13 takes Venlafaxine.and Mirtazapine [both medications used to treat depression (persistent feelings of sadness and loss of interest)]. Review of the Order Summary Report printed on 02/18/2026, did not show Resident 13 had orders for Venlafaxine and Mirtazapine. Review of Resident 13's December 2025 Medication Administration Record (MAR) showed Venlafaxine was discontinued on 12/07/2025 and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) was up to date for 1 of 5 residents (Resident 3), reviewed for pneumococcal immunizations. This failure placed the resident at risk for acquiring, transmitting, and/or experiencing potential complications from pneumococcal disease.Findings included. Review of the facility's policy titled, Pneumococcal Vaccine, dated October 2025, showed that all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy further showed, Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. According to CDC's official website publication titled, Adult Immunization Schedule Notes, dated 10/07/2025, showed an adult who had previously received both PCV [Pneumococcal Conjugate Vaccine-a type of vaccine]13 and PPSV…

    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 · D2025-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the necessary treatment and services for pressure ulcer/pressure injury (PU/PI - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) was provided consistent with professional standards of practice for 1 of 1 resident (Resident 1), reviewed for pressure ulcer care. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life. Findings included . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised in March 2014, showed, The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement [the process of removing adherent dead or foreign material from wounds to minimize the risk of infection and promote healing] approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 11/01/2024, 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 · Ecited before2024-11-29 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 5 of 6 residents (Residents 41, 67, 36, 46 & 20), reviewed for PASARR Screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR, revised on 03/22/2024, showed that the social services department would review residents for any indicators that would need a level II screening, such as SMI or ID, and contact the community mental health program to request a Level II screening. Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance…

    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 · E2024-11-29 · tag F0732 — pattern
    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 daily nurse staffing form was accurately completed with actual hours worked for each shift for 6 of 7 days (11/23/2024, 11/24/2024, 11/25/2024,11/26/2024,11/27/2024 & 11/28/2024), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, showed that shift staffing information must be recorded on a form for each shift. The policy further showed the form should include the actual hours worked during that shift for each category and type of nursing staff [Registered Nurse, Certified Nursing Assistant and Licensed Practical Nurse]. Observations on 11/23/2024 at 1:36 PM, on 11/24/2024 at 2:26 PM, on 11/25/2024 at 2:21 PM, on 11/26/2024 at 1:23 PM, on 11/27/2024 at 1:43 PM and on 11/28/2024 at 2:03 PM, showed that the facility's daily nursing staffing form…

    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
  • Potential for harm · E2024-11-29 · tag F0761 — failed to label and store drugs safely — pattern
    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, interview, and record review, the facility failed to ensure drugs and/or biologicals were properly labeled, stored, and/or expired supplies were removed/discarded in accordance with current accepted professional standards for 2 of 4 medication carts (Cascade and Olympic Medication Cart) and for 2 of 2 medication room refrigerators (Cascade and [NAME] Medication Room Refrigerators), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications and medical supplies. Findings included . Review of the undated facility's dispensing pharmacy reference guide titled, Did you know? showed that Unless otherwise stated by manufacturer or stricter facility policy, open meds generally expire on the printed expiration date or one year since open date (whichever is sooner) .record an 'open date' on all opened meds (liquids, topicals, insulin [hormone that lowers blood sugar level] vials, insulin pens, eye drops, etc.)…

    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 · Ecited before2024-11-29 · 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 ensure insulin (hormone that lowers blood sugar level) pens were properly disinfected and hand hygiene practices were followed during medication administration for Resident 155, and failed to properly store personal care items for room [ROOM NUMBER] and Personal Protective Equipment (PPE) for 5 of 7 isolation carts in (Rooms 200, 215, 205, 118 & 325), reviewed for infection control. In addition, the facility failed to provide hand hygiene supplies for 2 of 2 medication rooms (Cascade & Baker), and failed to ensure disinfection of shared transfer lift equipment was conducted between resident use for 2 of 2 residents (Residents 82 & 301). These failures placed the residents 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 October 2018, showed, The program is based on accepted national infection prevention…

    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 · D2024-11-29 · tag F0623 — isolated
    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

    Based on interview and record review, the facility failed to properly notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents) in writing, describing the reason for transfer for 1 of 1 resident (Resident 36), reviewed for hospitalization. This failure placed the resident at risk for not having the access to an advocate who informed residents about options and resident rights. Findings included . Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed, A copy of the notice is sent to the Office of the State LTC Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of the progress note dated 09/30/2024, showed Resident 36 was transferred to the hospital for further evaluation. Review of Resident 36's nursing progress note date 09/30/2024 to 11/25/2024 showed no documentation to show that the notice of transfer was sent to the State LTC Ombudsman office. In an interview on 11/27/2024 at 2:32 PM, Staff I, Social Services Assistant, 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 · Dcited before2024-11-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 1 of 19 residents (Residents 68), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding capturing occurrences during the look-back period for oxygen placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note…

    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 · D2024-11-29 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop baseline care plans and/or provide a written summary of the baseline care plan to the residents and/or their representatives for 2 of 2 residents (Residents 40 & 151), reviewed for baseline care plan. 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, Care Plans - Baseline, revised in March 2022, showed, The resident and/or representative are provided a written summary of the baseline care plan (in language that the resident/representative can understand) that includes, but limited to the following: a. The stated goals and objects of the resident b. A summary of the resident's medication and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. RESIDENT 40…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-29 · 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 oxygen tubing were appropriately stored for 2 of 3 residents (Residents 17 & 46), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs and potential negative outcomes. Findings included . Review of the facility's policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised on November 2011, showed, Infection control considerations related to oxygen administration .keep the oxygen cannulae [NC -lightweight tube that splits into two prongs at one end and is inserted in the nostrils to deliver oxygen] and tubing used PRN [as needed] in a plastic bag when not in use. RESIDENT 17 Resident 17 admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a condition where the heart does not pump blood effectively, causing a backup of fluid in the body) and asthma (a chronic lung disease). Review of Resident 17's physician's 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 · D2024-11-29 · 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 ensure dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream) care was consistently evaluated after treatments according to professional standards for 1 of 1 resident (Residents 70), reviewed for dialysis. This failure placed resident at risk for unmet care needs, and deterioration of chronic condition. Findings included . The facility's policy titled, Hemodialysis (a medical procedure used to treat kidney failure, where the kidneys are no longer able to filter waste products and excess fluids from the blood effectively.) Access Care, revised in October 2010, stated that to prevent infection and/or clotting (a process by which blood transforms from a liquid to a semi-solid state), the access site must be always kept clean, and signs of infection (warmth, redness, tenderness or edema) should be checked at the access site when performing routine care and at regular intervals. Review of 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 before2023-08-23 · 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 face mask and nasal tubing used for nebulizer machine (breathing treatment) and/or Continuous Positive Airway Pressure (CPAP - a breathing therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) were stored properly for 2 of 2 residents (Residents 35 & 91) reviewed for respiratory care. This failure placed the residents at for unmet care needs, respiratory infections, and related complications. Findings included . Review of the facility's policy titled, Non-invasive ventilator used for CPAP/BIPAP [Bilevel Positive Airway Pressure - a device that helps with breathing], dated April 2015, showed under maintenance/cleaning, 3. Reassemble and store in a plastic bag. RESIDENT 35 Review of the electronic medical record (EMR) showed, Resident 35 admitted on [DATE], and was readmitted back to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease…

    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

“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

$44,753 in federal fines across 1 penalty.

  • $44,753 — penalty dated 2023-08-23

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 AVAMERE — 27 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 4 of 53.0+1.0 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 5 of 53.8+1.2 vs chain
The other 26 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avamere Rehabilitation Of EugeneEugene, OR 1 of 5Avamere Rehabilitation Of LebanonLebanon, OR 2 of 5Avamere At Pacific RidgeTacoma, WA 2 of 5Avamere Health Services Of Rogue ValleyMedford, OR 2 of 5Avamere Olympic Rehabilitation Of SequimSequim, WA 2 of 5Avamere Rehabilitation At Park WestSeattle, WA 2 of 5Avamere Rehabilitation Of Coos BayCoos Bay, OR 2 of 5Avamere Rehabilitation Of IssaquahIssaquah, WA 2 of 5Avamere Rehabilitation Of Oregon CityOregon City, OR 2 of 5Avamere Rehabilitation Of ShorelineSeattle, WA 2 of 5Avamere Rehabilitation of BurienBurien, WA 2 of 5Avamere Riverpark Of EugeneEugene, OR 2 of 5Avamere Transitional Care At SunnysideSalem, OR 3 of 5Avamere Rehabilitation Of HillsboroHillsboro, OR 4 of 5Avamere Court At KeizerKeizer, OR 4 of 5Avamere Crestview Of PortlandPortland, OR 4 of 5Avamere Rehabilitation At RidgemontPort Orchard, WA 4 of 5Avamere Rehabilitation Of ClackamasGladstone, OR 4 of 5Avamere Rehabilitation Of Junction CityJunction City, OR 4 of 5Avamere Rehabilitation Of King CityTigard, OR 4 of 5Avamere Rehabilitation Of NewportNewport, OR 4 of 5Avamere Transitional Care Of Puget SoundTacoma, WA 4 of 5The PEARL AT KRUSE WAYLake Oswego, OR 5 of 5Avamere At Three FountainsMedford, OR 5 of 5Avamere Rehabilitation Of Cascade ParkVancouver, WA 5 of 5Queen Anne HealthcareSeattle, WA

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
ARISO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 01/06/2006
ARI OPERATIONS, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/06/2006
AVAMERE GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/06/2006
KARL RICKARD MILLER JR REVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 07/11/2011
MILLER, KARLIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2003
MIDCAP FINCO LLCOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/22/2010
CAVALLO, GLENIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2025
FEAKIN, CODYIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/01/2025
FUNDERBERG, MICHELLEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/01/2025
HASKINS, DAMIENIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/01/2025
HILL, KEVINIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 03/12/2022
HOSKINS, TONIAIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/01/2025
INSKEEP, TODDIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/21/2022
KOFSTAD, MARYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/13/2024
MUNRO, JOLYNNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
OKOLI, IKEIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2025
POLSON, JUSTINIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2025
POWELSON, MICHELEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/25/2015
REID, MISTYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2025
SANDERS, AMANDAIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2025
SIMPSON, ANDREWIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2024
STRUNK, COLBYIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/01/2025
VANDERZANDEN, CARRIEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/01/2025
AVAMERE HEALTH SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
AVAMERE SKILLED ADVISORS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
FANUNAL, LORIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2023
FOWLER, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
MANGIO, DIANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2025
MIRZAIE AMIRABADI, ARASHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2024
PRESLEY, YOLANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2025
RAJU, DARSHNIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2023
SCHEIDERER, ALISONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2023
GAMES, KIMIndividualADP OF THE SNFsince 08/15/2024
GRIFFITH, JOSHUAIndividualADP OF THE SNFsince 04/01/2024
MULLENIX, ALIDAIndividualADP OF THE SNFsince 11/01/2022
STAPLES, CAROLYNIndividualADP OF THE SNFsince 10/05/2023
WOOLSEY, SCOTTIndividualADP OF THE SNFsince 06/01/2020

CMS files one row per role, so the 67 rows in the source record cover these 37 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.

7 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.

$14.6M
Net patient revenuemost recent cost report
-2.2%
Operating marginrevenue minus expenses
$1.4M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 7%Other / private 21%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M 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

$447per resident / day
operating cost
$13,599per month
≈ monthly operating cost
$438per 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 505488. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, 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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