Cycle 1
Health 2024-10-22 · Fire 2024-10-22
14 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Tacoma, WA
The Oaks At Lakewood
5-star overall rating with 4-star inspections with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
11411 Bridgeport Way, Tacoma, WA
(253) 581-9002
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1989-07-26
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
0.46
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,619
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.58% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.49
Baseline 6.78% · Performance 7.09% · Measure score 2.49 · Achievement 2.49 · Improvement 0
Total nurse turnover
6.77
Performance 36.00% · Measure score 6.77 · Achievement 6.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.64
Baseline 3.51 hours · Performance 4.11 hours · Measure score 3.64 · Achievement 3.64 · Improvement 2.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 8.96% · Lower 95% interval 6.96% |
| Discharge to community | 57.11% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 157 · Observed rate 49.04% · Lower 95% interval 49.7% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.04% |
95.27%
0.2 pts worse
|
Numerator 115 · Denominator 121 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 121 |
| Discharge self-care score | 61.63% |
53.69%
7.9 pts better
|
Numerator 53 · Denominator 86 |
| Discharge mobility score | 61.63% |
50.94%
10.7 pts better
|
Numerator 53 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0.83% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 121 · Adjusted rate 0.77% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 109 · Observed rate 7.34% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 0.7% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 143 |
| Staff flu vaccination coverage | 30.77% |
42%
11.2 pts worse
|
Numerator 44 · Denominator 143 |
| Discharge function score | 72.09% |
56.45%
15.6 pts better
|
Numerator 62 · Denominator 86 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 53 · Denominator 54 |
| Transfer of health information to patient | 93.62% |
96.28%
2.7 pts worse
|
Numerator 44 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 27.4% |
25.2%
2.2 pts better
|
Numerator 20 · Denominator 73 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.8 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
96.0%
3 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.8%
2.4 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
16.3%
4.9 pts better
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 13.5% · Q3 12.2% · Q4 6.4% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.8%
2.4 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 2.6% · Q3 0.0% · Q4 2.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
12.1%
3.2 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 10.0% · Q3 6.5% · Q4 11.1% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
15.9%
6.6 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 12.0% · Q3 8.6% · Q4 6.5% · 4Q avg 9.3% · 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 | 13.8% |
20.0%
6.2 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 31.4% · Q4 4.0% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
15.8%
0.2 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.2% · Q3 4.9% · Q4 18.6% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.2%
0.3 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 25.3% |
23.5%
1.8 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 31.2% · Q3 25.4% · Q4 11.7% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.7%
0.2 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.1% · Q3 9.4% · Q4 4.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
87.7%
7.5 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 94.9% · Q3 97.4% · Q4 96.8% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
13.2%
0.2 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 13.0% · Expected 11.2% · 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 | 85.1% |
82.0%
3.1 pts better
|
79.7%
5.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
19.9%
0.6 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 19.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-08 · Fire 2023-12-08
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-09-19 · Fire 2022-09-19
12 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (14 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-10-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-26
F · Potential for more than minimal harm
2023-12-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-12-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-12-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-22
F · Potential for more than minimal harm
2022-09-19
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-09-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-19
E · Potential for more than minimal harm
2022-09-19
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-19
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-19
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
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 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
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 2024-11-26
D · Potential for more than minimal harm
2024-10-22
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 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
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 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
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 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-26
E · Potential for more than minimal harm
2023-12-08
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-08
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-08
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-08
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 2024-01-12
D · Potential for more than minimal harm
2023-12-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-08
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 2024-01-12
D · Potential for more than minimal harm
2023-12-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-12
C · Minimal harm
2023-12-08
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-01-12
F · Potential for more than minimal harm
2022-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-19
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 2022-10-28
E · Potential for more than minimal harm
2022-09-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-19
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-19
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 2022-10-28
D · Potential for more than minimal harm
2022-09-19
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 2022-10-28
D · Potential for more than minimal harm
2022-09-19
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 2022-10-28
D · Potential for more than minimal harm
2022-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
Ownership
Pennant Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Bradburn, Kasey
Operational/Managerial Control · Individual
Bradburn, Kasey
W-2 Managing Employee · Individual
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Hoopes, Tyler
Corporate Director · Individual
Jenkins, Tracy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Tacoma Nursing And Rehabilitation Center
Tacoma, WA
5-star overall rating with 5-star inspections with $36,446 in total fines with 2 fire-safety deficiencies in the latest cycle
#2
Birch Creek Post Acute & Rehabilitation
Tacoma, WA
2-star overall rating with 2-star inspections with 30 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Alaska Gardens Health And Rehabilitation
Tacoma, WA
1-star overall rating with 1-star inspections with Special Focus status with $196,648 in total fines with 29 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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