Washington State Walla Walla Veterans Home
92 Wainwright Drive, Walla Walla, WA 99362 · Walla Walla County · 80 certified beds · avg 77 residents/day · certified since Mar 5, 2018
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 27, 2026 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 3, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 3, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 27, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 16, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 16, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 18, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 16, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 7, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 17, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 12 | 0 | E |
| 2025 | 2 | 0 | D |
| 2026 | 12 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $10,358.
| Date | Type | Amount / length |
|---|---|---|
| Feb 27, 2026 | Fine | $10,358 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Washington avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.56 | 4.24 | 3.95 | top 3% in Washington; top 2% in the U.S. |
| Registered Nurse hours | 1.73 | 0.91 | 0.69 | top 3% in Washington; top 3% in the U.S. |
| Weekend total nurse staffing | 5.88 | 3.69 | 3.50 | top 4% in Washington; top 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.39 | 0.67 | 0.48 | top 2% in Washington; top 2% in the U.S. |
| Total nursing staff turnover (%) | 22.8 | 45.1 | 45.8 | top 3% in Washington; top 5% in the U.S. |
| RN turnover (%) | 26.5 | 45.4 | 42.9 | top 15% in Washington; top 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 6.41, RN 1.69, weekend 5.75. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Government - State
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Washington State Department of Vete | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/15/2017 |
| Gilbert, Solomon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/22/2023 |
| Gomez Bautista, Jose | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/02/2023 |
| Gomez Bautista, Jose | Individual | ADP of the SNF | NOT APPLICABLE | 07/16/2025 |
| Leno, Lonna | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/16/2021 |
| Leno, Lonna | Individual | ADP of the SNF | NOT APPLICABLE | 07/16/2025 |
| Murray, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/16/2021 |
| Puente, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/01/2023 |
| Puente, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2023 |
| Washington State Department of Vete | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/15/2017 |
| Westhoff, Terrance | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2020 |
| Westhoff, Terrance | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you learn about each resident's background and history, and how does that shape their care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Park Manor Rehabilitation Ctr | 2.4 mi | Walla Walla, WA | ★★★★★ | 5/5 | |
| Washington Odd Fellows Home | 2.4 mi | Walla Walla, WA | ★★★★☆ | 3/5 | |
| Regency at the Park | 3.4 mi | College Place, WA | ★★★★★ | 4/5 | |
| Milton Freewater Health and Rehabilitation | 8.4 mi | Milton Freewater, OR | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 505530.