Home / Washington / Tacoma
6220 South Alaska Street, Tacoma, WA 98408 · Pierce County · (253) 476-5300
123 certified beds, about 110 residents a day · For profit - Individual · Medicare and Medicaid since 1993
CMS Care Compare ratings, data as of September 1, 2026 · CCN 505483 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 7, 2026, inspectors cited 12 health deficiencies (the Washington average is 15.8, the national average 9.2).
Of 63 health citations since March 2024, 6 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 2 fines totaling $170,372 in the last three years; the largest was $157,934, and the latest is dated April 29, 2025.
Nurses and nurse aides worked 3.90 hours per resident per day, against 4.36 across Washington and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.
50.0% of nursing staff left within the year CMS measured (Washington average 45.1%).
CMS links it to Evergreen Healthcare Group, an affiliated group of 43 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 63 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to coordinate care and implement wound care orders from an outside provider for 1 of 3 residents (Resident 1) reviewed for wound care. Failure of the facility to update dressing change orders placed residents at risk of wound complications and delayed wound healing.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse for 3 of 5 residents (Resident 1, 2 & 3) reviewed for abuse/neglect. Resident 1 experienced sexual abuse when Resident 2 touched their breast without consent. Resident 2 experienced physical abuse when they were hit by Resident 1. Resident 3 experienced mental/verbal and physical abuse when Resident 4 yelled at them and kicked their bed while they were sleeping. This failure placed the residents at risk of experiencing fear, intimidation, mental anguish, and emotional distress.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened for additional mental health supports through the Pre-admission and Resident Review (PASARR, a mental health screening tool) process for 2 of 5 sampled residents (Residents 97 and 6) reviewed for PASARR. This failure placed residents at risk of unidentified mental health needs, avoidable decline in mental health, unintended increase in negative behaviors, and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts (Hallways 400 and 500) reviewed for medication storage and labeling. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs, and what information was conveyed to the receiving provider for 1 of 4 sampled residents (Resident 14) reviewed for hospitalization. This failure placed residents at risk of potential delays in emergent hospital treatment and potential medical complications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' care plans were revised and accurately reflected the resident's status and care needs for 2 out of 21 sampled residents (Residents 6 and 71) reviewed for care planning and revision of care plans. Failure to address Resident 6's generalized anxiety disorder with target behaviors and interventions and Resident 71's dentures placed the residents at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities for 1 of 3 sampled residents (Residents 5) reviewed for activities. This failure placed residents at risk of boredom, isolation, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement pressure reducing strategies for 1 of 3 sampled residents (Resident 90) reviewed for pressure injuries. This failure placed residents at increased risk for pressure injuries, poor clinical outcomes, and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to address residents' hearing and vision needs for 1 of 2 sampled residents (Resident 112) reviewed for communication-sensory. This failure placed the residents at risk of not being able to participate in activities, difficulty communicating, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 sampled residents (Residents 53 and 14) reviewed for respiratory care. Failure to transcribe/obtain and follow physician orders for oxygen (O2) therapy with indication for use, consistently monitor O2 saturation (Sats, measuring the percentage amount of O2 in the blood), and/or ensure O2 tubing was regularly changed and maintained, placed the residents at risk for unmet needs and potential negative outcomes.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received needed dental care for 1 of 3 sampled residents (Resident 112) reviewed for dental. This failure placed the residents at risk of dental pain, decreased nutritional intake, unintended weight loss, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the amount of food eaten for 1 of 3 sampled residents (Resident 13) reviewed for nutrition. This failure placed residents at risk of inaccurate assessments, lack of timely interventions, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was functioning for 1 of 3 call light panels (500 hall) when reviewed for call lights. This failure placed residents at risk of inability to receive timely assistance, possible neglect, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nurse staffing data in a prominent place to include name of facility and total number and actual hours worked for 5 of 5 observed days during the survey period (05/03/2026 -05/07/2026) reviewed for nurse staff posting. This failed practice prevented residents, family members and visitors from knowing the facility's actual number of available nursing staff.
Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place that ensured basic life support was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) when 1 of 1 resident (Residents 1) was reviewed for unexpected death in the facility. The facility failed to maintain the required unexpired supplies & equipment on the crash carts ready for immediate use and failed to maintain accurate Physician Orders for Life-Sustaining Treatment (POLST) data for immediate accessibility. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 5 staff (Staff N & O) reviewed had the appropriate knowledge, competencies, and skill sets to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air), to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments, individual plans of care, and facility policy. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 8 out of state licensed nurses (Staff C) reviewed had a multistate license authorizing practice in the state the facility was located. This failure placed residents at risk of receiving care from an unlicensed and unqualified individual.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide ensure care and services were provided in a manner that maintained and promoted dignity and respect for 8 of 9 current residents (Residents 3, 4, 5, 6, 7, 10, 12 and 13) interviewed. Failure of the facility to respond to resident's requests in a timely, respectful and professional manner, placed residents at risk for diminished self-worth, frustration, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to convey the refunds of 2 of 3 residents (Resident 8 & 14) to the resident or to the individual or jurisdiction administering the resident's estate, or the Office of Financial Recovery within thirty days of the discharge, transfer or death. This failure placed resident family and/or representatives at risk for financial hardship.
Inspectors wroteBased on interview and record review, the facility failed to identify and investigate allegations of abuse/neglect for 4 of 7 sampled residents (Residents 85, 32, 38 and 68) when reviewed for abuse/neglect. These failures placed the residents at risk of continued abuse/neglect, diminished quality of life and unmet needs. Review of a facility policy titled, Abuse Neglect and Misappropriation of Resident Property Prohibition, dated March 2025, showed each resident had the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 medication storage refrigerators (ASSISI and Long-Term Care), were secured when reviewed for controlled substance storage for lorazepam (a scheduled IV controlled substance medication used in the treatment of anxiety). In addition, the facility failed to ensure 2 of 3 medication carts (ASSISI and Long-Term 2) had medications dated once opened for an insulin pen (a prefilled insulin injector used to deliver as set number of units) and multiple eye medications. These failures had the potential for adverse side effects, ineffective dosage and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan, with goals and interventions to communicate resident care needs to staff for 1 of 19 sampled residents (Resident 5) reviewed for care planning. This failure had the potential to place residents at risk for unmet care needs, negative outcomes, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' care plans were revised and accurately reflected the resident's care needs and/or care conferences occurred timely for 3 out of 21 sampled residents (Resident 48, 51 and 53) when reviewed for care planning and revision of care plans. This failure placed the resident at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' ability to communicate was maintained for 1 of 3 sampled resident (Resident 33) when reviewed for communication. This failure placed the resident at risk of inability to communicate needs, social isolation, feelings of worthlessness, and diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure that residents were shaved and/or dressed in clean clothing for 2 of 3 sampled residents (Residents 30 and 15) when reviewed for dependent activities of daily living (ADLs) care. These failures placed the residents at risk of unmet needs, poor self-esteem, and a diminished quality of life.
Inspectors wroteBased on interview, and record review the facility failed to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders for 2 of 4 sampled residents (Residents 53 and 148) reviewed for nutrition. This failure placed residents at risk for medical complications and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide prompt dental care and services and obtain post dental visit documentation for 1 of 4 sampled residents (Residents 30) when reviewed for dental. These failures placed the resident at risk for continued dental problems, unmet needs, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide prompt dental services for 1 of 4 sampled residents (Residents 53) when reviewed for dental. This failure placed the resident at risk for continued dental problems and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to maintain equipment so that they could be disinfected for 1 of 5 sampled halls (400 Hall) when reviewed for environment. This failure placed residents at risks of exposure to unsanitary surfaces, avoidable illness, and a diminished quality of life.
Inspectors wroteBased on interviews and record review, the facility failed to provid the supervision of two staff for bed mobility assistance per the plan of care for 1 of 5 sampled residents (Resident 1) reviewed for falls with injury. Resident 1 experienced harm when they received bed mobility assistance from one staff member, fell out of the bed and broke their arm.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care and services to maintain acceptable parameters of nutritional status and there was a safe and accurate system to prevent complications from enteral (feedings administered through a tube) feedings for 12 of 12 residents (Residents 8, 19, 20, 22, 33, 21, 18, 26, 24, 14, 31 & 40) reviewed for nutrition and hydration. The failure to: accurately assess (and re-assess as needed) residents nutritional status and develop/revise/implement person-centered care plans (CP) for residents at risk; reconcile, accurately transcribe, and implement nutrition related physician orders and/or Registered Dietician (RD) recommendations; ensure timely RD evaluations; ensure residents were weighed according to policy/physician orders and monitored routinely; [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a resident-centered fall prevention care plan (CP) to reduce their specific risk factors for falls, consistently provide adequate supervision, and ensure residents were consistently monitored for post-fall injuries for 3 of 6 Residents (Residents 1, 8, & 11) reviewed for falls. Resident 1 experienced harm when they fell out of their wheelchair at the nurse's station and sustained a hip fracture. These failures placed all residents at risk for avoidable future falls, adverse events, physical injuries, pain, functional decline, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were assessed and person-centered pain care plans (CPs) were developed/implemented and revised to meet their pain management needs for 3 of 5 sample residents (Residents 1, 2, & 13) reviewed for pain. Resident 2 experienced harm when the facility failed to accurately clarify and transcribe admission orders for pain medications, ensure scheduled pain medications were administered timely, evaluate for the underlying cause of sudden onset of severe chest pain after open heart surgery, monitor for adverse effects of opioid use, was transferred to the hospital in acute respiratory failure, and found to have broken chest wires (internal fixation hardware in place to hold the chest together after open heart surgery) that required surgical intervention to repair. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure residents entire drug/medication regimen was managed and monitored to promote or maintain their highest practicable mental, physical, and psychosocial well-being for 3 of 4 Residents (Residents 1, 2, & 38) who received psychotropic medications. Resident 1 experienced harm when the facility continued to administer antipsychotic medication without an approved clinical indication, evaluation of appropriateness, consideration for approved alternative treatments, monitoring, or evidence of non-pharmacological approaches that resulted in psychosocial and physical harm when they were transferred to the hospital due to altered mental status from the adverse effects of antipsychotic medication and was found to have an acute hip fracture the facility failed to identify after a fall. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure baseline care plans (CP) were developed/implemented and provided in written summary to the resident/responsible party, in a language they understood, within 48 hours of admission for 5 of 5 sample residents (Residents 1, 2, 8, 19, & 13) reviewed for baseline CPs. The failure to ensure completion of the baseline or comprehensive CP timely after admission, that addressed the resident's immediate health/safety needs and provided the instructions necessary to properly provide effective, person-centered care that met professional standards of quality placed the residents at risk for unidentified and/or unmet care needs, rehospitalization, adverse events, substandard quality of care, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure [it] was administered in a manner that used resources effectively and efficiently to attain or maintain the residents highest practical physical, mental, and psychosocial well-being, and the facility maintained substantial compliance with state and federal regulations. The failure to ensure adequate clinical administrative oversight in the absence of both the Director of Nursing (DNS) and Regional [NAME] President of Clinicals and implement an effective Quality Assurance Process Improvement (QAPI) program placed residents at risk for adverse events, substandard quality of care, rehospitalization, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance/Performance Improvement (QAPI) Committee that self-identified deficient practices, and/or implemented corrective action for identified deficiencies. The failure to utilize the facility's QAPI procedures to sustain compliance with regulations for the facility, placed residents at risk for adverse events, unsafe conditions, delay in necessary care and services, and a diminished quality of care/quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incidents, accidents, and alleged violations were thoroughly investigated for 3 of 3 sample residents (Residents 1, 8, & 38) reviewed for investigations. These failures placed residents at risk for abuse, neglect, adverse events, significant injuries, rehospitalizations, and diminished quality of care/quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services provided met professional standards of practice for 8 of 12 sample residents reviewed for professional standards. The failure to: hold anti-hypertensive blood pressure (bp) medications when vital signs were outside ordered parameters (Residents 2, 38, & 40), ensure labs specimens were collected and results reported to the physician timely (Residents 22, 8, 1, & 26), and ensure residents were consistently monitored (and documented) regarding alert charting (events and changes of condition) and daily skilled nursing documentation (for residents who were admitted under their skilled Medicare A benefit) (Residents 8, 2, 14, & 38) was timely, thorough, and complete with the required relevant information to show they continued to require skilled nursing care. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services in accordance with professional standards of practice and quality care to meet their physical, mental, and psychosocial needs for 5 of 6 residents (Residents 38, 2, 13, 5, & 10) reviewed. The failure to conduct weekly skin checks, follow physician orders for dressing changes, and monitor residents with wounds (Residents 38, 2, 13, & 5) and failure to develop/implement heart failure/respiratory care plans that aligned with professional standards, follow physician ordered heart failure care interventions, and provide consistent monitoring of their chronic/acute/change of conditions (Residents 2 & 10) placed the residents at risk for adverse events, rehospitalizations, worsening skin conditions, infections, pain, and diminished quality of care/quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 12 of 12 sampled residents (Residents 26, 2, 22, 13, 10, 38, 14, 8, 17, 34, 23, & 15) were free from significant medication errors. The failure to: conduct a thorough medication reconciliation on admission, verify allergies prior to administration, clarify duplicate or questionable orders, correctly transcribe orders into the electronic Medication Administration Record (MAR), administer medications timely in accordance with professional standards of practice, and report/investigate all identified medication errors placed residents at risk for adverse events, rehospitalization, poorly managed health conditions, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff were educated on all required topics specified on their Facility Assessment for 4 of 4 sampled staff (Staff Q, R, S & T) reviewed for annual education and training. Failure to ensure staff received required trainings placed residents at risk for unmet care needs, inadequate quality of care, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 4 Certified Nursing Assistants (CNAs) (Staff Q, R, S, & T) were provided mandatory Quality Assurance and Performance Improvement (QAPI) training. Failure to ensure staff received the required QAPI training, which included how to communicate concerns, problems, or opportunities for improvement placed residents at risk for unmet care needs, unsafe environment, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review the facility failed to notify the resident's responsible party of orders for a new medication for 1 of 3 sample residents (Resident 2) reviewed for notification of changes. This failure prevented the person responsible for making healthcare decisions from being part of the care planning process and being knowledgeable about medications the resident was taking.
Inspectors wroteBased on interview and record review, the facility failed to document a measurable and descriptive baseline, and routinely monitor the progression of healing or worsening, of a skin impairment for 1 of 3 sample residents (Resident 4) reviewed for skin impairments. This failure placed the resident at risk for undetected worsening of the skin impairment, delay in treatment, complications in healing, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure administration of a prescribed respiratory medication (a medication used to treat breathing problems) for 1 of 1 sample resident (Resident 8) reviewed for medication errors. This failure placed residents at risk for medical complications and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a change in medication orders for two of four residents (Residents 1 and 2) reviewed for notification of changes. This failure prevented the residents' representatives from being included in the plan of care and having the ability to provide input and make decisions on the resident's behalf.
Inspectors wroteBased on interview and record review, the facility failed to follow up on concerns of the resident council related to resident care for 3 of 4 resident council meeting minutes reviewed. This failure placed residents at risk for unmet care needs and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to respond timely to abuse/neglect allegations and thoroughly investigate and/or follow up on identified interventions for incidents of falls and abuse/neglect allegations for 3 of 3 sampled residents (Residents 12, 64, and 157) reviewed for abuse/neglect and 2 of 3 sampled residents (Resident 7 and 70) reviewed for accident/falls. These failures placed residents at risk for ongoing abuse/neglect, continued falls, unmet needs, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess residents for mental health supports through the Preadmission Screening and Resident Review (PASRR, a tool to refer residents for further mental health supports) for 3 of 3 sampled residents (Residents 83, 64 and 23) reviewed for PASRR. This failure placed residents at risk of not receiving needed mental health supports, avoidable behaviors, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide quarterly care conferences/care plan review which included the resident and/or their representative in a timely manner for 4 of 26 sampled residents (Residents 15, 51, 73, and 80) reviewed for care planning. These failures placed residents at risk for unmet care needs and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow recommendations made by the wound care provider for 1 of 2 sample residents (Resident 91) reviewed for non-pressure skin injury and failed to follow the care plan/provider orders for positioning for 1 of 4 sampled residents (Resident 159) reviewed for positioning. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary medications for 5 of 9 sampled residents (Residents 7, 357, 1, 159, and 161) reviewed for unnecessary medications and/or pain management. The facility failed to ensure Residents 7 and 357 were provided non-pharmacological interventions (NPI, non-medication) prior to the use of as needed (PRN) pain medications, monitor Resident 1's blood pressure and heart rate, implement pain medication parameters for Residents 159, and monitor Resident 161's blood thinner side effects. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to report a staff to resident abuse allegation of a verbal threat of physical harm to law enforcement for 1 of 3 sampled residents (Resident 157) reviewed for abuse. This failure placed residents at risk of staff having lack of ability to recognize required reportable abuse to the police, potential unrecognized abuse or neglect, and recurrence of incidents.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess a resident's bowel elimination for 1 of 26 sampled residents (Residents 95) when reviewed for accuracy of assessments. This failure placed the resident at risk for unidentified and/or unmet care needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff contacted the Level II Evaluator for a Preadmission Screening and Resident Review (PASRR) Level II assessment for 1 of 5 sampled residents (Resident 80) reviewed for PASRR. This failure placed the resident at risk of health and/or emotional decline related to a lack of professional evaluation to determine if further mental health interventions were required.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free from accident hazards for 2 of 3 sampled residents (Residents 73 and 60) reviewed for accident hazards. The facility failed to remove an inappropriate transfer device (Resident 73) and assess and monitor for risk of smoking (Resident 60). These failures placed residents at risk of avoidable injury and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate monitoring and documentation for fluid restrictions and completion of daily weights for 1 of 3 sampled residents (Resident 1) reviewed for hydration. This failure placed Resident 1 at risk for medical complications and a diminished quality of life.
Inspectors wroteResident 357 admitted to the facility on [DATE] with diagnoses to include fracture of the right tibia (shinbone), alcoholic polyneuropathy (nerve damage from alcohol use), muscle weakness, and was able to make needs known. Review of the provider order dated 03/06/2024 showed Resident 357 was prescribed duloxetine (an anti-depressant medication) 60 milligram (mg) for depression. Review of the March 2024 MAR showed the duloxetine had been administered since 03/07/2024; however, behavior monitoring had not been implemented until 03/12/2024. During an interview on 03/14/2024 at 11:12 AM, Staff F, RN/UM, stated behavior monitoring for the antidepressant medication should have been documented on the MAR upon the first administration. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide routine dental services for 2 of 2 sampled residents (Residents 73 and 51) when reviewed for dental. This failure placed residents at risk of avoidable dental pain, difficulty eating, unintentional weight loss, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to properly notify the Office of State Long-Term Care Ombudsmen (an advocacy group for residents in a nursing home) of discharges for 4 of 4 residents (Residents 9,15, 53 and 95) reviewed for hospitalization. This failure placed residents at risk for an inappropriate discharge and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer to the hospital, for 4 of 4 sampled residents (Residents 9,15, 53 and 95) reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding their right to hold their bed while in the hospital.
Inspectors wroteBased on interview and record review, the facility failed to implement pressure ulcer care and prevention measures for 1 of 3 sampled residents (Resident 1) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed residents at risk for new and worsening pressure injuries, pain, and a decreased quality of life.
23 fire safety citations on file: 4 on May 7, 2026, 10 on May 23, 2025, 9 on March 15, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| April 29, 2025 | Fine | $12,438 |
| January 22, 2025 | Fine | $157,934 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Washington | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.90 | 4.36 | 3.86 |
| Registered nurses | 0.56 | 0.94 | 0.69 |
| All nursing staff on weekends | 3.53 | 3.80 | 3.42 |
| Nurse aides | 2.30 | ||
| Licensed practical nurses | 1.03 | ||
| Nursing staff turnover (share who left in a year) | 50.0% | 45.1% | 45.8% |
| Registered nurse turnover | 75.0% | 45.4% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.96 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.04 on weekdays and 3.53 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.98 in April to June 2025 to 3.90 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.90 | 0.56 | 4.04 | 3.53 | 0.7% | 0 of 90 | 110 |
| Oct to Dec 2025 | 3.86 | 0.41 | 4.03 | 3.45 | 1.1% | 1 of 92 | 111 |
| Jul to Sep 2025 | 3.75 | 0.35 | 3.90 | 3.37 | 0.0% | 0 of 92 | 108 |
| Apr to Jun 2025 | 3.98 | 0.42 | 4.14 | 3.58 | 0.0% | 0 of 91 | 97 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Washington, Jan to Mar 2026 | 4.21 | 0.90 | 4.44 | 3.66 | 3.7% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Washington, all employers | |||
| CNAs (nursing assistants) | $23.65 | $22.59 to $27.85 | 30,270 |
| LPNs and LVNs | $39.98 | $36.98 to $45.18 | 6,780 |
| Registered nurses | $59.71 | $49.57 to $64.54 | 69,260 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Washington | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 14.2 | 14.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 1.0 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.2 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.7 | 2.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.5 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 22.0 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.0 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 15.1 | 15.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 17.7 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.8 | 13.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.9 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Alaska Gardens Health and Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
55.1% this home
No different from the national rate
US median of homes 51.5% · Washington: 71 better, 16 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 157 eligible stays.
9.2% this home
No different from the national rate
US median of homes 10.7% · Washington: 7 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 146 eligible stays.
7.2% this home
No different from the national rate
US median of homes 7.1% · Washington: 4 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 91 eligible stays.
54.4% this home
Median of homes: Washington61.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 68 residents counted.
1.0% this home
Median of homes: Washington0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 103 residents counted.
5.7% this home
Median of homes: Washington1.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 103 residents counted.
91.7% this home
Median of homes: Washington98.3% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 48 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: ALASKA GARDENS SNF OPERATIONS LLC. CMS links this home to Evergreen Healthcare Group, a group of 43 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Alaska Gardens SNF Operations Holdings LLC | Direct ownership interest | Organization | 07/01/2021 | |
| Ch Alaska Gardens Holdings LLC | Indirect ownership interest | Organization | 07/01/2021 | |
| Cw Alaska Gardens Holdings LLC | Indirect ownership interest | Organization | 07/01/2021 | |
| Lionheart SNF LLC | Indirect ownership interest | Organization | 07/01/2021 | |
| Witzcorp LLC | Indirect ownership interest | Organization | 07/01/2021 | |
| Herzka, Yisroel | Indirect ownership interest | Individual | 07/01/2021 | |
| Kopelowitz, Shaul | Indirect ownership interest | Individual | 07/01/2021 | |
| Wolofsky, Chava | Indirect ownership interest | Individual | 07/01/2021 | |
| Yenowitz, Yitzchok | Indirect ownership interest | Individual | 07/01/2021 | |
| Gray, Nani | Managing control - governing body | Individual | 05/19/2025 | |
| Stout, Christina | Managing control - governing body | Individual | 08/31/2023 | |
| Alaska Gardens SNF Management LLC | Operational/managerial control | Organization | 07/01/2021 | |
| Alaska Gardens SNF Opco Manager LLC | Operational/managerial control | Organization | 07/01/2021 | |
| Alaska Gardens SNF Operations LLC | Operational/managerial control | Organization | 07/01/2021 | |
| Couve Healthcare Consulting LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Veritas Health Solutions LLC | Operational/managerial control | Organization | 03/03/2025 | |
| Gray, Nani | Operational/managerial control | Individual | 05/19/2025 | |
| Kogut, Lucas | Operational/managerial control | Individual | 07/01/2021 | |
| Spielman, Shimon | Operational/managerial control | Individual | 08/31/2023 | |
| Stites, Bonnie | Operational/managerial control | Individual | 07/01/2021 | |
| Stout, Christina | Operational/managerial control | Individual | 08/31/2023 | |
| Wingard, Ann | Operational/managerial control | Individual | 07/01/2021 | |
| Yenowitz, Yitzchok | Operational/managerial control | Individual | 07/01/2021 | |
| Alaska Gardens SNF Management LLC | Adp of the SNF | Organization | 05/01/2025 | |
| Alaska Gardens SNF Opco Manager LLC | Adp of the SNF | Organization | 05/01/2025 | |
| Alaska Gardens SNF Operations LLC | Adp of the SNF | Organization | 05/01/2025 | |
| Alaska Gardens SNF Realty LLC | Adp of the SNF | Organization | 05/01/2025 | |
| Ch Alaska Gardens Holdings LLC | Adp of the SNF | Organization | 07/01/2021 | |
| Couve Healthcare Consulting LLC | Adp of the SNF | Organization | 05/01/2025 | |
| Cw Alaska Gardens Holdings LLC | Adp of the SNF | Organization | 07/01/2021 | |
| Veritas Health Solutions LLC | Adp of the SNF | Organization | 06/11/2025 | |
| Witzcorp LLC | Adp of the SNF | Organization | 07/01/2021 | |
| Gray, Nani | Adp of the SNF | Individual | 05/19/2025 | |
| Herzka, Yisroel | Adp of the SNF | Individual | 07/01/2021 | |
| Kogut, Lucas | Adp of the SNF | Individual | 07/01/2021 | |
| Kopelowitz, Shaul | Adp of the SNF | Individual | 07/01/2021 | |
| Spielman, Shimon | Adp of the SNF | Individual | 08/31/2023 | |
| Stites, Bonnie | Adp of the SNF | Individual | 07/01/2021 | |
| Stout, Christina | Adp of the SNF | Individual | 08/31/2023 | |
| Wingard, Ann | Adp of the SNF | Individual | 07/01/2021 | |
| Wolofsky, Chava | Adp of the SNF | Individual | 07/01/2021 | |
| Yenowitz, Yitzchok | Adp of the SNF | Individual | 07/01/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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