Washington State Walla Walla Veterans Home
92 Wainwright Drive, Walla Walla, WA 99362 · Government - State · 80 certified beds · (509) 394-6800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,358 in federal fines (most recent 2026-02-27)
- its payroll-based staffing 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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 | 4 of 5 |
| Long-stay residentspeople who live here | 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 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 | 19.6% | 14.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.7% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.6% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.3% | 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 | 3.9% | 2.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.2% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 12.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 93.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.3% | 22.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.3% | 15.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.5% | 1.3% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.29 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.49 | 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.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 6.2–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 80 beds and averages 77.4 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.41 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.69 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 5.75 hrs/resident/day on weekends vs 6.67 on weekdays — 14% thinner on weekends. RN hours go from 1.82 to 1.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 23% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2026-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify hazards and risks to ensure the resident's environment remained free of accident hazards for 1 of 3 residents (Resident 80) reviewed for hospitalization. The failure to consistently complete a thorough safety assessment of Resident 80's environment with the use of their powered wheelchair (w/c) caused Resident 80 to experience harm when they drove their powered w/c off a curb and sustained an injury that required hospital and surgical intervention. Findings included . Resident 80 Review of the resident's medical records showed they admitted with diagnoses to include bladder cancer (the uncontrolled growth of abnormal cells in the body), wet macular degeneration (an eye condition that causes blurred or reduced central vision, and can cause distortions, such as straight lines that appear to be bent), and myopia (an eye condition that leads to vision loss) of an unidentified eye/eyes. The 11/22/2025 comprehensive assessment showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure adequate supervision was consistently implemented to prevent resident-to-resident altercations with Resident 1 for 1 of 4 residents (Resident 2) reviewed for avoidable accidents. This failure placed the residents at risk for additional physical altercations, serious injury, and emotional distress.Findings included. Review of a policy titled, Safety and Supervision of Residents, revised 07/2017, showed the interdisciplinary care team (a group of healthcare professionals from different disciplines to help people receive the care they need) would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. The care team would target interventions to reduce individual risks, including adequate supervision. Resident supervision was a core component of the system approach to safety. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive…
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 · D2026-04-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by Resident 2 for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed the residents at risk for continued abuse, injury, and emotional distress. Findings included. Review of a policy titled, Abuse and Neglect, dated 12/18/2024, showed physical abuse was the willful action of inflicting bodily injury or physical mistreatment that included striking with or without an object, slapping, pinching, choking, kicking, shoving, or prodding. Mental abuse was a willful verbal or nonverbal action that threatens, humiliates, harasses, coerces, intimidates, isolates, or punishes a vulnerable adult (a person [AGE] years of age or older who has the functional, mental, or physical inability to care for themselves) that may include ridiculing, yelling, or swearing. Resident 1Review of the medical record showed Resident 1 was admitted to the facility 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 · D2026-04-14 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement their abuse prevention policy in the areas of prevention and protection for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed the residents at risk for continued unidentified abuse, fear, and dissatisfaction with their living situation.Findings included. Review of a policy titled, Resident Abuse Prevention, dated 12/18/2024, showed prevention of abuse included identifying, correcting, and intervening in situation in which abuse, neglect, and/or misappropriation of resident property was likely to occur. The facility would provide sufficient staff to meet the needs of the residents and ensure the staff assigned had knowledge of the individual resident's care need. Assessments, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. Review of a policy titled, Abuse and Neglect, dated 12/18/2024, showed upon receiving notice of allegations of resident abuse, the Administrator, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide adequate supervision and update care plan interventions to prevent resident-to-resident altercations with Resident 2 for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for potential verbal and physical abuse, serious pain and injury, and emotional distress.Findings included. Review of a policy titled, Safety and Supervision of Residents, revised 07/2017, showed the interdisciplinary care team (a group of healthcare professionals from different disciplines to help people receive the care they need) would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. The care team would target interventions to reduce individual risks, including adequate supervision. Resident supervision was a core component of the system approach to safety. The type and frequency of resident supervision may vary over time for the same resident. Resident 1Review of the medical record showed Resident 1 was admitted…
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 · E2026-02-27 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] accurately reflected residents' mental health conditions for 4 of 8 residents (Resident 5, 12, 13, and 7) reviewed for unnecessary medications. This failure placed the residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included.Resident 5 Review of the medical record showed Resident 5 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder [(PTSD) a mental health condition triggered by witnessing or experiencing terrifying events, such as violence, accidents, or disasters], depression, anxiety, and dementia (a progressive syndrome characterized by severe cognitive decline that interferes with daily…
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 before2026-02-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard expired foods and complete daily cleaning tasks for 6 of 8 kitchens ([NAME], Umatilla, Palouse, [NAME], [NAME], and [NAME]) and 1 of 1 dry storage area, and the facility failed to consistently monitor cooked food temperatures prior to serving regular and pureed food for 1 of 3 staff (Staff W) observed for safe and sanitary kitchen. This failed practice placed residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]). Findings included.Kitchens [NAME] An observation and concurrent interview on 02/25/2026 at 12:07 PM, showed. Three 13.5-ounce (oz., a unit of measure) containers of Strawberry Jello, expired 02/21/2026 one six oz. container of cottage cheese with blueberries, expired 01/26/2026 16 round individual cream cheese, dated 12/19/2025 with no use by date Three 25 oz…
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 · D2026-02-27 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, 1) residents on as needed (PRN) psychotropic medications (drugs that affect brain activities associated with mental processes, emotions and behavior) were limited to 14-days or had a documented rationale for the extended use of the PRN psychotropic and, 2) that non-pharmacological interventions (alternative treatment of a resident's symptoms that are directed toward understanding, preventing and relieving a resident's distress or loss of abilities and do not involve the use of medications) were consistently attempted to reflect an adequate need of the medication for 2 of 5 residents (Residents 7 and 35) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Findings included . Review of the facility's policy titled, Psychotropic Medication Use, dated February 2025, showed that PRN psychotropic medications were limed to 14-days…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-27 · 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
Based on observation, interview, and record review, the facility failed to recognize a change in condition for 1 of 3 residents (Resident 13) reviewed for hospitalization and follow physician orders as written for 3 of 4 residents (Resident 8, 6, and 80) reviewed accuracy of physician orders related to fluid restrictions and hospitalization. This failure placed all residents at risk for delay in treatment, medical complications, and negative health outcomes. Findings included. Review of a policy titled, Change in a Resident's Condition or Status, revised 12/2016, showed the facility would promptly notify the resident, their attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline in the resident's status that would not normally resolve itself without intervention by staff or implementing standard…
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 · D2026-02-27 · 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 interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care (TIC), complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (occurs when a current situation triggers the emotional and physical responses of past trauma, making it feel as if the original traumatic event was happening again) for 1 of 4 residents (Resident 7) reviewed for TIC. This failure placed the resident at risk for unidentified triggers and re-traumatization.Findings included .Review of the policy titled, Trauma Informed Care and Culturally Competent Care, dated August 2022, showed that TIC was an approach to care delivery that recognized the widespread impact and signs/symptoms of trauma within the facility's residents and incorporating the knowledge of a resident…
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 · D2026-02-27 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) program that, 1) included the thorough collection of data/feedback and systematic investigations and/or analysis regarding adverse events (an unexpected, undesirable and usually unanticipated event that causes death or serious injury to a resident) within the facility and, 2) showed actions taken towards development of activities regarding, recent adverse events within the facility, problem prone areas, and contributing factors that could impact quality of care, quality of life, and/or resident safety for 1 of 1 QAPI program, reviewed for quality assessment and assurance. This failure placed residents at an increased risk for unidentified complications, prompted corrective action regarding adverse events and unmet care needs.Findings included .Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Plan, dated 05/15/2025 showed, the facility's QAA/QAPI committee members included the Administrator, Director of Nursing Services…
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 16 citations
- Potential for harm · D2026-02-27 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 Quality Assessment and Assurance (QAA) committee included the required members that met at least quarterly (once every quarter of the year or every three months) for 2 of 4 quarters (Q3 2025 and Q4 2025) reviewed for QAA. The failure to meet quarterly increased the facility's risk of unrecognized quality deficiencies, the facility's ability to effectively correct identified issues and ongoing unmet care needs regarding residents' quality of life.Findings included .Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Plan, dated 05/15/2025 showed, the facility's QAA/QAPI committee staff would include the Administrator, Director of Nursing Services (DNS), Infection Preventionist (IP)/QAPI coordinator and the Medical Director. The policy showed the committee would meet quarterly and prioritize/identify .areas of improvement and rank them by factors such as prevalence, risk, cost, relevance, responsiveness, feasibility, and continuity. Performance Improvement Projects (PIPs) will…
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 before2025-12-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 notification of injury to the Resident's Representative (RR) for 1 of 3 residents (Resident 1) reviewed for notification. This failure placed the resident at risk of not having their representative involved in health care decision making for timely care and services.Findings included. Review of a policy titled, Incident Report - Resident, dated 04/02/2018, showed when the facility became aware of an incident that involved a resident, a Resident Incident Report would be initiated by the person that first became aware of the incident. The report should include family notification. The notification should be completed in a timely manner and contact attempts should be recorded on the Incident Report and in the nursing progress notes. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including heart failure, dementia with behavioral disturbance (distressing personality and behavior changes that occur alongside cognitive decline that include aggression, wandering, 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.
- Potential for harm · Dcited before2025-11-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide supervision to prevent elopement (leaving the facility unsupervised and undetected) for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for exposure to the elements, serious harm and/or death.Findings included. Review of the facility policy titled Missing Resident/Elopement, dated 09/22/2023, showed residents who were at risk for wandering and/or elopement would be monitored, and staff would take necessary precautions to ensure their safety. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive brain disease that destroys memory and thinking skills), Dementia (a progressive disorder that impairs memory, thinking, language, and decline in cognitive abilities that affect daily life) and Post-Traumatic Stress disorder [(PTSD) a mental health condition that's caused by an extremely stressful or terrifying event]. The 08/05/2025 comprehensive assessment showed Resident…
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 · E2024-12-16 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 prepare palatable, appetizing, and appealing meals for 8 of 15 residents (Resident 78, 48, 46, 39, 6, 20, 71, and 38) who voiced concerns regarding food quality during a Resident Council (a group of residents from each of the neighborhoods who meet to discuss and address concerns) meeting and other interviews. This deficient practice placed residents at risk for dissatisfaction with the food, a diminished dining experience and the potential for less than adequate nutritional intake. Findings included . Review of the facility document, titled Resident Council Minutes September 2024, showed meeting minutes documented multiple complaints regarding the food quality including the food needed more taste. Review of the facility document, titled Resident Council Minutes October 2024, showed complaints of food quality including reports of cold food. <Resident 78> Review of the medical record showed Resident 78 admitted to the facility on [DATE],…
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 · D2024-12-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 conduct a complete and thorough assessment for self-administration of medications for 1 of 2 residents (Resident 39) reviewed for safe self-medication administration. This deficient practice placed residents at risk for medication errors and adverse medication interactions. Findings included . Review of the facility policy, dated December 2012, titled Administering Medications showed residents were able to self-administer their medications once the resident was assessed by the Interdisciplinary Care Planning Team, including the physician, and determined to have the decision-making capacity to do so safely. <Resident 39> Review of the medical record showed Resident 39 admitted to the facility on [DATE] with diagnoses of chronic lung disease, heart disease, and dizziness. Review of the comprehensive assessment, dated 11/21/2024, showed Resident 39 had an intact cognition and required the assistance of one person for Activities of Daily…
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 · D2024-12-16 · 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 provide an environment that reflected the physical needs and preferences of 1 of 2 residents (Resident 6) reviewed for accommodation of needs. This deficient practice placed the resident at risk for a diminished quality of life and increased dependence on staff. Findings included . <Resident 6> Review of the medical record showed Resident 6 admitted to the facility on [DATE] with diagnoses of chronic kidney disease, chronic lung disease and muscle weakness. Review of the comprehensive assessment, dated 09/30/2024, showed Resident 6 had intact cognition, required the assistance of two people for transfers, toileting, and used an electric wheelchair for mobility. During a concurrent observation and interview, on 12/10/2024 at 11:33 AM, Resident 6 stated they were unable to access things on the side of their bed that was near the window. There was a pathway of less than two feet between Resident 6's bed and desk, and Resident 6 stated they…
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 · D2024-12-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accuracy for the Pre-admission Screening and Resident Review [(PASARR) a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care] and Level II comprehensive evaluations were obtained for 2 of 6 residents (Resident 10 and 70) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Resident 10> Resident 10 was admitted to the facility with diagnoses including major depressive disorder (MDD - a mood disorder of persistent feelings of sadness, loss of interest, changes in sleep affecting how a person feels, thinks and behaves), dementia (a progressive disease that destroys memory and other important mental functions), anxiety, and hallucinations. The 09/27/2024 comprehensive assessment showed Resident 10 was dependent on one to two staff members for activities of daily living (ADLs) and 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 · D2024-12-16 · 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 review and revise the care plan related to urinary tract infection (UTI) treatment and prevention for 1 of 3 residents (Resident 17) review for care plan accuracy and revision. This deficient practice placed residents at risk for unmet and unidentified care needs. Findings included . <Resident 17> Review of the medical record showed Resident 17 was admitted to the facility on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (a condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in bladder control issues), diabetes (disease that occurs when body is unable to regulate the amount of sugar in the blood), and presence of a suprapubic catheter (a tube that's inserted into the bladder through a small incision in the lower abdomen to drain urine). Review of the comprehensive assessment dated [DATE] showed Resident 17 had moderate cognitive impairment and required the assistance of one person for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDED Based on observation, interview, and record review the facility failed to comprehensively assess and determine potential causative factors for recurrent urinary tract infections (UTIs) and provide UTI treatment consistent with professional standards of practice for 1 of 3 residents (Resident 17) reviewed for continuous urinary catheter (a flexible tube that inserted into the bladder to drain urine) use. This deficient practice placed residents at risk of unnecessary UTIs, antibiotic (medication used to fight infections caused by bacteria) use and delays in UTI treatment. Findings included . <Resident 17> Review of the medical record showed Resident 17 was admitted to the facility on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (a condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in bladder control issues), diabetes (disease that occurs when body is unable to regulate the amount of sugar in the blood), and presence of a suprapubic catheter…
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 · D2024-12-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted standards of practice for 2 of 2 residents (Resident 17 and 6) reviewed for respiratory care related to CPAP (Continuous Positive Airway Pressure) and BiPAP [(Biphasic Positive Airway Pressure) medical devices used to maintain an open airway while sleeping] use. This deficient practice placed residents at risk for respiratory status complications and potentially contributed to a recently treated sinus infection for Resident 17. Review of the facility policy, titled CPAP /BiPAP Support showed device pieces such as mask and tubing were to be cleaned with soap and water daily, and the filter and water chamber cleaned weekly. <Resident 17> Review of the medical record showed Resident 17 admitted to the facility on [DATE] with diagnoses of sleep apnea (a sleep disorder that causes breathing to repeatedly stop and start while asleep), diabetes (a disease resulting from the body's inability to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-16 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed proper food handling and storage practices for 2 of 3 residents' (Resident 20 and 72) personal refrigerators and 2 of 3 dining areas ([NAME] House and Cayuse House) reviewed for food safety. The failure to obtain and record refrigerator temperatures and store residents' personal condiments based on manufacturers' recommendations placed residents at risk for consuming expired food and food borne illness. Findings included . Review of the facility policy, titled Resident Personal Food Storage, dated 01/05/2021, showed all refrigeration units would have an internal thermometer to monitor for safe food storage temperatures and residents' personal refrigerators would be monitored by designated staff for food safety. Review of the Food and Drug Administration, Food Safety Code 2022, dated January 18, 2023, showed food products that are packaged are not all shelf-stable and must be refrigerated. If not, temperature…
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 · D2024-12-16 · 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 observation, interview, and record review, the facility failed to ensure staff followed infection prevention and control measures for the use of Personal Protective Equipment (PPE) and hand hygiene with contact enteric precautions (safety measures used by healthcare workers to prevent the spread of infectious agents that pose an increased risk for transmission through direct or indirect contact) for 6 of 7 staff (Staff G, H, I, L, J, and K) reviewed for infection control. These failures placed residents, staff, and visitors at risk of exposure and cross contamination of an infectious disease. Findings included . Review of the 08/03/2023 Washington State Department of Health guidance titled, Contact Enteric Precautions, showed prior to entering a room of a Clostridioides Difficile [(C-diff), a highly contagious bacterium that causes diarrhea and inflammation of the colon], resident, staff were required to perform hand hygiene, don (put on) an isolation gown, secure the straps/ties, and don gloves. 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.
- Potential for harm · Dcited before2024-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide the necessary adequate supervision for 1 of 3 residents (Resident 1) reviewed for elopement (leaving a facility without notice or supervision). This failure allowed Resident 1 to exit the facility unnoticed and placed the resident at risk for serious injury and/or exposure to the elements. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of Resident 1's comprehensive assessment, dated 09/19/2024, showed they had moderately impaired cognition. Review of Resident 1's plan of care, revised on 11/02/2024, showed they could walk from their room in [NAME] house outside to the Administration Building for activities or exercises, but on occasion would become disoriented to time and attempt to leave after hours or when offices were locked, believing it was time for an activity. The resident was not to leave their house…
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 · D2024-09-16 · 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 the medication cart was locked when left unattended by 2 of 4 staff (Staff B and C) reviewed for medication storage. This failure placed the residents, staff, and visitors at risk for unauthorized access to medications resulting in negative health outcomes. Findings included . Review of a policy titled, Administering Medications, revised 12/2012, showed during the administration of medications, the medication cart would be kept closed and locked when out of sight of the medication nurse. A concurrent observation and interview on 09/13/2024 at 9:56 AM, showed Staff B, Registered Nurse (RN), standing at the medication cart located in the main hallway, outside of the resident rooms. Staff B proceeded to prepare medications for the resident in room P10, placed the medication cards in the medication cart drawer, and closed the drawers. At 9:58 AM, Staff B, without locking the medication cart, entered the resident's room and closed the door. Staff B returned to the medication cart at 10:02 AM, four minutes…
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 before2024-03-07 · 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 services were provided to treat a resident for an uncontrolled elevated heart rate for 1 of 3 residents (Resident 1) reviewed for quality of care, despite staff awareness of new medication and treatment orders sent by the provider to the facility and Resident 1's continued elevated heart rate (HR). The failure of providing timely staff follow up with the provider's office to obtain the medication and treatment orders for Resident 1, placed them at risk for development and/or worsening medical conditions. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses including heart failure (the heart does not pump enough blood throughout the body), atrial fibrillation ([A-fib] an abnormal heart rhythm and fast irregular heartbeat) and Alzheimer's disease (a brain condition that caused a progressive decline in memory, thinking and behaviors). The 12/21/2023…
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 · Dcited before2023-11-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 notify the resident's representative for 1 of 3 residents (Resident 1), reviewed for notification of change. Failure to notify the representative of a change in the resident's skin condition placed the resident at risk of not having their representative involved in the health care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, diabetes, and chronic kidney disease. Resident 1's most recent comprehensive assessment, dated 08/30/2023, showed they required extensive assistance of two caregivers for bed mobility, transfers, dressing, and toileting and was moderately impaired cognitively regarding decision making of tasks for daily living. Review of Resident 1's nursing progress notes and skin assessments from 11/01/2023 through 11/15/2023 showed on 11/06/2023 a new reddened…
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
$10,358 in federal fines across 1 penalty.
- $10,358 — penalty dated 2026-02-27
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WASHINGTON STATE DEPARTMENT OF VETE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 02/15/2017 |
| GILBERT, SOLOMON | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/22/2023 |
| MURRAY, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/16/2021 |
| PUENTE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
| WESTHOFF, TERRANCE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2020 |
| GOMEZ BAUTISTA, JOSE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2025 |
| LENO, LONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 2024. 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, FY2024). 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 505530. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, 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 →
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