Colonial Vista Post-Acute & Rehab Center
625 Okanogan Ave, Wenatchee, WA 98801 · For profit - Corporation · 100 certified beds · (509) 663-1171 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — 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 | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 7.0% | 14.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.5% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.4% | 1.0% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.1% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.1% | 17.7% | 6.5% | better 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 | 4.2% | 2.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 0.0% | 17.2% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 5.8% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 93.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 22.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.7% | 15.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 82.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.5% | 19.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.7% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.65 | 1.52 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
62.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 304 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 135 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 39% 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 | 62.6%CMS range 57.3–67.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.7%CMS range 6.3–12.0 | 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 | 52.6% | 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 | 62.2% | 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 | 49.6% | 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 | 100.0% | 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 | 95.5% | 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 | 1.6% | 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 | 3.2% | 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 | 6.6%CMS range 4.3–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 100 beds and averages 80.7 residents a day — about 81% occupied, or roughly 19 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.63 hrs/resident/day on weekends vs 3.99 on weekdays — 9% thinner on weekends. RN hours go from 1.01 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · E2025-08-22 · 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 Preadmission Screening and Resident Review [(PASARR)-an assessment used to identify people referred to nursing facilities with serious mental illness (SMI), intellectual disabilities (ID), and related conditions were not inappropriately placed in nursing homes for long-term care] had the required Level II referral sent when residents had a positive Level 1 PASARR and were an exempted hospital discharge (a process that allowed residents admission to a nursing facility from a hospital without undergoing the PASSAR screening when certain criteria were met) in the facility for more than 30 days for 4 of 7 residents (Resident 35, 64, 44 and 8) reviewed for PASARR. Additionally, the mental health diagnoses were not accurately documented on the PASARR Level I. These failures placed the residents at risk for inappropriate placement and not receiving timely and necessary services to meet mental health care needs. Findings included. Resident 35 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 · E2025-08-22 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 ongoing program of meaningful activities for 6 of 6 residents (Resident 74, 14, 66, 57, 15, and 69) reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom. Findings included. Resident 74 Review of the medial record showed Resident 74 admitted to the facility on [DATE] with diagnoses including poliomyelitis (an infection that affects nerves, brain and spinal cord and can result in loss of muscle functions), diabetes (a disease that results in excess sugar in the blood), and obesity. The comprehensive assessment dated [DATE], showed Resident 74 required total assistance of one to two staff members with activities of daily living (ADLs) and was cognitively intact. Resident 14 Review of the medical record showed Resident 14 admitted to the facility on [DATE] with diagnoses including diabetes and kidney disease. The comprehensive…
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 · D2025-08-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for 2 of 5 residents (Resident 6 and 15) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity, respect and embarrassment. Findings included . Review of the policy titled Activities of Daily Living dated 03/2021, showed residents would be provided with care, treatment, and services to ensure their ADLs were maintained and did not diminish. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently in accordance with the care plan including appropriate support with assistance with elimination (toileting), hygiene (dressing) and eating. Resident 6Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain) and Alzheimer's Disease (a progressive brain disorder where brain cells are…
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 · D2025-08-22 · 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
Based on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed for safe administration of medications for 2 of 3 residents (Residents 35 and 79), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment placed the residents at risk for medication errors, adverse medication interactions, and complications. Findings included. Review of the policy titled, Self-Administration of Medications, revised 02/2021, showed residents had the right to self-administer medications when the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help people receive the care they need] determined it was safe and appropriate through an evaluation and assessment of the residents cognitive and physical abilities. The policy showed when a resident was identified as appropriate and safe to self-administer medications, it would be documented in the resident's medical record and care plan. Resident 35Review of the medical record showed Resident 35 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.
- Potential for harm · D2025-08-22 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were able to use personal possessions in their room, specifically a personal refrigerator, for 2 of 2 residents (Residents 74 and 69) reviewed for resident rights. This failed practice placed the residents at risk of feeling like their rights had been taken away and emotional distress. Findings included . Resident 74Review of the medial record showed Resident 74 admitted to the facility on [DATE] with diagnoses including poliomyelitis (an infection that affects nerves, brain and spinal cord and can result in loss of muscle functions), diabetes (a disease that results in excess sugar in the blood), and obesity. The comprehensive assessment dated [DATE], showed Resident 74 required total assistance of one to two staff members with activities of daily living (ADLs) and was cognitively intact.Resident 69Review of the medical record showed Resident 69 admitted to the facility on [DATE] with diagnoses including heart disease…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-22 · 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
Based on interview and record review, the facility failed to ensure adequate monitoring and indications for use was in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 1 of 5 residents (Resident 10) reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and adverse side effects. Findings included .Review of the policy titled, Antipsychotic Medication [used to treat mental health symptoms], dated 08/2024, showed nursing staff would observe and document information regarding the effectiveness of any antipsychotic medications. It further showed that nursing staff would review for appropriate indications for use for the drug, monitor for and report to the attending physician, side effects and adverse consequences.Resident 10Review of the medical record showed Resident 10 admitted to the facility with diagnoses including dementia (a decline in mental ability, specifically affecting thinking, memory, and reasoning), depression (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-22 · 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 provide adequate supervision during meals consistent with resident needs for 1 of 3 residents (Resident 15) reviewed for accidents and supervision. This failure placed Resident 15 at risk for choking and adverse health outcomes. Findings included. Resident 15 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included cerebral palsy (a disease due to abnormal brain development which causes disorders of movement, muscle tone and posture), and dysphagia (difficulty swallowing). Review of the comprehensive assessment dated [DATE] showed the Resident 15 was cognitively intact and dependent on staff for dressing, grooming and personal hygiene however they were able to eat independently after their meal was set up. Review of a physician order dated 08/20/2025 showed Resident 15's diet was regular texture with soft bite sized pieces served with gravy or sauce to decrease choking risk and thin…
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 · D2025-08-22 · 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 Based on observation, interview, and record review, the facility failed to ensure a resident who was continent of bowel and bladder received services and assistance to maintain their continent status for 1 of 2 residents (Resident 19) reviewed for bowel and bladder function. Failure to identify the decline in bladder and bowel continence and assess/determine causative factors, left the resident at risk for continued decline, feelings of embarrassment, and a decreased quality of life. Findings included. Resident 19 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory disease, diabetes, obesity, kidney disease, and depression. Resident 19's comprehensive assessment dated [DATE], showed they required total assistance of two staff members for bed mobility and transfers with a mechanical lift and were cognitively intact. During a concurrent observation and interview with Resident 19 on 08/19/2025 at 10:40 AM, showed them lying in bed with only a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-22 · 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 Infection Prevention and Control Guidelines and standards of practices were followed; 1. During a facility COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) outbreak to mitigate the risk for transmission of COVID-19 on 1 of 3 halls (South Hall); 2. During a residents Peripherally Inserted Central Catheter [(PICC) a long thin tube inserted through a vein in an arm to the heart to administer fluids, medications, and blood draws] dressing change for 1 of 2 residents (Resident 79). These failures placed residents, staff and visitors at risk for exposure to cross contamination (harmful spread of diseases) and the transmission of infectious diseases. Findings…
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 · D2024-11-15 · tag F0560 — isolatedProtect a residents' right to refuse some types of non-requested transfers within the nursing home.
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 honor residents' right to refuse a room transfer when their payor source changed for 1 of 2 residents (Resident 1) reviewed for choices. This deficient practice placed residents at risk for feeling vulnerable, disheartened and powerless. Findings included . Review of the undated facility policy, titled Room Change/Roommate Assignment, showed residents had the right to refuse a room transfer if the purpose was to relocate a resident from a Skilled Nursing unit (a living unit with the focus of regaining strength, endurance and independence through the skilled services of nursing and therapy) to a Long-Term Care (LTC) unit [a living unit with the focus of being a home with staff assistance to complete Activities of Daily Living (ADLs) ongoing]. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of respiratory failure, diabetes (a condition that happens when the body can't use glucose [a 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.
Show the remaining 15 citations
- Potential for harm · F2024-09-27 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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
Based on observation, interview, and record review, the facility failed to maintain safe food holding temperatures for 1 of 2 meal preparations (lunch meal on 9/26/2024) reviewed for safe and sanitary kitchen. This failed practice placed all 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 . Review of a policy titled Food Preparation and Service dated 11/2022, showed the danger zone for food holding temperatures is below 135 Farenheit (F, a unit of temperature measurement) and the longer food sits below 135 F the higher the risk for the growth of harmful pathogens. A lunch meal preparation observation and concurrent interview on 09/26/2024 at 10:55 AM, showed the prepared food had been stored in the steam table at 11:05 AM for a serve out time of 11:45 AM. The temperatures of the food were as follows; Baked Chicken was at 119 F, ground chicken 134 F, brown gravy 132 F, carrots 127 F. Further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 discard expired foods in 1 of 1 dry storage and 1 of 1 walk in refrigerator reviewed for safe and sanitary kitchen. This failed practice placed all 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 . During the general tour of the kitchen on 09/23/2024 at 10:31 AM, showed expired foods in the dry storage room of the kitchen as follows; 1) three 46-ounce (oz, a unit of measure) containers of orange juice concentrate that expired on 09/18/2024, 2) four 46 oz containers of thickened cranberry cocktail that expired on 06/26/2024, 3) two packages of six-inch (in, a unit of measure) flour tortillas (24 tortillas to a bag) that expired on 06/30/2024 and four packages that expired on 08/07/2024, 4) four packages of eight-in flour tortillas (12 tortillas per package) that expired on 08/06/2024, 5) two packages of 12-in flour tortillas (12…
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 · E2024-09-27 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 3 residents (Residents 62 and 214) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and monetary charges associated with the bed hold while in the hospital. Findings included . Review of a policy titled, Bed Hold - [NAME], dated 08/01/2024, showed when a resident was transferred or discharged , the nursing department would provide the resident and/or their representative with a copy of the bed hold policy. If nursing was unable to provide the notice at the time of transfer or discharge, the Social Services Director or designee would contact the resident and/or their representative to notify them of the facility policy and obtain a decision on bed hold. <Resident 62> Review of the medical record 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 · E2024-09-27 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 the provision of ongoing assessments and monitoring in accordance with professional standards of practice for 5 of 5 residents (Residents 7, 23, 25, 122 and 1) reviewed for quality of care. The failure to assess and monitor for impaired skin integrity, edema, (swelling caused by presence of excess fluid in the body tissues) and bowel management placed the residents at risk for unmet care needs and negative health outcomes. Findings included . <Skin> Review of a facility policy and procedure document titled Skin at Risk/Skin Breakdown last revised on 09/2020 showed .A full body skin evaluation is completed on admission and weekly by the licensed nurse. Updates of current non-pressure areas coincide with the weekly full body skin audit and monitors bruises, skin tears and abrasions on the resident's Treatment Administration Record (TAR). All other skin impairment concerns are documented on the 'Skin-Wound Form' (an electronic health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 prevent accidents by not ensuring residents who smoked were assessed for safety and kept their smoking paraphernalia stored in a locked area not accessible to other residents for 3 of 3 residents (Residents 23, 30, and 164) reviewed for smoking. Additionally, the facility failed to store a portable oxygen tank in a safe manner for 1 of 3 oxygen storage rooms (oxygen storage room [ROOM NUMBER]). This failure placed all residents at risk for avoidable accidents, injuries, and the potential risk of fire. Findings included . <Smoking> Review of the Smoking policy dated 08/01/2024, showed residents who smoke independently or require supervision would be evaluated for their ability to smoke safely upon admission or at the time they decide to smoke, and the policy would be signed prior to them smoking. The policy showed residents would be reassessed at least quarterly or with significant changes in condition and that all smoking paraphernalia…
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 · D2024-09-27 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer are able to make decisions for themselves because of illness or incapacity) for 2 of 3 residents (Residents 1 and 10) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include breast cancer (when abnormal breast cells grow out of control and form tumors) and diabetes (a chronic disease that affects how the body uses insulin and glucose). The 07/16/2024 comprehensive assessment showed Resident 1's cognition was intact and able to make their own decisions. During an interview on 09/23/2024 at 11:55 AM, Resident 1 stated they 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 · D2024-09-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to assess, monitor, or treat skin to prevent the development of facility-acquired pressure injuries (PIs) for 1 of 3 residents (Resident 1) reviewed for PIs. This failed practice placed residents at risk for worsening or new pressure injuries, pain, and unmet care needs. Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: • Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). • Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). • Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which…
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 · D2024-09-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral feedings [(EF) the delivery of nutrients through a tube directly into the stomach to provide nutrition for those who cannot obtain nutrition by mouth, were unable to safely swallow, or need nutritional supplementation] for 1 of 1 resident (Resident 214) reviewed for EF. This failed practice placed the resident at risk for receiving expired and/or inaccurate enteral nutrition, adverse consequences, and complications of tube feeding. Findings included . Review of a policy titled, Enteral Feeding Tubes, dated [DATE], showed the Registered Dietician (RD) calculated the nutritional value of the EF and made recommendations as needed. Upon admission or initiation, the licensed nurse (LN) obtained a physician's order for the recommended EF formula. Additionally, when the EF bag and tubing was hung, the LN labeled the enteral feeding container/bag with the resident's name, date, time,…
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 · D2024-09-27 · 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
Based on observation, interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 5 residents (Resident 34) reviewed for trauma informed care. The facility failed to identify triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding Resident 34's history of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Record review of the facility policy titled Trauma-Informed Care, dated 08/01/2024, showed .The facility will recognize how trauma effects individuals through evaluation and identification of triggers during the admissions process. The facility will develop an appropriate plan of care and interventions based upon the residents' triggers and will modify the plan of care for any changes in behavior . <Resident 34> 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 · Dcited before2024-09-27 · 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 infection prevention and control measures were implemented for hand hygiene/handling medications during medication administration for 1 of 5 staff (Staff M), and use of personal protective equipment when entering a contact precautions (safety measures used by healthcare workers to prevent the spread of infectious agents that can be transmitted through direct or indirect contact) room for 1 of 3 resident rooms (room [ROOM NUMBER]) reviewed for infection control. These failures placed residents, staff, and visitors at risk for exposure to cross contamination of infectious disease. Findings included . Review of a policy titled, Hand Hygiene, dated 08/01/2024, showed hand hygiene was the primary means of preventing the transmission of infection and should be performed as soon as possible after contamination such as before/after direct contact with a resident. Review of a policy titled, Transmission Based Precautions (a set of infection…
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 · D2024-09-27 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to provide a safe and functional environment for residents, staff, and visitors related to the handicap push plate (a button that allows people with disabilities to access an area by the push of a button) being out of service on 1 of 2 doors (main entrance). This failure placed residents, staff, and visitors at risk for accidents and a disrupted environment. Findings included . During an interview on 09/23/2024 at 11:20 AM, Resident 3 stated that the front door handicap push plate opener was not working and had not been for a very long time. Resident 3 stated they had to ask staff to take them outside and they had to ring a bell to get back inside. Resident 3 stated it took a while for someone to come and take them outside when requested and then they had to wait a long time for someone to come and let them back inside. Resident 3 further stated they would like to be able to go out of the facility and come back in when they wanted to as it was their right to do so. During an interview on 09/24/2024 at 3:21 PM, Staff Q,…
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 · E2023-08-08 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 repairs were made to 3 of 10 resident rooms (Residents 13, 15, and 39 - [NAME] Hall) that had large gouges (indentation or groove made in a surface to cause holes or damage) with peeling paint to the wall in the back and to the side of the resident's head of their bed and damage to the floor. Additionally, there were no curtains on the windows and the vertical blinds had missing panels/slats for 5 of 9 resident rooms (Rooms 13, 15, 16, 17, and 18-West Hall). The doors and furniture were worn and scratched. These failures placed residents in a less than homelike environment. Findings included . Review of the facility's job description titled, Maintenance Director Essential Duties and Responsibilities, dated June 2019, showed they .inspect physical plant, furnishings and equipment on a regular basis identifying needed repairs or improvements .and coordinates maintenance services with other departments, team members and residents .…
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 before2023-08-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 standard infection prevention and control precautions were implemented for 1) Hand hygiene practices for 2 of 5 staff (Staff J and N) observed during meal tray delivery to residents, 2) Staff use of personal protective equipment (PPE) when entering/exiting a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) Transmission Based Precaution (TBP, safe guards put in place to help prevent the spread of disease) room for 4 of 5 staff (Staff R,O,P and Q) reviewed for infection control, and 3) Staff's N95 mask (a specific type of mask used to protect against certain diseases) fit testing (a procedure that ensure the masks is properly fitted to the users face to prevent the spread of disease) completion 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 · D2023-08-08 · 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 1) identify and monitor individualized targeted behaviors prior to administering a psychotropic medication (drugs that affect brain activities associated with mental processes and behavior), 2) monitor for adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition), and 3) ensure adequate indications of use for 1 of 5 residents (Resident 54), reviewed for unnecessary medications. These failures placed the resident at an increased risk of medical complications, unnecessary psychotropic medication side effects and a decreased quality of life. Findings included . Review of the facility's policy titled, Psychoactive Medications, dated October 2022, showed on admission, the resident's medication regimen was reviewed for psychotropic medication orders and a nursing review for complete orders as follows: • Appropriate diagnosis for the drug • Monitoring…
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 · D2023-08-08 · 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 1 of 2 medication storage rooms (East/West Hall) and 2 of 5 medication carts (East/West Medication Cart #2 and South Hall Medication Cart) was free from expired medications. This failed practice placed the residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications. Findings included . Review of the facility policy titled, Storage of Medication, dated 01/2023, showed that outdated, discontinued, or deteriorated medications were immediately removed from stock and disposed of. Medication storage was to be kept clean, well lit, organized, and free from clutter. Additionally, medication storage conditions were to be monitored on a regular basis. During an observation on 08/07/2023 at 1:44 PM, showed the medication storage room on the East/West Hall contained locked cabinets lining the perimeter of the room along with three medication carts in the center of the room. There was a long countertop located on the East side of the room that held several cardboard…
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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2024-12-27 for 39 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PROVIDENCE GROUP INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2013 |
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST | — | since 08/01/2024 |
| APT, FREDERICK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/14/2024 |
| CARPENTER, KYRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2024 |
| HAMMONDS, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/07/2025 |
| JERGENSEN, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/14/2024 |
| JONES, CAMILLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/29/2024 |
| MITCHELL, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/14/2024 |
| PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC | Organization | ADP OF THE SNF | — | since 08/01/2024 |
| WENATCHEE 625 REALTY LLC | Organization | ADP OF THE SNF | — | since 08/01/2024 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 505413. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-22, 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 →
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