Home / Washington / Tacoma
1649 East 72nd, Tacoma, WA 98404 · Pierce County · (253) 472-9027
120 certified beds, about 103 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1988
CMS Care Compare ratings, data as of September 1, 2026 · CCN 505326 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 30, 2026, inspectors cited 23 health deficiencies (the Washington average is 15.8, the national average 9.2).
Of 85 health citations since September 2023, 6 were rated as actual harm or immediate jeopardy to residents.
CMS lists 4 fines totaling $351,357 in the last three years; the largest was $153,010, and the latest is dated March 30, 2026.
Nurses and nurse aides worked 3.96 hours per resident per day, against 4.36 across Washington and 3.86 nationally. Registered nurses accounted for 0.78 of those hours.
42.6% of nursing staff left within the year CMS measured (Washington average 45.1%).
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 85 health citations on file.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement a process to maintain inventory of residents' personal belongings for 2 of 3 residents (Residents 1 and 2) reviewed for loss of personal property. This failure placed residents at risk for inability to safeguard personal property, inability to receive replacement/reimbursement for missing property, and increased the risk of theft, loss and misappropriation.
Inspectors wroteBased on interview and record review the facility failed to conduct a thorough investigation into a resident's allegations of neglect to determine if abuse or neglect had taken place for 1 of 3 residents (Resident 3) reviewed for investigations. This failure placed residents at risk for ongoing abuse and/or neglect, feelings of insecurity in the facility, unmet care needs, psychological harm, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate podiatrist services for 3 of 3 residents (Residents 1, 2, and 3) reviewed for foot care. This failure placed residents at risk of infection, pain, discomfort, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to identify fall trends, evaluate the effectiveness of previous fall prevention interventions and to implement progressive resident centered interventions for 1 of 2 sampled residents (Resident 66) reviewed for falls. Resident 66, who had six falls in 10 weeks (two unwitnessed non-injury and four unwitnessed with injury), experienced harm when they fell, sustained a fracture of their right distal clavicle (collar bone) that required transfer to the emergency department for evaluation and treatment. This failure placed residents at risk of repeated falls and injuries.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's menus were prepared in advance, followed, and reflected input received from the residents and resident group for 3 of 3 sampled days (03/25/2026, 03/26/2026, and 03/27/2026) when reviewed for kitchen. This failure placed residents at risk of dissatisfaction with kitchen services, reduction in food consumed, avoidable weight loss, a decline in clinical condition, and a diminished quality of life.
Inspectors wroteBased on observation interview and record review, the facility failed to implement an infection control program that ensured the surveillance of possible communicable diseases was completed for 1 of 3 months (January 2026) and to ensure the proper handling and processing of soiled linens for 1 of 1 laundry rooms when reviewed for infection control. These failures placed the residents at risk for infections, poor clinical outcomes and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety devices did not restrict residents' ability to move and the resident or resident representative consented to the use of restrictive safety devices for 3 of 4 sampled residents (Residents 66, 105 and 51) reviewed for physical restraints. This failure placed the residents at risk of being unnecessarily restrained and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide Nursing Home Transfer/Discharge Notices and bed hold notices at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 5, 6, 66, and 110) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital, protection of resident's rights during transfer, and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the resident assessment for 6 of 20 sampled residents (Residents 11, 32, 51, 33, 10, and 105) reviewed for accuracy of assessments. Failure to accurately code Residents 11 and 32's use of blood thinning medication, Resident 51's use of side rails, Resident 33's use of a breathing device, Resident 10's dental status, and Resident 105's use of a safety device placed residents at risk of unmet care needs, inaccurate information in the electronic health record, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to inform and provide written information on the formulation of advanced directives for 2 of 3 sampled residents (Residents 99 and 15) reviewed for advanced directives. This failure placed the residents at risk of unmet needs and lack of knowledge of their rights to formulate an advanced directive.
Inspectors wroteBased on interview and record review, the facility failed to ensure personal property was protected for 1 of 1 sampled resident (Resident 9) when reviewed for personal property. This failure placed residents at risk loss of property, compromised dignity, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled resident (Residents 9) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure injuries of unknown sources were reported to the State Hotline for 1 of 2 sampled residents (Resident 5) when reviewed for accident hazards. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate the potential for abuse and/or neglect for 1 of 2 sample residents (Resident 9) reviewed for abuse and neglect. This failure placed Resident 9 at risk for psychosocial harm and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 2 of 20 sampled residents (Residents 10 and 1) reviewed for care plans. Failure to develop care plans that accurately reflected resident care needs related to dental issues placed residents at risk for not receiving needed care and services, negative outcomes, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide and/or conduct quarterly care conferences in a timely manner to include the residents and/or their representative for 2 of 3 sampled residents (Residents 87 and 99) when reviewed for care planning. 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 ensure providers orders were followed for 2 of 2 sampled residents (Residents 66 and 71) when reviewed for pain and edema. This failure placed residents at risk of increased pain and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to ensure that residents received their showers as scheduled and incontinent briefs for 2 of 3 sampled residents (Residents 9 and 1) reviewed for activities of daily living (ADLs). This failure placed the residents at risk for compromised dignity, unmet needs, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with meal service for 1 of 3 sampled residents (Resident 8) reviewed for position and mobility. This failure placed the resident at risk for weight loss, malnutrition, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide prompt services to maintain vision for 1 of 3 sampled residents (Resident 10) reviewed for communication sensory. This failure placed the resident at risk of unmet vision needs, continued visual impairment, decreased mood, and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing programs were provided, thoroughly evaluated for effectiveness, carried out, and accurately documented for 1 of 4 sampled residents (Resident 10) reviewed for rehabilitation and restorative services, and/or position and mobility. This failure placed the resident at risk for worsening mobility, developing contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for 2 of 4 sampled residents (Residents 106 and 12) when reviewed for respiratory care. Failure to provide oxygen (O2) per provider's order, notify provider when O2 saturation (Sats, measuring the percentage amount of O2 in the blood) were not within ordered parameters, clarify unclear O2 orders, and/or O2 use care planned placed residents at risk for negative outcomes, discomfort, unmet needs and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide pain management that met professional standard for 1 of 8 sampled residents (Resident 106) when reviewed for unnecessary medications and/or pain management. Failure to thoroughly complete pain assessments/evaluations and to address any need for non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) with Resident 106, placed the resident at risk of having unmet pain needs, and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure medication and treatments were securely stored for 1 of 1 sampled resident (Resident 96) and 2 of 2 sampled treatment carts (Rose and Emerald Wings). These failures placed residents at risk for access to restricted medications and treatments, avoidable injury, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services for 2 of 2 sampled residents (Residents 1 and 10) reviewed for dental services. This failure placed the residents at risk for unmet dental needs 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 actual hours worked for 6 of 6 observed days during the survey period (03/23/2026 - 03/30/2026) 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 accurately assess and manage the diagnosis of congestive heart failure (CHF, a weakened heart condition, in which the heart doesn't pump blood as effectively as it should, and causes fluid build-up in the feet, arms, lungs and other organs) for 1 of 3 sample residents (Resident 2) reviewed for the management of CHF. This failure placed the resident at risk for fluid overload, respiratory complications, exacerbation of (worsening of) heart failure, kidney and liver damage, hospitalization, and sudden death.
Inspectors wroteBased on interview and record review, the facility failed to provide risks/benefits and obtain consent for the use of a psychotropic (affecting the mind) medication for 1 of 5 sampled residents (Resident 72) when reviewed for unnecessary medications. This failure placed residents at risk of avoidable side effects, chemical restraint, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 4 sampled residents (Residents 67) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an assessment for the use of a low bed for 1 of 1 sampled resident (Residents 39) reviewed for use of physical restraints. This failure placed the resident at risk for injury, unmet needs and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to identify and investigate allegations of abuse/neglect for 1 of 7 sampled residents (Resident 56) when reviewed for abuse/neglect. This failure placed the resident at risk of continued abuse/neglect and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for hospital transfer to the resident or responsible party for 1 of 3 sampled residents (Resident 291) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility and diminished protection from been inappropriately discharged .
Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 3 sampled residents (Resident 291) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the comprehensive assessment for 3 of 21 sampled residents (Residents 79, 18, and 88) when reviewed for accuracy of comprehensive assessment. This failure placed residents at risk of not receiving needed care, a decline in ability, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed conduct timely care planning meetings with residents or responsible party for 1 of 2 sampled residents (Residents 31) reviewed for care planning. These failures placed residents at risk for unmet needs, care not provided as directed, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary was completed and included recapitulation (overview) of the residents stay, a final summary of the resident's status, and the resident and/or their representative signature for 1 of 3 sampled residents (Resident 88) reviewed for discharge. This failure placed the resident at risk for unsafe discharge, complications and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary interventions were in place to ensure correct positioning for 1 of 5 sampled residents (Resident 17) when reviewed for positioning and mobility. The facility also failed to consistently monitor and document bowel movements and implement the bowel program as needed for 2 of 4 sampled residents (Residents 4 and 82) reviewed for bowel protocol. These failures placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services to ensure residents increased or maintained range of motion (ROM) were provided for 1 of 5 sampled residents (Resident 67) reviewed for position, range of motion/mobility. This failure placed the residents at risk for worsening mobility, developing of contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environments were free from accident hazards for 1 of 3 sampled shower rooms (200 Hall) and failed to ensure fall interventions were implemented for 1 of 1 sampled residents (Resident 67) reviewed for accident hazards. These failures placed residents at risk of having access to dangerous items, repeated falls, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Registered Dietician's (RD) recommendations were administered as ordered for 1 of 5 sampled residents (Resident 31) and ensure fluid restrictions were followed for 2 of 5 sampled residents (Residents 18 and 82) when reviewed for nutrition/hydration. This failure placed the residents at risk for unmet nutritional needs, dehydration, medical complications, and continued weight loss.
Inspectors wroteBased on observation, interview, and record review, the facility failed to have order and monitor oxygen services to meet professional standards for 1 of 2 sampled residents (Resident 18) reviewed for respiratory services. This failure placed the resident at risk for oxygen toxicity, injury, infection and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff conducted pain assessments for 1 of 3 sampled residents (Resident 9) who received an as necessary pain medication (oxycodone, a narcotic pain medication used to treat moderate to severe pain) when reviewed for pain management. This failure had the potential for the residents to not receive the necessary pain medication as ordered, a diminished quality of life and unmet needs.
Inspectors wroteBased on interview and record review, the facility failed to provide dialysis (a process to remove waste from blood) care consistent with professional standards for 1 of 1 sampled resident (Resident 18) when reviewed for dialysis care. This failure placed the resident at risk for receiving substandard dialysis care, injury, infection and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed or as the situation demands (PRN) psychotropic medication (drugs that affect the brain and central nervous system, that alter mood, thoughts, emotions and behavior) was limited to 14 days for 1 of 5 sampled residents (Resident 9) when reviewed for unnecessary medications. This failure had the potential to place the resident at risk for increased medical complications and decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services for 1 of 3 sampled residents (Resident 18) when reviewed for dental services. Failure to provide routine dental services placed the resident at risk for infection, pain, decrease ability to eat and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: consistently applied Personal Protective Equipment (PPE) in accordance with the Enhanced Barrier Precautions/Transmission Based Precaution (EBP/TBP, implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms for 1 of 3 sampled residents (Resident 47) and consistently ensure respiratory care equipment (an aerosol machine and oxygen tubing) were stored in a clean and sanitary manner for 1 of 2 sampled residents (Resident 18) when reviewed for infection control. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual nursing staffing hours daily for 30 of 30 days when reviewed for nurse staff posting. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility.
Inspectors wroteBased on interview and record review, the facility failed to timely refund charges paid (less what was owed to the facility) for 1 of 3 residents (Resident 2) reviewed for misappropriation and personal funds. This failed practice placed the prior resident at risk of financial instability with their current housing placement and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 3 sampled residents (Residents 6) with urinary catheters (a flexible tube inserted into the bladder to drain urine) and bowel incontinence received care and services consistent with professional standards of care. The failure to obtain physician orders for the use of a catheter, develop/implement a care plan (CP) for catheter care/monitoring and a personalized bowel program, placed the residents at risk for infections, skin breakdown, constipation, and diminished quality of care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and develop/implement a care plan (CP) for the management of chronic heart problems and failed to timely identify/assess/implement interventions for a related change in condition for 1 of 3 sampled Residents (Resident 51) reviewed for hospitalization. The facility also failed to consistently monitor and document bowel movements (BMs) and implement the bowel program when needed for 2 of 3 sampled residents (Residents 16 and 66) reviewed for bowel management. Resident 51 experienced harm when they had a significant fluid volume overload (too much fluid in the body causing difficulty breathing, increased weight and swelling/edema) and a delay in respiratory interventions resulting in an emergency transfer to the hospital for respiratory failure. [...]
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, sanitary, and homelike environment in 1 of 2 units (Rose unit-100 Hall and 300 Hall) and 1 of 3 shower rooms (300 Hall) for 3 sampled Residents (Resident 9, 36, & 52) plus 5 supplemental Residents (Residents 7, 13, 57, 60 & 77) reviewed for environment. The failure to ensure walls, wallpaper, privacy cubical curtains, doors/door handles, window coverings, resident rooms, shower equipment, linen cart covers, and wheelchairs were sanitary, clean, odor-free, and in good repair placed residents at risk for infections, accidents, injuries, medical complications, and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess 7 of 20 sampled residents (Residents 27, 88, 6, 9, 51, 69, and 72) whose minimum data sets (MDS, a required assessment tool) were reviewed. The failure to accurately assess the residents care needs directly affected the ability to develop a comprehensive care plan that met the residents care needs and placed them at risk for further unmet needs, inaccurate medical records, medical complications,and diminished quality of care/quality of life.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop, implement, and/or update person-centered comprehensive care plans (CP) and ensure the appropriate CP information for direct care staff carried over to the Kardex (bed-side CP direct care staff depend on to provide person-centered care) for 6 of 20 residents (Residents 55, 70, 13, 52, 6, and 69) reviewed for comprehensive CPs. These failures placed the residents at risk for poor clinical outcomes, lack of services, unmet care needs, medical complications, diminished quality of care/quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for anti-hypertensive medication administration, orthostatic vital signs, physician orders, insulin administration, injection site rotation for injections, weight monitoring, edema monitoring, and care of patients with heart failure for 9 of 20 sampled residents (Residents 70, 73, 47, 16, 51, 52, 6, 36, and 69) reviewed. These failures placed residents at risk of unmet needs, medical complications, injuries, and diminished quality of care/quality of life.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide food that accommodated identified resident preferences for 4 of 20 Residents (Residents 3, 62, 301, and 91) reviewed for food preferences. This failure placed residents at risk for weight loss, malnutrition, and diminished quality of life.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure preplanned menus were followed and the appropriate portion sizes were served according to the tray card for 3 of 20 Residents (Resident 75, 76, and 92) reviewed for dietary services. These failures placed residents at risk for decreased/increased caloric intake, nutritional deficits, and a diminished quality of life.
Inspectors wroteBased on observations and interviews, the facility failed to ensure food was prepared and served according to in accordance with professional standards. These failures placed residents at risk of foodborne illness and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to include documentation of the Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement to the resident and/or representative for 4 of 4 residents (Residents 81, 87, 73 and 66), reviewed for Arbitration Agreement. This failure placed the residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to include documentation of the Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement to the resident and/or representative for 4 of 4 residents (Resident 81, 87, 73 and 66), reviewed for Arbitration Agreement. This failure placed the residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.
Inspectors wroteBased on interview, and record review the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the collection and analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 2 of 3 months (February and March 2024) reviewed for Infection Control. The facility also failed to implement isolation precautions for 1 of 2 wings (Rose wing) reviewed for transmission-based precautions. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 4 of 7 residents (Residents 69, 304, 56 and 305) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had access to their money during evenings and weekends for 1 of 37 sampled residents (Resident 36) reviewed for personal funds. This failure placed residents at risk for decreased autonomy (independence), dishonored residents rights, and a diminished quality of life.
Inspectors wroteBased on observations and interviews the facility failed to protect the resident's right to personal privacy for 2 of 4 Residents (Resident 52 and 69) reviewed for dignity. The failure to provide privacy and maintain dignity during the provision of personal cares and wound treatment for Resident 52 and for Resident 69 placed the residents at risk for embarrassment, frustration, and undignified quality of life.
Inspectors wroteBased on observation, interviews, and record review the facility failed to timely identify (or should have identified) a significant change is status for 1 of 2 residents (Resident 6) reviewed for change of condition. The failure to conduct a Significant Change in Status Assessment (SCSA) within 14 days of the determination of a resident's significant change in status placed the resident at risk for unmet care needs, diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review the facility failed to conduct timely/routine care planning conferences with the resident and/or responsible party for 3 of 4 residents (Residents 63, 72 and 78) reviewed for care conferences. This failure placed the residents at risk for unmet needs, not being involved and/or informed of their care plan (CP), and a diminished quality of life.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the care and assistance with activities of daily living (ADLs) they required to maintain good grooming, oral hygiene, and toileting for 2 of 6 Residents (Residents 52 and 69) plus 2 supplemental residents (Resident 60 and 7) reviewed for ADLs. These failures placed the residents at risk for unmet care needs, poor oral health, skin impairment, medical complications, and diminished quality of life/quality of care.
Inspectors wroteBased on observations, interview, and record review the facility failed to ensure residents were provided resident-centered activity programs that incorporated their interests, hobbies, and cultural preferences for 1 of 2 Residents (Resident 52) plus 3 supplemental Residents (Residents 60, 57, and 7) reviewed for activities. The failure to provide independent and/or community activities that met each resident's physical, mental, and psychosocial needs placed residents at risk for social isolation, boredom, decreased sense of security/identity/meaning, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free of accidents/hazards for 3 of 9 residents (Residents 13, 66, and 27) and 2 of 2 smoking areas (on the property and on the street sidewalk-adjacent to the facility property) reviewed for accidents. The failure to re-assess Residents 13 and 66 after unsafe smoking incidents and provide adequate supervision and/or assistance for smoking safety compliance, equally enforce the facility smoking policy for all residents, visitors, and staff; ensure smoking receptacles were available for safe and sanitary collection of cigarette refuse; and ensure a re-assessment and care plan (CP) update occurred for Resident 27 after a fall. These failures placed the residents at risk for further accidents, smoking related injuries, unsanitary environment, and diminished quality of life.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure 2 of 3 residents (Residents 69 and 70) with urinary catheters (a flexible tube inserted into the bladder to drain urine) received care and services consistent with professional standards of care. The failure to ensure routine catheter care was provided, and the catheters were properly secured and positioned placed the residents at risk for infections, skin breakdown, discomfort, and diminished quality of care.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff provided pain medication as ordered for 1 of 4 Residents (Resident 73) reviewed for pain. The failure administer a routinely scheduled anti-inflammatory analgesic (a medication to reduce swelling and pain) and accurately document the provision of acetaminophen (a mild analgesic that has potential for medical complications when taken in excess) in the clinical record placed the resident at risk for delay in care and services to treat their chronic pain condition, potential for acetaminophen toxicity, medical complications, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate hemodialysis (HD, a process in which blood is filtered of waste, toxins and fluid) services for 1 of 1 Residents (Resident 66) reviewed for dialysis. The facility failed to provide consistent monitoring of the dialysis documentation of communication, to the dialysis unit, to inform them of pertinent clinical information. This failure placed the resident at risk for unmet care needs, medical complications, and diminished quality of care.
Inspectors wroteBased on interview and record review, the facility failed to provide Influenza and Pneumococcal vaccines for 2 of 5 residents (Resident 55 and 70) reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to offer and follow-up on the completion of COVID-19 immunizations for 2 of 5 residents (Residents 55 and 70) reviewed for vaccinations. This failure placed the residents at an increased risk for complications related to COVID-19 infection that could result in severe illness or death.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an environment free of avoidable accidents/hazards for 1 of 7 residents (Resident 1) reviewed for mechanical lift transfers. The failure to assess and develop a safe care plan for the use of a mechanical lift device, ensure staff training and competency in the use of the Named Mechanical Lift system, utilize the mechanical lift according to the manufacturers recommendations, and conduct post-fall resident assessment and investigation procedures resulted in harm to Resident 1 when they were dropped to the floor during an improper mechanical lift transfer, sustained cuts and bruising to their head and body, experienced pain, and created intense sense of fear for Resident 1 surrounding further use of the mechanical lifts. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for 1 of 1 Residents (Resident 20) reviewed for re-hospitalization. The facility's failure to: recognize and assess risk factors that placed the resident at risk for decline or complications,; develop a person-centered care plan with interventions that met their specific care needs related to arterial ulcers (a wound developed from prolonged inadequate blood flow) caused by Peripheral Artery Disease (PAD-narrowing or blockage of the blood vessels that carry blood from the heart to the legs),; implement physician orders timely,; [...]
Inspectors wroteBased on interview and record review the facility failed to develop and implement an effective, personalized discharge plan for 6 of 6 sampled residents (Residents 1, 10, 11, 13, 14, & 15) reviewed for discharge planning. The facility failed to: ensure the discharge needs of each resident were identified,; the Interdisciplinary Team (IDT) involved the resident/responsible party to develop a personalized discharge care plan based on each resident's needs, goals, & preferences,; provide timely referrals to the LCA for residents who desired to discharge to the community,; and ensure the Home Health Agency (HHA) was provided all required documents to start services and issued a preliminary start date. These failures placed residents at risk for unmet care needs after discharge, potential for re-hospitalization, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents experienced a smooth transition during their discharge, received medications and post-discharge care and services timely for 6 of 6 sampled residents (Residents 1, 10, 11, 13, 14, & 15) reviewed for discharge planning. The facilities failure to: prepare a complete discharge summary that included a recapituation of the resdient's stay with all required components, a complete final summary of the resident's status, a reconciliation of all pre-discharge and post-discharge medications, and ensure a discharge plan of care was implemented, documented, and provided to the Resident and/or Responsible Party placed the residents at risk for unmet care needs, potential for re-hospitalization, and diminshed quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide or arrange for care and services consistent with accepted standards of quality for 3 of 6 sampled residents (Residents 2, 18, & 20) reviewed for change of condition and tube feeding. The facility's failure to develop and implement a care plan to meet resident specific care needs; identify, document, and timely notify the appropriate parties of a change of condition; timely implement Physician Orders (POs); and ensure documentation was accurate and complete placed the residents at risk of diminished quality of care, unmet care needs, and potential for significant medical complications.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's medical records were complete, accurately documented, readily accessible, and systematically organized according to professional standards of practice for 5 of 5 residents (Residents 20, 1, 2, 11, & 14) reviewed for medical records. These failures placed the residents at risk for significant medication errors, unmet care needs, delayed response to changes of condition, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, physicians, and resident representative of a significant change of condition for 1 of 1 sampled residents (Resident 20) reviewed for change of condition. This failure placed residents at risk of potential life-threatening clinical complications, psychosocial harm, and diminished quality of care/quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care and services were provided according to resident's needs, physician orders (POs), and professional standards of practice for 2 of 5 sampled residents (Residents 2 & 18) reviewed for tube feeding. The facility's failure to: follow POs for tube feeding administration to ensure the resident received the ordered amount of formula, ensure POs were in place to monitor and document the frequency and volume of water flushes for medication administrations, ensure the total volume of formula was accurately documented to monitor daily intake of calorie needs, and ensure formula and water tubing/containers were properly labeled placed the residents at risk of potential illness, weight loss, altered nutritional status, and diminished quality of care/quality of life.
Inspectors wroteBased on interview and record review, the facility failed to permit 1 of 6 residents (Resident 1) reviewed for hospitalization to return to the facility after a facility-initiated transfer to the emergency room (ER). The facility's failure to provide bed hold information in writing upon transfer to the hospital, provide appropriate discharge/transfer notice and rights to an appeal prior to the facility-initiated transfer and discharge, and failure to permit Resident 1 to return to the facility and resume residence after the ER visit caused physical and psychological harm to Resident 1 who experienced unnecessary pain, anxiety, fear, humiliation, and re-traumatization.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received effective pain management consistent with professional standards of practice and according to residents' goals/preferences for 7 of 11 residents (Residents 1, 2, 3, 4, 5, 6, & 7) reviewed for pain. The facility's failure to re-evaluate Resident 1's pain after medication change and ensure they had an adequate supply of medication to administer their scheduled and PRN (as needed) pain medication caused harm when Resident 1 experienced unnecessary extreme pain and was transferred the emergency room (ER) for pain medication administration. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative, written information that specified the facility's bed-hold policy, including the Washington State specific bed-hold periods, rights to return to the facility, and bed-hold facility rates before and at the time of transfer to the hospital for 6 of 6 residents (Residents 1, 4, 9, 10, 11, and 12) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to return and resume residence at the facility after hospitalization.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that addressed the risk for pressure injury for 1 of 3 residents (Resident 1) reviewed for pressure injury. This failure placed the resident at risk for unmet needs, reoccurrence of a pressure injury, development of new pressure injuries, complications, and a diminished quality of life.
24 fire safety citations on file: 7 on March 30, 2026, 8 on February 13, 2025, 9 on April 12, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| March 30, 2026 | Fine | $58,136 |
| March 27, 2024 | Fine | $153,010 |
| March 27, 2024 | Payment Denial | 30 days from June 27, 2024 |
| December 13, 2023 | Fine | $107,955 |
| October 25, 2023 | Fine | $32,256 |
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) | 3.96 | 4.36 | 3.86 |
| Registered nurses | 0.78 | 0.94 | 0.69 |
| All nursing staff on weekends | 3.52 | 3.80 | 3.42 |
| Nurse aides | 2.39 | ||
| Licensed practical nurses | 0.79 | ||
| Nursing staff turnover (share who left in a year) | 42.6% | 45.1% | 45.8% |
| Registered nurse turnover | 43.8% | 45.4% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.72 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 4.13 on weekdays and 3.52 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.16 in April to June 2025 to 3.96 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 | 3.96 | 0.78 | 4.13 | 3.52 | 0.0% | 0 of 90 | 103 |
| Oct to Dec 2025 | 3.88 | 0.66 | 4.03 | 3.51 | 0.0% | 0 of 92 | 91 |
| Jul to Sep 2025 | 3.84 | 0.53 | 3.99 | 3.46 | 0.0% | 0 of 92 | 83 |
| Apr to Jun 2025 | 4.16 | 0.58 | 4.36 | 3.65 | 0.0% | 0 of 91 | 85 |
| 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 | 19.3 | 14.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.8 | 1.0 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.5 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.7 | 2.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 4.4 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 32.7 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.7 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.5 | 15.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.8 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.8 | 13.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Heartwood Extended Healthcare's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (38.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
38.0% this home
Worse than 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. 79 eligible stays.
11.3% 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. 66 eligible stays.
6.7% 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. 37 eligible stays.
45.2% 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. 31 residents counted.
6.4% 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. 47 residents counted.
4.0% 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. 47 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 15 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: HEARTWOOD OPERATOR LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Heartwood Operator Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 04/01/2020 |
| Heartwood Realty LLC | 5% or greater direct ownership interest | Organization | 04/01/2020 | |
| Heartwood Realty Holdings LLC | Direct ownership interest | Organization | 04/01/2020 | |
| Pacific Northwest Consulting Holdings LLC | Direct ownership interest | Organization | 04/01/2020 | |
| Ch Heartwood Washington Holdings LLC | 5% or greater indirect ownership interest | Organization | 03/03/2025 | |
| Heartwood Washington Care Operations Holdings LLC | 5% or greater indirect ownership interest | Organization | 04/01/2020 | |
| Stout, Christina | Managing control - governing body | Individual | 04/01/2020 | |
| Ch Heartwood Washington Holdings LLC | Operational/managerial control | Organization | 04/01/2020 | |
| Couve Healthcare Consulting LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Heartwood Evergreen Healthcare LLC | Operational/managerial control | Organization | 04/01/2020 | |
| Heartwood Operator LLC | Operational/managerial control | Organization | 04/01/2020 | |
| Veritas Health Solutions LLC | Operational/managerial control | Organization | 04/18/2025 | |
| Henry, Catlin | Operational/managerial control | Individual | 04/01/2020 | |
| Herzka, Yisroel | Operational/managerial control | Individual | 04/01/2020 | |
| Kopelowitz, Shaul | Operational/managerial control | Individual | 04/01/2020 | |
| Lemma, Wendwesen | Operational/managerial control | Individual | 04/01/2020 | |
| Stout, Christina | Operational/managerial control | Individual | 04/01/2020 | |
| Wise, Ginnette | Operational/managerial control | Individual | 04/01/2020 | |
| Yenowitz, Yitzchok | Operational/managerial control | Individual | 08/31/2023 | |
| Ch Heartwood Washington Holdings LLC | Adp of the SNF | Organization | 03/03/2025 | |
| Couve Healthcare Consulting LLC | Adp of the SNF | Organization | 04/16/2025 | |
| Heartwood Evergreen Healthcare LLC | Adp of the SNF | Organization | 04/30/2025 | |
| Heartwood Operator LLC | Adp of the SNF | Organization | 04/03/2025 | |
| Heartwood Realty LLC | Adp of the SNF | Organization | 04/30/2025 | |
| Pacific Northwest Consulting Holdings LLC | Adp of the SNF | Organization | 07/30/2025 | |
| Veritas Health Solutions LLC | Adp of the SNF | Organization | 07/29/2025 | |
| Henry, Catlin | Adp of the SNF | Individual | 04/01/2020 | |
| Herzka, Yisroel | Adp of the SNF | Individual | 04/01/2020 | |
| Kopelowitz, Shaul | Adp of the SNF | Individual | 04/01/2020 | |
| Lemma, Wendwesen | Adp of the SNF | Individual | 04/01/2020 | |
| Stout, Christina | Adp of the SNF | Individual | 04/01/2020 | |
| Wise, Ginnette | Adp of the SNF | Individual | 04/01/2020 | |
| Yenowitz, Yitzchok | Adp of the SNF | Individual | 04/01/2020 |
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.
These are the official offices in Washington. NursingHomeClear cannot take or act on complaints.