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
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing
LPN hours / resident day
1.21
Licensed practical nurse staffing
Aide hours / resident day
2.52
Nurse aide staffing
Weekend hours
3.62
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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