Josephine Caring Community
9901 272nd Place Northwest, Stanwood, WA 98292 · Non profit - Church related · 160 certified beds · (360) 629-2126 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- 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 (31) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.0% | 14.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 1.0% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.5% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 98.0% | 17.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.1% | 2.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 21.1% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.5% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 93.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.6% | 22.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.1% | 15.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 76.2% | 82.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.8% | 19.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.2% | 13.4% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.74 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.63 | 1.52 | 1.80 | 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.
56.6% 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 157 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.1% 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 109 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.6%CMS range 49.3–63.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.8–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 42.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.4–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 160 beds and averages 115.6 residents a day — about 72% occupied, or roughly 44 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 4.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 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 3.82 hrs/resident/day on weekends vs 5.04 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.88 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% 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
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2024-07-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to consistently and accurately obtain weights, recognize significant weight loss, and provide consistent assistance with eating and cueing for 1 of 4 sampled residents (Resident 33) reviewed for nutrition. Resident 33 experienced a significant 14.6% weight loss from 05/27/2024 to 07/10/2024. This failure placed the resident at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life. Findings included . Review of the facility policy titled Nutritional Management, dated 12/27/2023, showed that weekly weights would be obtained on new admissions for 4 weeks. After assessing the weight accuracy, the Licensed Nurse or Nursing Assistant would record the weight in the resident's electronic medical record under vital signs. Re-weighs were required for any unplanned 3-pound (lb) variance from week to week. Resident 33 admitted on [DATE] with diagnoses which included protein calorie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-22 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 resident choices/preferences regarding their bathing schedule were honored for 3 of 4 sampled residents (Residents 2, 3, and 4) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life. Findings included .<RESIDENT 2>Resident 2 admitted to the facility on [DATE] with diagnosis to include a stroke with right side hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body). Review of the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 12/08/2025, documented the resident was moderately impaired in decision making skills, dependent with showers/bathing and shower transfers. Review of Resident 2's Preference care plan, with a target date of 03/05/2026, documented the resident preferred to take a shower two times a week before breakfast.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure quality of care and services was provided for 2 of 3 sampled residents (Residents 1 and 2) reviewed for skin, positioning, and assistance with meals. These failures placed residents at risk of medical complications and a diminished quality of life. Findings included .<RESIDENT 1>Resident 1 re-admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a disorder of the nervous system affecting movement), Cerebellar ataxia (damage to the brain causing poor coordination and balance problems), Dementia (affects memory), and Muscle Weakness. Review of quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 12/23/2025, the resident had no cognitive impairment. In a joint interview on 01/21/2026 at 12:37 PM, with Resident 1 and (Collateral Contact) CC1, Resident 1 stated they had talked to CC1 on 01/18/2026 and reported the rash to her toes and feet had worsened and was painful. Resident 1 stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with the state and federal laws appropriately for 1 of 2 (Rehab Unit) Medication Storage Rooms. The facility failed to ensure Schedule II-V (Substances with high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in separate locked, permanently affixed compartments not accessible to others. These failures left controlled substances unattended with potential of unauthorized access to drugs that should have been securely stored.Findings included . In an observation and interview on 09/10/2025 at 9:50 AM, Staff H, Registered Nurse/Case Manager opened the refrigerator in the Medication Room in the Rehab Unit, inside the refrigerator was a locked metal box not permanently affixed to the refrigerator. They took the locked box out of the refrigerator and Staff H opened it with a key. Observed in the box were 2 unopened bottles of Lorazepam (Scheduled IV medication that treats anxiety) oral liquid and 1 unopened…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 5 of 11 residents (Residents 5, 8, 74, 78, and 100) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the physician visit documentation for 3 of 6 residents (Residents 5, 78, and 100), failed to include dialysis provider notes for 1 of 3 residents (Resident 74), failed to ensure accurate documentation for advanced directives for one of one resident (Resident 8). This failure placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included .Review of the facility policy titled, Medical Records, revised date 12/06/2024 stated the medical records department will maintain the records on each resident as complete, accurately documented, readily accessible and systematically organized.Review of the facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to coordinate with the preadmission screening and resident review program (PASARR) for 1 of 5 residents (Resident 8) reviewed for PASARR coordination. Resident 8 required a level II evaluation (in depth evaluation of a resident by the state designated authority) for a serious mental disorder which was not completed which placed residents at risk for unmet behavioral care needs. Findings Included.Resident 8 was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. Resident 8's diagnoses included Parkinson's disease, depression and dementia with psychotic features (hallucinations or delusions). Review of Resident 8's PASARR Level I (screening tool for possible serious mental illness) dated 01/10/2025 documented they required a level II evaluation. Review of Resident 8's PASARR Level II invalidation statement dated 03/06/2025 documented a level II evaluation could not be completed as they were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident care plans were updated for 1 of 1 residents (7) reviewed for Hospice services and 1 of 1 residents (100) reviewed for dental services. This failure placed residents at risk for decreased quality of care. Findings included .<DENTAL> Review of Resident 100's care plan dated 07/09/2024 documented they had no natural teeth. The goal was Resident 100 would have no signs or symptoms of improper fit of their dentures. Interventions included assisting Resident 100 with cleaning their dentures and monitor for any oral discomfort. Review of Resident 100's progress notes documented: - On 01/09/2025 Resident 100 met with social services and reported their bottom dentures did not fit properly. -On 01/30/2025 Resident 100 was placed on alert charting related to irritation on their gums. Resident 100 reported their gums were hurting. -On 03/22/2025 Resident 100 was placed on alert for an ulcer to their lower gum and complained of sore spots on 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.
- Potential for harm · D2025-09-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 38) reviewed for oxygen, and 1 of 3 residents (Resident 13) reviewed for diabetic (disease that affects the blood sugar levels in blood) management. The facility failed to follow physician's orders for oxygen administration and failed to ensure appropriate monitoring for diabetes was completed based on national standards. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs. Findings included . Review of the facility policy titled, Oxygen Safety, reviewed 12/09/2024, documented the licensed nurse will verify the order and adjust the oxygen flow rate as determined by the physician. Oxygen was administered by a licensed nurse under the order from the attending physician. Review of the American Diabetes Association website on 09/15/2025, documented the national standards for monitoring a hemoglobin A1c (type 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.
- Potential for harm · D2025-09-15 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and provide pain management to adequately control residents pain for 1 of 3 residents (Resident 63) reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Review of the facility policy titled, Pain Management, revised 01/22/20205 stated all resident would receive appropriate assessment and management for pain. Appropriate measures for pain control would be documented, then implemented according to a resident's plan of care. when a resident has pain, a pain assessment would be completed. Case Managers and the Minimum Data Set (MDS - an assessment tool) nurse will assess that the residents pain medication and management are effective, and update for further interventions and notifications. Resident 63 admitted to the facility on [DATE] with diagnoses to include osteoporosis, dementia, and muscle weakness. The Quarterly MDS dated [DATE] documented that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled resident (Resident 28), reviewed for mood and behavior. This failure placed residents at risk of re-traumatization, unmet behavioral health needs, and diminished quality of life.Findings included .According to the website www.mayoclinic.org Post Traumatic Stress Disorder (PTSD) was a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event. Symptoms could include flashbacks (feelings that the traumatic event was occurring again), nightmares (repeated disturbing dreams), intrusive thoughts, severe anxiety, avoidance (not wanting to think or talk about a traumatic event), changes in mood or thinking and physical and emotional reactions. These symptoms last more than one month, cause major problems in social or work situations and affect how well a person gets…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 interviews and record review the facility failed to ensure timely physician visits (once every 30 days for the first 90 days after admission) were completed for 4 of 7 residents (5, 49, 79 and 84) reviewed for physician visits. This failure placed residents at risk of being denied face-to-face contact with a physician, comprehensive reviews and physician assessments of their health and well-being. Findings included .According to CMS (Centers for Medicare and Medicaid); The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. After the initial physician visit in SNFs (Skilled Nursing Facility), where States allow their use, a NPP (Nurse Practitioner) may make every other required visit. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.Review of the facility policy titled, Physician Visits reviewed and revised on 12/06/2024, showed it was 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.
Show the remaining 20 citations
- Potential for harm · D2025-09-15 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely laboratory results to meet the needs of one of two residents (121) reviewed for laboratory services. This failure had the potential for negative complications related to delay of obtaining and receiving follow up of laboratory results placing residents at risk for delay in treatment and adverse outcomes.Findings included.Review of the facility policy titled Laboratory Services, (revised date 12/09/2024), documented the facility would obtain ordered laboratory testing according to provider's orders and would promptly notify providers of results that fell outside of clinical reference ranges.Resident 121 readmitted to the facility on [DATE] with diagnoses which included acute and chronic wounds with infection of the bone. Review of Resident 121's physician's orders dated 08/29/2025 showed orders for laboratory testing to be completed every week on Tuesday. Review of the resident record on 09/12/2025 showed that the resident should have had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff adhered to infection control practices when providing care to 1 of 3 (Resident 78) residents that were on Transmission-Based Precautions. The facility failed to ensure staff used appropriate hand hygiene and personal protective equipment (PPE - equipment worn to minimize exposure to infections or diseases) when entering a room that had a sign of Contact Enteric Precaution (combination of contact precaution and enteric precautions used for infections that spread through contact with fecal matter or contaminated objects). This failure placed residents and staff at risk for potential infections.Findings included .Review of the facility policy titled Infection Control Policy/Procedure, Transmission-Based Precautions, revised date 08/28/2025 documented, Contact Enteric Precautions should don (put on) a gown and gloves prior to entry for all interactions that may involve contact with the resident or the resident's environment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and interview, the facility failed to transport and serve food in a sanitary manner in 3 of 3 units (East, West, North) reviewed for food service. The failure to cover cold foods like fruit cups and desserts placed residents at risk for receiving contaminated foods and for diminished quality of life. Findings included . In an observation on 07/08/2024 at 12:05 PM, the East unit hall tray cart had trays with uncovered mandarin oranges that were served to residents. In an observation on 07/08/2024 at 12:08 PM, the North unit hall tray cart had trays with uncovered mandarin oranges that were served to residents. In an observation on 07/09/2024 at 12:00 PM, the East unit hall tray cart had trays with uncovered fruit that were served to residents. In an observation on 07/09/2024 at 12:09 PM, the East unit had uncovered fruit cups with melon and mandarin oranges that were served to residents. In an observation on 07/10/2024 at 12:15 PM, the East unit hall tray cart had trays with uncovered cups of apricots that were uncovered and were served to residents. In 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.
- Potential for harm · Ecited before2024-07-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 6 of twelve residents (33, 49, 78, 92, 103, and 107) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the accurate, and complete weights and bathing documentation for 2 residents (33, and 49), failed to contain the consents for use of restraints for 1 resident (92), failed to include consultant provider notes for podiatry and wound clinic documentation for 2 residents (78, and 103), failed to ensure accurate documentation for meal tray monitoring for 1 resident (92), and failed to ensure accurate documentation for a urinary catheter for one resident (107). This failure to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included . Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs and preferences for 1 (Resident 92) of 6 sampled residents reviewed for nutrition, 1 (Resident 7) of 5 sampled residents reviewed for unnecessary medications, 2 (Resident 87 and 92) of 2 sampled residents reviewed for restraints, and 1 (Resident 73) of 1 sampled resident reviewed for bowel and bladder. This failure placed residents at risk for not receiving needed, preferred care and services and a diminished quality of life. Findings included . <RESIDENT 7> Resident 7 admitted to the facility with diagnoses to include congestive heart failure (a condition of the heart not pumping blood efficiently which can cause extra fluid in the body), and hypertension (high blood pressure). A review of Resident 7's current care plan printed on 07/14/2024 showed no care plan problem or interventions related to the resident's congestive heart failure or hypertension. In an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 2 of 7 sampled dependent residents (10 and 33) reviewed for ADL's. The facility failed to provide showers/bathing assistance to a resident (Resident 10), who was dependent on staff for bathing, and failed to ensure a resident that was dependent for assistance with meals was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Shower/Bed-Bath, revised 12/28/2023 stated the facility was to provide bathing assistance by the shower team to ensure and maintain the resident's dignity. Review of the facility policy titled, Standards of Care, revised 03/29/2024 stated care was provided based on the residents physical and mental capabilities. Staff are to offer assistance for dining, feeding assistance, nail care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer appropriate services and assistance to maintain or improve mobility and range of motion for 1 of 1 sampled resident (Resident 107) reviewed for restorative nursing program. This failed practice placed the resident at risk for losing strength and range of motion they gained while receiving therapy services. Findings included Review of the facility policy titled Restorative Nursing Program, dated 12/27/2023, showed the facility would provide maintenance and restorative services designed to maintain and improve residents' abilities to the highest practicable level. It also stated residents may receive restorative nursing services upon discharge from skilled therapy. Resident 107 admitted to the facility on [DATE] with diagnoses to include multiple facial fractures from a fall, iron deficiency anemia (low red blood cells in the blood), and essential tremors. According to the admission Minimum Data Set (MDS- an assessment tool) assessment 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.
- Potential for harm · Dcited before2024-07-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 15) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure a medical provider assessed and documented a rationale for extended use of an as necessary (PRN) anti-psychotic (medication that treats symptoms that affect the mind, and reality) medication for use over 14 days and provided no duration of use of the anti-psychotic medication. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . Review of the facility policy titled, Psychoactive Medications, revised 12/27/2023 stated any psychotropic medication prescribed as a PRN will be for 14 days and will be re-evaluated for discontinuance or justification from the provider. Resident 15 admitted to the facility on [DATE] with diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure dependent residents received assistance with activities of daily living to include grooming for 1 of 1 resident (18) and bathing for 4 of 6 residents (61, 84, 91, and 102) in accordance with their needs and preferences reviewed. This failure placed residents at risk for diminished dignity, decreased quality of life and poor hygiene. Findings included . <Grooming> Resident 18 Resident 18 admitted to the facility on [DATE]. The resident had diagnoses that included Parkinson's Disease (a disorder that affects movements often including tremors) and Dementia. Review of Quarterly Minimum Data Set (MDS, an assessment tool) dated 3/13/2023, showed Resident 18 had moderate cognitive impairment and required one person extensive assistance with personal hygiene. In an observation on 04/18/2023 at 2:15PM, the resident's hand and fingers nails were soiled with dried food. On 04/19/2023 at 10:35 AM, Resident 18 was observed to have dirty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-25 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure non-medication interventions were attempted prior to administration of psychoactive medications (medications that affect the mind or behavior), for two of five residents (7 and 68) and failed to monitor and evaluate for potential adverse side effects related to use of psychotropic medication for one of five residents (36) reviewed for unnecessary medications. This failure put the residents at risk for receiving and/or experiencing adverse side effects from unnecessary medication use and a decreased quality of life. Findings included . Resident 7 Resident 7 was admitted on [DATE] with diagnoses that include anxiety disorder. Review of resident's records showed the resident had a physician's order for Vistaril (an antianxiety medication) every six hours as needed for anxiety dated 04/14/2023. Review of the resident's Medication Administration Record (MAR) for April 2023, showed the resident was given Vistaril nine times from 04/14/2023-…
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.
- Potential for harm · Ecited before2023-04-25 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 were prepared and served in a sanitary environment and that safe food practices were maintained in the facility kitchen. Failure to: 1) test chemical rinse concentrations for pots/pans sanitation, 2) ensure kitchen overhead light fixtures were free of dust and debris, 3) ensure dietary staff utilized hair restraints, and 4) to ensure potentially hazardous foods that were to be used at a later date were cooled using time/temperature controls for safety, placed residents at risk for foodborne illnesses and diminished quality of life. Findings included . In an observation on 04/20/2023 at 10:12 AM, Staff E, Dietary Aide, was observed to not be wearing a hair restraint while preparing food in the facility kitchen. In an interview on 04/20/2023 at 10:12 AM, Staff F, Dietary Manager, stated they had not been requiring Staff E to wear a hair restraint because they used to have a shaved head, but they would start having them wear one now. In an observation and interview on 04/20/2023 at 10:12 AM, staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of resident needs and preferences for 1 of 1 residents (Resident 60) reviewed for accommodation of needs. Failure to ensure residents received requested or alternate mobility equipment in their room placed them at risk for diminished independent functioning, dignity, and comfort. Findings included . Review of the facility policy titled: Bed rails, Side Rails and/or Bed Canes revised 01/02/2023 showed the facility did not allow the use of bed rails, side rails or bed canes due to the concern for the risk of entrapment and asphyxia hazard. The policy further stated the facility would provide alternate intervention and/or assistive device recommendations to the resident/ responsible party, based upon an individualized clinical and environmental assessment. Findings included . Resident 60 admitted [DATE]. The resident had diagnoses which included chronic cardiac and respiratory disorders history of compression…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-25 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 recognize and ensure that allegations of abuse were reported to the State Agency within the required timeframe for one of two residents reviewed for abuse (102). This failed practice placed residents at risk for potential harm due to unrecognized abuse/neglect. Findings included . Review of the facility policy titled 'Abuse Prevention', dated 11/21/17, revised on 01/18/2023 showed that the Administrator had overall responsibility and accountability and was the Abuse Prevention Coordinator, and was responsible for implementing the Resident Abuse Prevention Program and was assisted by team members. Under the subheading 'Training,' showed that upon hire and at least annually, all employees received training in the following areas: Proper techniques for reporting suspected abuse facts without fear of reprisal, and Definitions of abuse, neglect, and misappropriation of resident property. Prohibiting & preventing all forms of abuse, neglect, misappropriation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (83) with limited range of motion received appropriate treatment and services to increase range of motion (ROM) or prevent further decrease in range of motion. This failed practice placed the resident at risk for further declines in their ROM. Findings included . RESIDENT 83 The resident admitted to the facility on [DATE] and had diagnoses to include a stroke that affected their ability to move their right side, generalized muscle weakness, reduced mobility, and a need for assistance with personal cares. According to their annual Minimum Data Set (MDS) assessment (an assessment tool), dated 03/07/2023, they had moderate cognitive impairment, and had hemiplegia/hemiparesis (paralysis of one side of the body), and they had no restorative days (documentation they received range of motion type services by nursing staff) during the assessment period for that MDS. In an observation and interview on 04/18/2023 at 2:53 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three residents (112) received adequate assessment and monitoring of unexpected weight loss. This failure placed residents at risk for experiencing further weight loss and failing to maintain adequate nutrition/hydration status. Findings included . Review of the facility policy titled: Resident weights and skin observations revised 01/17/2023 showed that residents would be weighed on their shower days and the prior weight was reviewed. If the weight changed by 3 pounds (plus or minus) the resident would be re-weighed to confirm the new weight. The Licensed nurse would ensure the correct weight and follow up needed. RESIDENT 112 Resident 112 admitted [DATE] with diagnoses which included Parkinson's disease (degenerative disorder of the nervous system affecting movement), dementia, dysphagia (swallowing deficit) and history of falls. Review of the resident record and weights on 04/19/2023 showed: 02/10/2023= 163 lbs. 02/22/2023= 166 lbs.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the consultant pharmacist conducted thorough reviews and identified relevant irregularities for 1 of 5 residents (36) reviewed. The failure to identify a lack of adverse side effect monitoring for antipsychotic medication treatment for several months placed the resident at risk for unidentified medication-related irregularities. Findings included . RESIDENT 36 The resident admitted to the facility 10/19/2022, and had diagnoses to include an unspecified psychosis. On 04/19/2023, a review of the resident's Medication Administration Records (MARs) and Treatment Administration Records (TARs) from October 2022 - April 19, 2023 showed the resident was being treated with Seroquel (an antipsychotic medication), but no adverse side effects monitoring was found. In an interview on 04/21/2023 at 10:06 AM, Staff I, Registered Nurse/Resident Care Manager, stated there should be adverse side effects monitoring under the Info tab in the electronic health record, none could be found. On 04/24/2023, a review of the resident'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.
- Potential for harm · Dcited before2023-04-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that medications and biologicals were labeled and stored in accordance with applicable state and federal laws for two of seven medication carts. This failure placed residents at risk to receive incorrect medications, possible side effects, harm, and diminished quality of life. Findings included . In an observation on 04/18/2023 at 9:59 AM, unattended medications were found on top of the medication cart on the rehab unit. The medication cup contained three capsules. Staff B, Registered Nurse (RN) Director of Nursing Services (DNS), entered the hallway and surveyors notified her of unsecured medications. In an observation on 04/24/2023 at 1:14 PM, the medication cart was left unattended and unlocked in a hall by resident rooms. Four drawers on the right side of the medication cart were unlocked and held over the counter medications, vitamins, supplements and multiple residents' medication bubble packs, and diabetic supplies that were accessible. In an interview on 04/24/2023 at 1:23 PM with Staff M,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-25 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide assistance and follow up on an appointment for dental care services for one of one sampled resident, (102) reviewed for dental services. This failure placed the resident at a potential risk for continued dental needs, discomfort, and decreased quality of life. Findings included . Resident 102 was admitted to the facility on [DATE] with diagnoses to include Amyotrophic Lateral Sclerosis (ALS) (a disease that affects the nervous system, and spinal cord which causes progressive weakness and atrophy, (wasting) of muscles), depression, and muscle weakness. Review of Resident 102's Quarterly Minimum data Set (MDS) (assessment tool of resident) dated 03/29/2023 showed that the resident was cognitively intact. Review of Resident 102's care conference progress note dated 03/30/2023 by Staff L, Social Services (SS) that the resident had a pending dentist appointment. Review of care conference progress notes by Staff P, Social Services (SS) 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.
- Potential for harm · Dcited before2023-04-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure staff used appropriate hand hygiene practices during wound care for one of one residents (81) reviewed for pressure ulcers. This failed placed Resident 81 at risk for wound infection. Findings included . Review of the facility policy titled: Hand Hygiene revised 12/21/2022, showed the facility staff would perform hand hygiene per professional standards between dirty and clean tasks. In an observation on 04/24/23 at 11:01 AM, Staff D, Licensed Practical Nurse, Resident Care Manager, was observed performing wound care for Resident 81. Staff S, Nursing Assistant, was present and assisted only with positioning the resident on their side. Staff D was observed to don gloves prior to removing the soiled dressing and placing it in a plastic bag. Staff D then squirted saline onto gauze squares and cleansed the wound. The wound was observed to have depth and Staff D was observed to have their gloved fingers come in contact with the wound surfaces as the wound was cleansed. Staff D placed the soiled gauze in 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.
- No harm found · B2023-04-25 · tag F0623 — patternProvide 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 provide written notice to 1 of 2 residents (57) and/or their responsible party of the resident's transfer to the hospital. The facility also failed to send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. Failure to provide the written notice disallowed the resident/responsible party an opportunity to fully understand the rationale and resident rights associated with the resident's discharge. Findings included . Review of facility policy titled, Discharge/Transfer of Resident, dated 01/18/2023, showed that a transfer/discharge form was to be completed within 24 hours of discharge and forwarded to reception who mailed the form to the resident/responsible party and the Ombudsman. Resident 57 Review of a progress note, dated 04/13/2023, showed that Resident 57 was unresponsive, had a distended abdomen with abdominal pain and was transferred to the hospital. Review of Resident 57's clinical record on 04/24/2023 showed no documentation that a notice of transfer/discharge form was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| U.S. BANK | Organization | 5% OR GREATER SECURITY INTEREST | since 10/08/2025 |
| BARNES, JANET | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2024 |
| CHRISTOFERSON, BARBARA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| FOSSE, ERNEST | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2022 |
| KINNEY, BRETT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2022 |
| LAMBING, KRISTI | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2024 |
| NELSON, IRENE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 10/28/2025 |
| SHOUP, PAUL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2021 |
| VAIL, JILL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2025 |
| CURTIS, EARL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| JOHNSON, JULIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2025 |
| LARSEN, MICHAEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2018 |
| LUCAS, THOMAS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2020 |
| ROBERTSON, TERRY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/21/2008 |
| BURCHARD, CLINT | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/05/2023 |
| ELLERTON, R | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/29/2018 |
| GREEN, CHARLOTTE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2025 |
| HANSON, ALISHA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/23/2008 |
| HUTCHISON, KAY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/31/2017 |
| LINDGREN, TERI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/20/2008 |
| STECKLER, THERESA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| STICKLE, HERBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/30/2026 |
| ANDREA O'NEILL | Organization | ADP OF THE SNF | since 07/01/2014 |
| BAKER TILLY US LLP | Organization | ADP OF THE SNF | since 01/01/2004 |
| DEW, JOHN | Individual | ADP OF THE SNF | since 02/26/2025 |
CMS files one row per role, so the 43 rows in the source record cover these 25 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.
3 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Washington Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505465. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-15, 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.