Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington Soldiers Home during CMS and state inspections, most recent first.
A resident with a history of heart disease reported chest pain and difficulty breathing to staff on multiple occasions, but did not receive timely intervention and was sent to the hospital several hours later. The resident's subsequent allegation of neglect was not reported to the State Agency within the required timeframe, as facility procedures dictate, resulting in a delay of three days before the report was made.
The facility failed to serve food at appetizing temperatures, with residents reporting overcooked and flavorless meals. During a lunch service, a food service worker added gravy to dried-out meatloaf, which was not on the menu, and served tilapia at an inadequate temperature. The dietary manager confirmed these practices did not meet expectations.
The facility failed to provide physician-ordered therapeutic diets and portion sizes to 22 residents, risking medical complications and nutritional deficits. Observations revealed that residents on specific diets received incorrect items, such as garlic bread instead of wheat rolls, and incorrect portion sizes, such as insufficient protein servings. Staff acknowledged the discrepancies but could not explain the failure to adhere to dietary orders.
A facility failed to document and review a resident's healthcare advance directive (AD), leaving the resident without confirmed healthcare decision-making authority. The resident believed their sister was their DPOA for healthcare, but the EHR only showed a DPOA for financial matters. Staff interviews confirmed the absence of required documentation and review of the AD.
A resident reported concerns about personal items being stolen and was distressed over the lack of a lock on their closet. Despite filing a grievance, the facility did not report the alleged theft to law enforcement or the State Survey Agency. Interviews with staff confirmed that the required notifications were not made, placing the resident at risk for further abuse.
A resident reported concerns about stolen personal items and the lack of a lock on their closet, causing emotional distress. The facility addressed the lock issue but failed to investigate the theft allegations. Interviews with staff confirmed that an investigation should have been conducted, but it was not, leading to a deficiency finding.
A resident was admitted with diagnoses of depression and PTSD, but the PASRR assessment completed prior to admission failed to document these serious mental illness indicators. Facility staff acknowledged that the assessment was inaccurate and should have been updated upon admission.
A resident with a left leg amputation received a shrinker to prepare for a prosthetic leg, but the facility failed to document its arrival, obtain provider orders, or update the care plan. The resident applied the shrinker independently without formal guidance from nursing staff, leading to a deficiency in professional standards of care.
A resident with severe malnutrition, a sacral ulcer, and diabetes experienced a decline in ADLs due to the facility's failure to provide a wheelchair. The resident, dependent on staff for transfers, was confined to bed without mobility plans in their care plan or EHR. The DON stated that a loaner wheelchair should have been provided.
The facility failed to monitor and document bowel movements for a resident at risk of constipation, and did not implement the bowel program as needed. Additionally, two residents were not properly positioned or provided with necessary supportive devices, despite having care plans that required specific interventions. Staff interviews confirmed that expectations for monitoring, documentation, and use of devices were not met.
A facility failed to accurately assess a resident's smoking safety, leading to potential fire and injury risks. The resident, with multiple health issues and a history of stroke, was observed with a right-hand splint and an untrimmed beard, yet was allowed to smoke independently. Staff interviews confirmed the assessment was inaccurate, as the resident lacked the dexterity to hold a cigarette safely and had a large untrimmed beard.
A resident with chronic pain syndrome and a recent toe amputation reported inadequate pain management, with medication not administered on time and insufficient to control pain. Facility staff interviews confirmed a lack of documentation and monitoring of the resident's pain levels, contrary to the care plan and facility protocol.
A facility failed to limit PRN psychotropic medication to 14 days for a resident with chronic respiratory failure and anxiety. The resident had an order for lorazepam without a stop date, and the medication was administered multiple times over several months. The pharmacist and DON acknowledged the oversight, as the PRN lorazepam should have been discontinued or justified within 14 days.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to identify and timely report an allegation of neglect for one resident. The resident, who had a history of atherosclerotic heart disease and prior heart attacks, reported experiencing chest pain and difficulty breathing during the early morning hours. Despite informing staff of these symptoms multiple times, the staff did not take immediate action, and the resident was not sent to the hospital until several hours later. The resident later reported this incident to facility staff, expressing that their concerns were not addressed promptly and that they felt their life was at risk while waiting for assistance. A grievance form documented the resident's complaint, and the staff member who received the complaint reported it to their supervisor. However, the facility did not report the allegation of neglect to the State Agency until three days after the resident voiced the allegation. The facility's operating procedure required immediate reporting of suspected abuse or neglect to a licensed nurse and the State Agency hotline, but this protocol was not followed. The Director of Nursing Services confirmed that the delay in reporting was not acceptable and did not meet facility expectations.
Failure to Provide Appetizing and Safe Food Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature, as observed during a review of Kitchen Services. Residents expressed dissatisfaction with the quality of the food, noting that the meat was overcooked and lacked flavor. Specifically, one resident mentioned that the meat was overcooked, while another stated that the food did not taste good. A third resident commented on the lack of flavor and dryness of the chicken and other meats. These observations were made during interviews conducted on July 15, 2024. On July 17, 2024, during the lunch tray service, it was observed that a food service worker was adding gravy to meatloaf slices that appeared dried out, even though gravy was not listed on the menu for regular diets. The temperatures of the food items on a test tray were taken, revealing that the orzo and asparagus were at 135 degrees Fahrenheit, the meatloaf at 136 degrees Fahrenheit, and the tilapia at 125 degrees Fahrenheit. The food service worker acknowledged that the tilapia was not at an appropriate temperature. The dietary manager confirmed that only altered texture diets should have received gravy and that dried-out menu items should not have been served. The tilapia's temperature did not meet the facility's expectations, indicating a failure to maintain proper food quality and safety standards.
Failure to Provide Physician-Ordered Therapeutic Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that 22 out of 90 sampled residents received physician-ordered therapeutic diets or portion sizes, which placed them at risk for medical complications, nutritional deficits, and a decreased quality of life. During an observation of the lunch tray preparation service, it was noted that residents on Easy to Chew, Soft and Bite Sized, and Puree diets were served garlic bread instead of the wheat roll specified in the lunch extension menu. Staff L, a Food Service Worker Lead, confirmed that only garlic bread and garlic bread sticks were prepared, and there were no wheat rolls available. Staff L was unsure why the wheat rolls were not prepared, indicating a failure to follow the prescribed dietary requirements. Additionally, there were discrepancies in portion sizes provided to residents. For instance, Resident 60's tray card indicated a Large Portion, but they received only one and a half portions of meatloaf, with regular diet portion sizes for other items. Similarly, Resident 48's tray card indicated Double Protein, but they were initially served only one slice of meatloaf, consistent with the regular diet. Staff N, the Food Service Supervisor, had to intervene to correct the portion size for Resident 48. Staff M, the Dietary Manager, acknowledged that tray cards indicating Large Portion should have received one and a half portions of protein and starch, and that the expectation was for extension menus and tray cards to be followed. However, Staff M could not explain why the wheat rolls were not prepared, highlighting a lapse in adherence to dietary orders.
Failure to Document and Review Healthcare Advance Directive
Penalty
Summary
The facility failed to obtain or offer assistance in formulating or periodically checking if a resident had a healthcare advance directive (AD). This deficiency was identified for one of the sampled residents, who was able to make their needs known upon admission. The resident believed their sister was their durable power of attorney (DPOA) for healthcare, but there was no documentation to confirm this in their electronic healthcare record (EHR). The resident's care plan only indicated a DPOA for financial matters, not healthcare. Interviews with facility staff revealed that the necessary documentation and review of the resident's AD for healthcare were not conducted as required. The psychiatric social worker confirmed the absence of documentation offering AD information or reviewing it in the EHR. The facility administrator acknowledged that AD information should be offered, obtained, and reviewed upon admission and quarterly, and that the lack of documentation did not meet the facility's expectations.
Failure to Report Alleged Theft of Resident's Property
Penalty
Summary
The facility failed to report an incident of potential abuse involving the misappropriation of personal property for one resident. Resident 37, who was able to communicate their needs, expressed concerns about personal items being stolen and was distressed over the lack of a lock on their closet. Despite the resident's grievance filed on June 10, 2024, which highlighted their emotional distress and the need for a lock, the facility did not address the allegation of stolen items or report the incident to law enforcement and the State Survey Agency as required. The facility's incident reporting log from February 2024 through July 12, 2024, showed no record of the alleged theft. Interviews with the Director of Nursing Services and the Administrator revealed that the police and State Agency should have been notified, but this did not occur. The failure to report the allegation of misappropriation of personal property placed the resident at risk for further abuse and diminished their quality of life.
Failure to Investigate Alleged Misappropriation of Resident's Property
Penalty
Summary
The facility failed to identify and investigate possible misappropriation of personal property for a resident who was able to communicate their needs. The resident, who had previously experienced theft of personal items, expressed concerns about stolen belongings and the lack of a lock on their closet, which caused them emotional distress. Despite the resident's grievance form indicating these concerns, the facility only addressed the installation of locks on the closet and did not investigate the allegations of stolen items. The facility's incident report log showed no recorded investigation into the resident's allegations of theft. Interviews with the Director of Nursing Services and the Administrator revealed that an incident report investigation should have been initiated but was not, which did not meet the facility's expectations. The failure to investigate the resident's allegations of misappropriation of personal property was identified as a deficiency.
Inaccurate PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) assessment was accurately completed for a resident upon or prior to admission. This deficiency was identified for one of seven residents reviewed for PASRRs and/or unnecessary medications. The resident in question was admitted with diagnoses including depression, adult failure to thrive, and post-traumatic stress disorder (PTSD). However, the PASRR assessment completed by the hospital prior to admission did not document any serious mental illness indicators, and it incorrectly indicated that no Level II evaluation was needed. Interviews with facility staff revealed that the PASRR assessment was not accurate and should have been reviewed and updated upon the resident's admission to include the diagnoses of depression and PTSD. Both the Psychiatric Social Worker and the Director of Nursing Services acknowledged that the PASRR did not meet expectations and should have been corrected to reflect the resident's mental health conditions.
Failure to Document and Plan for Shrinker Use in Resident with Amputation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident with an amputation of the left lower leg. The resident, who was admitted with a diagnosis of an amputation, was waiting for a shrinker to arrive in the mail to help prepare for a prosthetic leg. Upon receiving the shrinker, the resident was responsible for applying it themselves without any documented assessment, provider orders, or care plan in place. The resident was advised by a Certified Nursing Assistant/Restorative Aide to wear the shrinker for about an hour daily and to monitor for skin reactions, but there was no formal guidance or documentation from the nursing staff or physician. Interviews with staff revealed a lack of awareness and documentation regarding the resident's use of the shrinker. The Licensed Practical Nurse confirmed the absence of a provider order or care plan for the shrinker, and the Director of Nursing Services was unaware of the shrinker's arrival and use. The facility did not document the arrival of the shrinker, notify the provider, obtain necessary orders, or update the care plan, which led to a deficiency in meeting professional standards of care for the resident.
Failure to Provide Wheelchair Leads to ADL Decline
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 57, leading to a decline in their ability to perform activities of daily living (ADLs). Resident 57 was admitted with severe malnutrition, a large sacral skin ulcer, and diabetes, and was dependent on staff for transfers in and out of bed. Despite being able to communicate their needs, Resident 57 was observed lying in bed continuously over several days without a wheelchair, which was necessary for their mobility. The resident expressed frustration about being confined to bed since March, unable to go outside or attend medical appointments. The electronic health record and care plan for Resident 57 lacked any mention of a wheelchair or mobility plan. The Director of Nursing Services acknowledged that the facility's expectation was to provide a loaner wheelchair until the resident's personal wheelchair was available.
Deficiencies in Bowel Monitoring and Positioning
Penalty
Summary
The facility failed to consistently monitor and document bowel movements and implement the bowel program for Resident 28, who was at risk for constipation due to impaired mobility, medications, and diet. Despite having a care plan that required monitoring and documentation of bowel movements, there was no record of bowel movements for several days, nor was there documentation of administering constipation medications or any refusals. Interviews with staff revealed that the expectation was to administer medications if the resident did not have a bowel movement for more than 72 hours and to document any refusals, which was not done. Additionally, the facility did not properly position Resident 12, who was dependent on staff for bed mobility due to Parkinson's disease. Observations showed that the resident was not repositioned every two hours as required, and palm protectors were not used consistently, despite the resident having sores on their fingertips and being unable to use the call light. Staff interviews confirmed that the resident should have been repositioned every two hours and should have had palm protectors on at all times. For Resident 52, the facility failed to use prescribed positioning devices, such as an air cast and palm splint, for a resident with a stroke and a leg fracture. Observations showed that the resident's left hand was not supported with a splint, and the left leg was not properly positioned in an air cast. Documentation did not reflect the use of these devices, contrary to the care plan and treatment administration record. Staff interviews indicated that the expectation was for clear documentation and the use of devices as ordered, which was not met.
Inaccurate Smoking Safety Assessment for Resident
Penalty
Summary
The facility failed to provide necessary supervision and safety monitoring for a resident, identified as Resident 28, who was reviewed for accidents. The deficiency was related to an inaccurate smoking safety assessment, which placed the resident and the facility at risk for possible fire and serious injury. The facility's policy on smoking and tobacco use required smoking assessments for residents who smoked upon admission, quarterly, and when warranted by circumstances. However, the assessment for Resident 28, conducted on 06/11/2024, inaccurately indicated that the resident had the hand dexterity to safely hold a cigarette and that their facial hair was trimmed to avoid lit cigarette or ashes falling on it, despite observations to the contrary. Resident 28 was admitted with multiple diagnoses, including heart, lung, and kidney disease, and had a history of stroke with hemiplegia. During an observation, the resident was seen with a right-hand splint and a large, untrimmed beard, and stated they smoked independently after obtaining cigarettes and a lighter from the nurse's station. Interviews with facility staff revealed that the smoking safety assessment was not accurate, as the resident lacked the dexterity to hold a cigarette safely and had a large untrimmed beard, which posed a safety risk. The Director of Nursing Services confirmed that the assessment should have been accurate and that the resident's beard should be trimmed for safe smoking.
Failure to Monitor and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately monitor and manage pain for a resident, identified as Resident 67, who was admitted with a diagnosis of left toe amputation, chronic pain syndrome, and post-traumatic stress disorder. The resident had a provider order for narcotic pain medication to be administered three times a day. However, during an interview, the resident reported that the medication was not administered on time and was insufficient to control their pain, which was described as out of control. A review of the electronic health record revealed a lack of documentation regarding the resident's pain levels, which is necessary to assess the effectiveness of the pain medication. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the facility's protocol required pain levels to be documented every shift and the physician to be notified if the medication was ineffective. Despite this, the resident's care plan, which instructed staff to monitor and document pain management, was not followed. The resident reported experiencing pain at a level of 9 out of 10, and was observed shaking due to the intensity of the pain, indicating a significant lapse in the facility's pain management practices.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days for one resident, identified as Resident 59, when reviewed for unnecessary medications. Resident 59, who was admitted with multiple diagnoses including chronic respiratory failure and anxiety, had an order for lorazepam, an antianxiety medication, to be administered every four hours as needed, starting on February 21, 2024, without a stop date. The monthly pharmacy recommendations did not include a suggestion to discontinue the lorazepam PRN after 14 days. The medication administration record indicated that Resident 59 received lorazepam three times in July 2024, seven times in June 2024, and nine times in May 2024. During interviews, both the pharmacist and the Director of Nursing Services acknowledged that the PRN lorazepam should have been discontinued or justified within 14 days, which was not done, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 551 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orting
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of South Hill | 7 mi | — | 18 | 1 |
| Puyallup Post Acute | 7.1 mi | — | 36 | 0 |
| Rainier Rehabilitation | 7.6 mi | — | 0 | 0 |
| Linden Grove Health Care Center | 7.9 mi | — | 45 | 0 |
| Life Care Center Of Puyallup | 7.9 mi | — | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Washington Soldiers Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.