Cycle 1
Health 2025-08-27 · Fire 2025-08-27
25 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Des Moines, WA
Puget Sound Transitional Care
2-star overall rating with 2-star inspections with 25 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2800 South 224th Street,, Des Moines, WA
(206) 824-0600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
165
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2004-02-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,690
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.08
Baseline 17.78% · Performance 17.69% · Measure score 8.08 · Achievement 8.08 · Improvement 0.69
Healthcare-associated infections
1.41
Baseline 5.61% · Performance 7.41% · Measure score 1.41 · Achievement 1.41 · Improvement 0
Total nurse turnover
4.85
Performance 43.84% · Measure score 4.85 · Achievement 4.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.24
Baseline 4.04 hours · Performance 3.43 hours · Measure score 1.24 · Achievement 1.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 10.14% · Lower 95% interval 7.16% |
| Discharge to community | 55.93% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 46.58% · Lower 95% interval 45.01% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 86.49% |
95.27%
8.8 pts worse
|
Numerator 32 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 18 · Denominator 24 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 12 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 11.36% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 112 |
| Staff flu vaccination coverage | 56.69% |
42%
14.7 pts better
|
Numerator 72 · Denominator 127 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 15 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 10 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
96.0%
2.7 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.6% · Q4 98.4% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.5% |
93.8%
4.3 pts worse
|
95.5%
6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
2.6%
1.7 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 32.5% |
16.3%
16.2 pts worse
|
11.4%
21.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 40.8% · Q3 39.3% · Q4 40.0% · 4Q avg 32.5% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.8%
2.1 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 16.0% · Q3 0.0% · Q4 12.1% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
12.1%
7.1 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.8% · Q3 7.1% · Q4 3.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
15.9%
3.9 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 5.1% · Q3 13.0% · Q4 17.8% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.2% |
20.0%
19.2 pts worse
|
16.3%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.9% · 4Q avg 39.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
15.8%
9 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 48.9% · Q3 20.8% · Q4 13.0% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
23.5%
2.8 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 13.6% · Q3 22.5% · Q4 40.7% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.7%
1.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 1.6% · Q3 1.5% · Q4 1.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
87.7%
4.9 pts better
|
81.7%
10.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 87.6% · Q4 88.7% · 4Q avg 92.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
13.2%
3.3 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 11.9% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
82.0%
13.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
19.9%
0.1 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 23.9% · Expected 28.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-05-19 · Fire 2023-05-19
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-08-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-19
F · Potential for more than minimal harm
2024-06-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-08
F · Potential for more than minimal harm
2023-05-19
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-05-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-05-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-05-19
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-06-19
E · Potential for more than minimal harm
2023-05-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-05-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-27
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-08-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-08-27
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-08-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-08-27
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-10-09
J · Immediate jeopardy
2025-07-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-07-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-31
F · Potential for more than minimal harm
2024-06-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-17
F · Potential for more than minimal harm
2023-05-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-05-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
Ownership
Actriv Healthcare LLC
Operational/Managerial Control · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Eastside Healthcare Staffing LLC
Operational/Managerial Control · Organization
Jenkins, Tracy
Operational/Managerial Control · Individual
Port, Barry
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Wesley Homes Des Moines Health Center
Des Moines, WA
3-star overall rating with 2-star inspections with $33,540 in total fines with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Judson Park Health Center
Des Moines, WA
4-star overall rating with 3-star inspections with 20 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Benson Heights Rehabilitation Center
Kent, WA
3-star overall rating with 3-star inspections with $29,075 in total fines with 14 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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