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Summitview Rehab And Health Center

3801 Summitview Avenue, Yakima, WA 98902 · Non profit - Corporation · 78 certified beds · (509) 965-5240 Medicare & Medicaid certified

Call the home — (509) 965-5240 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 20243 actual-harm citations$194,266 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $194,266 in federal fines (most recent 2026-03-24)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3800 Summitview Ave 100 · (509) 248-7849 · Call to confirm hours
Pharmacy
3910 Summitview Ave · (509) 966-9672 · Call to confirm hours
Grocery
5605 Summitview
Park
Typically dawn to dusk
Place of worship
3902 Summitview Ave · (509) 307-7953

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.3%14.2%15.4%typical
Long-stay residents who lose too much weight5.5%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%1.0%0.9%better
Long-stay residents with a urinary tract infection0.6%1.6%2.0%better
Long-stay residents with depressive symptoms35.0%17.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.9%2.6%3.3%better
Long-stay residents whose ability to walk worsened27.0%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication4.8%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.8%95.3%typical
Long-stay residents with pressure ulcers3.1%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control28.4%22.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.2%15.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.7%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine90.7%82.0%79.4%better
Short-stay residents rehospitalized after admission18.9%19.9%22.6%better
Short-stay residents with an outpatient ER visit7.1%13.4%12.0%better
Long-stay hospitalizations per 1,000 resident days0.801.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.231.521.80better

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

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

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

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

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

55.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.5%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
70.5%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 70.5% 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 95 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.5%CMS range 48.3–64.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.3–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge70.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge62.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.3–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.16
RN hours/ resident / day
1.04
LPN hours/ resident / day
3.01
Aide hours/ resident / day
5.22
Total nurse hours/ resident / day
0.60
RN hoursweekends
25.3%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 78 beds and averages 54.0 residents a day — about 69% occupied, or roughly 24 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.01 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 4.42 hrs/resident/day on weekends vs 5.54 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.39 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below 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

6
deficiencies at the latest standard inspection (2026-05-22)
9
at the previous standard inspection (2025-04-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2026-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for falls with injury, was provided adequate supervision to prevent accident hazards. Resident 1 experienced harm when they were left alone on the toilet and found on the bathroom floor after an unknown amount of time. The fall resulted in a forehead hematoma (a pooling of blood in the surrounding tissues after an injury to the blood vessels) with bleeding, and transfer to the hospital where they were diagnosed with a brain bleed. Failure to identify residents that need supervision while on the toilet put residents at risk for injuries and diminished quality of health. Findings included .Review of Resident 1's medical record showed that they were admitted on [DATE] after a stroke (a medical emergency occurring when blood flow to part of the brain is blocked or a blood vessel bursts). Review of the 01/20/2026 comprehensive assessment showed that they had severe cognitive impairment and required assistance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions to prevent injuries or falls, during resident transfers (helping residents move safely from one place to another) for 2 of 5 residents (Resident 1 and Resident 4) reviewed for falls or injuries acquired during transfers by staff. Resident 1 experienced harm when the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in pain and ankle fractures and put residents that require transfer assistance at risk for injury. Findings included Record review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 07/2017, showed that a resident's safety will be incorporated into the goals and decisions regarding the safe moving of residents; Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' need for transfer assistance. Staff will document 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-06-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice to prevent facility acquired pressure injury (PI) and worsening of PIs for 2 of 3 residents (Residents 49, and 18) reviewed for PIs. Resident 49 experienced harm when they developed a stage 4 medical device-related PI (MDRPI) to their right lower leg from an immobilization brace (a rigid medical device that holds a joint or bone in place to aid in restricting movement of the injured area to assist with healing) that became infected and resulted in extreme pain. Resident 18 experienced harm when they developed a right buttock PI that worsened, became infected, and required antibiotic treatment. These failures placed residents at risk for medical complications, and unmet care needs. Findings included . Review of the National Pressure Injury Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-22 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 provide dignified care in a manner and in an environment that enhanced dignity and quality of life for 4 of 6 residents (Residents 2, 5, 7 and 28) reviewed for dignity. This failure placed residents at risk for unmet needs and a poor quality of life. Findings included. Record review of a facility policy titled, Dignity, dated 02/2021 showed .Residents are always treated with respect and dignity.Residents are provided with a dignified dining experience.Staff protect confidential clinical information, and verbal communication is kept outside the hearing of other residents or the public. Resident 2 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included a history of stroke (blood flow to the brain is blocked causing lack of oxygen to brain tissue), dementia (a decline in mental ability that interferes with daily life) and depression. The comprehensive assessment dated [DATE] showed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-22 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's Power of Attorney (POA), was fully informed of the admission agreement to include payment for services and co-payment requirements for 1 of 3 residents (Resident 43) reviewed for admission to the facility. This failure placed the resident/POA at risk for the inability to make informed decisions regarding the resident's health care, alternative treatments and the right to refuse care/services. Findings included. Resident 43Review of the medical record showed the resident was admitted to the facility on [DATE] with a post-operative diagnosis of a fractured left shoulder with a shoulder joint replacement. Other diagnoses included depression and delirium (a state of confusion, memory issues related to a medical or psychological condition). The 05/05/2026 nursing admission assessment showed the resident had cognitive impairment and required assistance with Activities of Daily Living (ADL) for transfers. Review of the 05/04/2026 Social…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-22 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR, a process to determine if a potential nursing home resident had a serious mental illness [SMI] or intellectual disability needs which required further assessment/treatment) had the required Level 2 PASARR referral sent when a resident had a positive Level 1 PASARR and was in the facility more than 30 days for 1 of 7 residents (Resident 10) reviewed for PASARR. 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.Review of the medical record showed Resident 10 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive brain disorder that affects movement and balance), syncopal episodes (fainting or a loss of blood flow to the brain leading to loss of consciousness) and depression. The 04/09/2026 comprehensive assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement documentation/monitoring of depression symptoms per the comprehensive resident centered care plan and honor resident preferences with nighttime routines for 1 of 6 residents (Resident 38) reviewed for care plan implementation. This failure placed residents at risk for unidentified mental health symptoms and unmet care needs.Findings included .Review of the medical record showed Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of a fracture to the left leg, respiratory failure (occurs when the lungs fail to provide adequate oxygen to the rest of the body), lung infection and protein calorie malnutrition (a form of undernutrition, caused by not eating enough protein/calories, leading to muscle/fat loss and impaired bodily functions). The 04/23/2026 comprehensive evaluation showed the resident was cognitively intact, able to make their needs known and required assistance from one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-22 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the nature/terms of entering into a binding arbitration agreement (an alternative means of settling disputes through a third party arbitrator, instead of traditional court/judicial systems) were explained to residents in a form and manner in which they could understand for 2 of 5 residents (Resident 11 and 5) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding concerning the legal contract that had been signed/entered into and being fully informed regarding their choice in the event of a dispute with the facility.Findings included.Resident 11Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnosis including multiple respiratory complications, stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage), altered mental status (a change in mental function from various illnesses, disorders, or injures affecting 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of infections were consistently implemented in the areas of hand hygiene (HH) for 1 of 2 dining rooms (DR 1 and Transmission Based Precautions ([TBP] specialized infection control measures used in health care settings alongside basic standard precautions) for 1 of 2 residents (Resident 12) reviewed for infection control practices. This failure placed the residents at risk for transmission of communicable diseases, and illness. Findings included. Hand Hygiene During an observation on 05/18/2026 at 11:36 AM, Staff P, Dietary, was in DR 1 with gloves on. Staff P touched resident wheelchairs to assist them to their tables, repositioned them, placed shirt protectors on the residents and touched multiple surfaces. Staff P, without performing HH or changing their gloves, proceeded to make drinks and serve them to the residents who were seated in the dining room. During an observation on 05/18/2026 at 11:46 AM, Staff P, still…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-18 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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 provide food at the proper temperatures, appetizing and palatable to taste for 4 of 7 residents (Resident 20, 25, 42, and 43) reviewed for nutrition. This failure placed residents at risk for foodborne illnesses, a decreased nutritional intake, and potential for weight loss. Findings included . Review of the facility's undated policy, titled Food Safety, showed food would be served in such a way as to prevent bacterial growth and served immediately. Additionally, to provide food that is fresh at the proper temperature to keep food safe, wholesome and appetizing. <Resident 20> During an interview on 04/16/2025 at 11:07 AM Resident 20 stated that they were served eggs daily in their room for breakfast, which were cold, and they are unable to eat them. <Resident 25> During an interview on 04/16/2025 at 11:10 AM Resident 25 stated that the food served was sometimes cold and reported this to the staff. <Resident 42> During an interview on 04/16/2025 at 11:15 AM Resident 42 stated that the meal service was too…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained by not performing hand hygiene and glove changes between dirty and clean tasks for 3 of 4 staff (Staff R, T and Q) reviewed during resident cares and dining. This failed practice placed residents at an increased risk for exposure to cross contamination (harmful spread of infections) and the development of communicable diseases. Findings included . Review of the facility's policy dated August 2019, titled Handwashing/Hand Hygiene showed the facility considered hand hygiene the primary means (define or source/action/infection preventions) for preventing the spread of infections. <Dining> An observation on 04/14/2025 at 11:58 AM, showed Staff R, Nursing Assistant, grabbed Resident 35's spoon and assisted the resident with a bite of food without performing hand hygiene. Staff R then grabbed an unidentified resident's napkin, wiped the unidentified resident's face and then placed the napkin in their hand. Staff R then proceeded to assist Resident 35…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-18 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's right to choose important aspects of their life including frequency and type of bathing preferences for 2 of 3 residents (Residents19 and 29) reviewed for choices. This failure to honor resident choices placed the residents at risk for impaired hygiene and feelings of embarrassment. Findings included . Review of the policy titled, Resident Rights, revised on 02/2021, showed the resident has the right to self-determination and be supported by the facility when exercising their rights. <Resident 19> Review of the medical record showed Resident 19 was admitted to the facility on [DATE] with diagnosis including Alzheimer's (a progressive disease that destroys memory and other important mental functions), pressure ulcer (a wound that develops when constant pressure on the skin restricts blood flow to the area, leading to tissue damage), and chronic pain. The 01/31/2025 comprehensive assessment showed Resident 19 was dependent on one…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-18 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that included the minimum requirements of resident specific goals, physician orders, dietary orders, treatment plans and social service needs for 3 of 5 residents (Residents 29, 208, and 258) reviewed for baseline care plan. This failure placed residents at risk of not receiving necessary care and services, and a continuity of care. Findings included . Review of the facility's policy titled Care Plans-Baseline, revised March 2022, showed a baseline plan of care would be developed within 48 hours of admission to meet the resident's immediate health and safety needs. The baseline care plan would include effective, person-centered care of the residents and contain the minimum healthcare to include initial goals based on admission orders, discussion with residents/representatives, physician orders, dietary orders, therapy services, and social services. <Resident 29> Review of the medical record…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2025-04-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident care plans were developed with appropriate interventions for 2 of 2 residents (Resident 18 and 208) reviewed for care planning. This failure to develop care plans with appropriate interventions placed the residents at risk for inadequate or unsafe care. Findings included . Review of the facility's policy dated March 2022, titled Care Plans, Comprehensive Person Centered, showed assessments of residents were ongoing, and care plans were to be revised as information about the residents and/or their condition changed. <Resident 18> Review of Resident 18's medical records showed they were admitted to the facility on [DATE] with diagnoses to include muscle weakness, right shoulder pain, osteoporosis (a bone disease that weakens and makes bones brittle, increasing the risk of fractures), and dementia (the loss of thinking, remembering, and reasoning to the extent that interferes with Activities of Daily Living [ADLs]). 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 bathing, nail care, and oral care for 3 of 10 dependent residents (Residents 26, 41 and 15) reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene, body odor, dental caries (cavities or tooth decay), decreased self-worth and diminished quality of life. Findings included . Review of the facility's policy dated March 2018, titled Activities of Daily Living (ADL's), Supporting, showed appropriate care and services would be provided for residents who are unable to carry out ADLs independently and receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. <Resident 26> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with multiple sclerosis (MS-a disease that causes breakdown of the protective covering nerves causing trouble walking, vision changes and numbness). A stroke (happens when…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 2 of 3 sampled residents (Residents 41and 18) reviewed for positioning and range of motion received services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) through use of assistive devices. This failure increased the resident's risk of being unable to maintain their current level of functioning, increased risk of pain and breaks in skin integrity related to a contracture. Findings included . <Resident 41> Review of the medical record showed the resident was re-admitted to the facility on [DATE] with diagnoses to include a stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with right side paralysis (loss of ability to move a body part due to nerve damage), and difficulty with swallowing and speaking. The 04/05/2025 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-18 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 honor food preferences for 2 of 4 residents (Resident 29 and 32) reviewed for dietary preferences. This failure placed the residents at risk for dissatisfaction with their dining experience and weight loss. Findings included . <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility on [DATE] with diagnoses including a stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with left-sided weakness, diabetes (a condition that results in too much sugar in the blood), and dementia (a progressive disease that destroys memory and other important mental functions). The 03/17/2025 comprehensive assessment showed Resident 29 required substantial/dependent assistance of one to two staff for activities of daily living (ADLs) and had moderately impaired cognition. Record review of a document titled, Nutrition Food Preference form, dated 03/28/2025, showed no…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-18 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the nutritional refrigerator was kept in a sanitary manner and undated /expired foods were discarded, for 1 of 2 nutritional refrigerators (recreational room refrigerator), reviewed for food safety. This failure placed residents at risk of consuming contaminated, expired foods and obtaining a food-borne (a disease transmitted to people by food) illness. Findings included . An observation on 04/16/2025 at 4:01 PM, of the nutritional refrigerator located in the resident recreation room, showed within the freezer there was a large container of ice cream without a resident's name or a date to show a open or use by date. The freezer contained three chocolate ice cream bars with resident names and had no date of when they were placed in the freezer, or a date of expiration. During the same observation of the nutritional refrigerator, showed a strong foul, sour odor of spoiled food. The shelves were filled with trays of food sitting on top of other plates or boxes of food. The refrigerator had five Jello cups…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the local health jurisdiction (LHJ) and the State of a communicable disease outbreak within required time frames for 20 of 20 residents (1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19, and 20) reviewed for symptoms of a highly contagious gastro-intestinal (GI) illness starting on 11/18/2024. Additionally, 19 staff reported symptoms with the last symptom onset on 12/09/2024. These failures placed residents at risk for a diminished quality of life, unmet care needs and placed residents at risk for the spread of infection. Findings included . Record review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev 02/03/2023, F880, showed the definition of an infectious disease outbreak was the occurrence of more cases of disease than expected in a given area over a particular period of time. Record review of [NAME] Administrative Code 246-101-101 Notifiable Conditions, showed that health care facilities…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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) including incorporating ADs into the care planning process for 1 of 5 residents (Resident 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 . Review of a policy titled Advanced Directives, dated September 2022, showed when a resident admitted , the facility would inquire about any existing written ADs and if not, would provide the resident or the resident's legal representative assistance and written information with the resident's right to refuse, accept, or formulate an AD. The facility would then document in the resident's medical record the resident's decision.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of abuse and/or neglect to the State Agency for 2 of 3 residents (Residents 27 and 13) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and ongoing abuse/neglect. Findings included . Review of the Nursing Home Guidelines, or The Purple Book, guidelines dated October 2015 showed facilities were required to report to the state agency immediately when there was a .reasonable cause to believe abuse, neglect .has occurred, or On the reporting log within 5 days of discovery. Review of facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021, showed, the facility would report of all alleged violations of abuse/neglect to the required agencies within specified timeframes required by Federal requirements. <Resident 27> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnosis including right femur…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 conduct a thorough investigation into an allegation of abuse for 2 of 3 residents (Resident 27 and 13), reviewed for abuse and neglect. This failure placed the residents at risk for unidentified abuse, unmet care needs, and the continued exposure to abuse and/or neglect. Findings included . <Resident 27> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnosis including right femur (thigh bone) fracture, high blood pressure, atrial fibrillation (irregular heartbeat) and Lymphedema (swelling caused by a build up of fluids usually in the arms or legs). The comprehensive assessment dated [DATE] showed the resident had an intact cognition and required assistance of one to two staff members for activities of daily living (ADLs, daily actions like dressing, transferring and toileting). Review of the form titled, Quality concern form, dated 05/29/2024, showed Resident 27 went to Staff B, Director 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 recognize a significant change in status assessment needed to be completed for 1 of 2 residents (Resident 18) reviewed for comprehensive assessments who experienced a decline in skin integrity, weight loss, and swallowing and eating abilities. Failure to complete significant change of status care assessment placed the resident at risk for not receiving the care and services they required. Findings included . Review of the Resident Assessment Instrument ([RAI], provides guidance on assessing a residents' health and functional status) manual, dated August 22, 2023, showed a significant change is identified by a decline or improvement in a resident's health that will not resolve itself without staff or clinical interventions, impacts more than one area of the resident's health, and requires a new Minimum Data Set ([MDS], a standardized comprehensive assessment of each resident's functional capabilities and helps nursing home and staff…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 36> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including delusional disorder (a type of mental health condition in which a person cannot tell what is real from what is imagined) and developmental disorder (impairments in physical, cognitive, language, or behavioral development). The comprehensive assessment dated [DATE] showed that resident had an impaired cognition and required extensive assist of one staff member for activities of daily living. Review of a Physicians visit note dated 07/25/2023, showed a diagnosis of Paranoid Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves. It causes a person to fear that others are watching them or trying to harm them) was added for Resident 36. Review of Resident 36's medical record showed no level I or level II PASARR had been updated since the new diagnosis of Paranoid Schizophrenia was added on 07/25/2023. During an interview on 06/06/2024 at 1:47 PM,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP to the resident for 1 of 5 newly admitted residents (Residents 49) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs. Findings included . <Resident 49> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including a fracture of their right lower leg bone, that did not require surgery but had a compression bandage (a stretchable cloth that applies pressure when wrapped around a limb to help reduce/prevent swelling) wrapped around a hard immobilization brace (a rigid medical device that holds a joint or bone in place to aid in restricting movement of the injured area to assist with healing) and an open…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion (ROM) received the necessary services to maintain their level of positioning in their tilt in space wheelchair (a wheelchair that can be tilted from the head rest to the seat of the wheelchair without changing the angle of the whole wheelchair) without further decline for 1 of 1 resident (Resident 20), reviewed for limited ROM and wheelchair positioning. This failure placed the resident at risk for increased pain, skin breakdown, and diminished quality of life. Findings included . <Resident 20> Review of the medical records showed the resident was admitted to the facility on [DATE] with gastric reflux disease, a stroke with left sided hemiparesis (muscle weakness/partial paralysis), significant contractures (shortening of a muscle or tendon resulting in joints and other areas to become stiff) of the which hands, arms, legs, and hips bilaterally. The resident was dependent on staff for all…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide prompt routine dental services for 1 of 3 resident (Resident 29) reviewed for dental services. The failure placed the resident at an increased risk for dental care complications and unmet care needs. Findings included . <Resident 29> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including a stroke, severe dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and moderate protein calorie malnutrition (an imbalance between the nutrients your body needs and he nutrient it gets). The 05/13/2024 comprehensive assessment showed the resident had severe cognitive impairment, had difficulty communicating but was usually understood. The resident was dependent on staff for oral hygiene and required maximal assistance from staff with eating. During an interview on 06/05/2024 at 9:19 AM, Resident 29's representative stated they had concerns that Resident 29 had not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure routine dental services were provided for 1 of 2 residents (Resident 20) reviewed for dental services. The failure to act on a routine dental referral for examinations, x-rays, and cleaning, resulted in a delay in treatment and placed the resident at risk for dental pain, difficulty chewing, and unmet dental needs. Findings included . <Resident 20> Review of the medical record showed the resident was admitted to the facility on [DATE] with a stroke, left sided paralysis, significant contractures (shortening of muscle, tendon causes tightening and lack of flexibility and makes movement difficult) of the left and right arms and legs, and many other health related conditions. The resident's 05/24/2024 comprehensive assessment, showed the resident was able to make needs known and was dependent on staff for all needs to include transfers by a mechanical lift, eating, bathing, personal care, oral care, and positioning. There were no…

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

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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions for, 1) hand hygiene and glove change for 3 of 10 staff (Staff BB, CC, and DD) reviewed during resident cares and wound treatment, 2) central venous catheter (central line, a tube often place through the skin in a large vein in the neck, chest or groin so that the tip of the tube sits near the heart in order to give medication/fluids or to collect blood and can remain in place for a longer period of time than normal venous catheters) sterile (free from bacteria ,totally clean) dressing change for 1 of 1 resident (Resident 8) reviewed for infection control practices, and 3) use of Personal Protective Equipment (PPE) in an enhanced barrier precautions (EBP, indicated with high contact resident care activities with an infection, a long term wound, central line device or colonization [the presence of a bacteria that has not yet started its infection process] of an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for 3 of 10 resident rooms (rooms [ROOM NUMBER]) that had large gouges (indentation or groove made in a surface to cause holes or damage)/peeling paint from the walls, 1 of 2 soiled utility rooms (600 hallway), 1 of 2 clean utility rooms (600 hallway), and 1 of 1 laundry room (LR1), reviewed for a safe and sanitary environment. This failure placed staff and residents at an increased risk for infections related to non-cleanable surfaces and not feeling safe/secure with their environment. Findings included . Review of the Document titled, [Name of Facility] Schedule of Charges, dated 04/01/2024, showed part of the services included in the daily rate were, the facility would provide maintenance and housekeeping services to ensure a safe and comfortable environment. Review of the facilities undated job description titled, Director of Building and Grounds, showed, .The Director of Building and Grounds is…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$194,266 in federal fines across 3 penalties.

  • $15,935 — penalty dated 2026-03-24
  • $91,985 — penalty dated 2025-01-24
  • $86,346 — penalty dated 2024-06-12

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 HUMANGOOD — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.5+0.5 vs chain
Health inspection 4 of 53.6+0.4 vs chain
Staffing 5 of 54.9≈ chain avg
Quality measures 5 of 54.2+0.8 vs chain
The other 16 homes this chain runs (chain average 4.5★, per CMS)

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 / managerTypeRoleShareSince
WEST VALLEY NURSING HOMES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/1966
HUMANGOODOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2016
HUMANGOOD CORNERSTONEOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/22/2022
WELLS FARGO BANK NATIONAL ASSOCIATIONOrganization5% OR GREATER MORTGAGE INTERESTsince 10/31/2000
BAKER, JUDITHIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
BATTISON, WILLIAMIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
BROWN, HERMANIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/10/2013
GRIFFITH, ALANIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 06/30/2019
HOLMES, MICHELLEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
KELLEY, ALBERTIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
WILLIAMS, ROBERTIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 03/13/2024
COCHRANE, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/10/2009
GHASSEMI, BETHANYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/28/2019
MCDONALD, ANDREWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
OGUS, DANIELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/06/2007
HUMANGOOD NORCALOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/22/2022
EMMANS, PAULIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/14/2013
LOPEZ, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/20/2020
SMEBACK, TAMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/08/2025
VANGELISTO, GWENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/30/2021
WALKER, TRAVISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/31/2021
BAKER TILLY ADVISORY GROUP LPOrganizationADP OF THE SNFsince 03/21/2025
BAKER TILLY US LLPOrganizationADP OF THE SNFsince 10/15/2024
PHARMERICA DRUG SYSTEMS LLCOrganizationADP OF THE SNFsince 02/22/2022
WASHINGTON FEDERALOrganizationADP OF THE SNFsince 05/11/2023

CMS files one row per role, so the 44 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$15.2M
Net patient revenuemost recent cost report
-12.8%
Operating marginrevenue minus expenses
$297K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 15%Medicare 3%Other / private 82%

This home reported $297K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$181per resident / day
operating cost
$5,490per month
≈ monthly operating cost
$160per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505409. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-22, 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 →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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