Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Health Care Ctr during CMS and state inspections, most recent first.
Infection control failures were observed with COVID-19 PPE use and catheter-related care. Staff were seen wearing N95s over face masks, moving between COVID-19 rooms in soiled PPE, reusing single-use face shields, and handling eye protection and masks inconsistently, while some staff reported PPE shortages or uncertainty about required items. An LPN also used contaminated gloves to apply ointment to a resident’s urethral area after treating the resident’s bottom, despite the resident having a retention catheter and an antibiotic cream order for a urethral rash.
Incomplete ABN for Medicare Non-Covered Services: A resident with anxiety, arthritis, heart failure, and moderately impaired cognition was found to have an incomplete SNF ABN after Medicare Part A coverage ended. The form lacked selections for the services that would continue, though an estimated daily cost was listed, and staff stated the ABN should have been completed and provided when non-coverage was notified.
A resident admitted with HF, anxiety, and depression had a PASARR Level I that required a Level II eval, but the eval was not completed. The Social Services Director said the referral was sent, yet there was no documentation of follow-up in the resident’s record and no follow-up email, and the DON stated the PASARR referral process was not followed.
Medication storage and labeling were not properly maintained in the Team 4 med room and on two med carts. The med refrigerator held vaccines and other meds with repeated missed temp checks, water accumulation, ice buildup, and wet expired boxes, while staff said the refrigerator should be checked each shift. Two med carts also had insulin vials and pens with inconsistent or missing open dates and expiration dates, and staff reported confusion about how the labels were being used.
Staff failed to assess and manage a resident's CHF as ordered by the physician, neglecting to monitor for and document leg swelling and not administering a prescribed diuretic when indicated by either weight gain or edema. Nursing staff and the DON were unaware that the medication order required action for swelling as well as weight changes, despite concerns raised by the resident's representative.
The facility failed to ensure accurate MDS assessments for six residents, leading to incorrect documentation of medication use and discharge status. Residents were inaccurately recorded as taking anticoagulants instead of antiplatelet medications, and one resident's discharge status was incorrectly documented. Staff interviews confirmed these inaccuracies.
A facility failed to implement its abuse prevention policy for a resident who reported rough handling by a Nursing Assistant (NA). Despite the resident's concerns, the NA continued to be assigned to their care. Interviews revealed ongoing issues, and the Director of Nursing (DON) was unaware of the allegations, acknowledging that proper procedures were not followed.
A resident reported rough handling by a Nursing Assistant, resulting in bruises, but the facility failed to report the allegations to the State Agency. Despite being aware of the resident's complaints, staff members assumed the issue had been addressed, and the Director of Nursing was not informed, leading to a breach in the facility's abuse reporting policy.
A resident reported rough treatment by a Nursing Assistant, resulting in bruises. Despite staff awareness, no investigation was conducted, and the Director of Nursing was not informed. The resident remained unprotected as the Nursing Assistant continued working.
A facility failed to monitor a resident's cardiac status as per physician's orders, missing multiple daily weights and not notifying the physician of significant weight gains. The resident, with conditions including congestive heart failure, experienced several instances of weight gain exceeding three pounds without physician notification, increasing the risk of health complications.
A facility failed to provide trauma-informed care to a resident with a history of abuse, as no assessment was conducted to identify potential triggers. The resident, who had a history of physical abuse, was triggered by a nursing assistant's unpredictable behavior, reminiscent of past trauma. Despite the facility's policy, staff were unaware of the resident's triggers, and no care plan was developed, placing the resident at risk of re-traumatization.
A resident was prescribed an antipsychotic medication without an appropriate mental health diagnosis or identified target behaviors to justify its use. The resident's records showed no documented behaviors related to psychosis, and the medication was used to treat anxiety and dementia, with targeted behaviors of sadness and hopelessness. However, there was no clinical indication or justification for the antipsychotic medication.
A facility failed to provide a resident's medical records in a timely manner, violating resident rights. Despite receiving a request from a local attorney's office, the Medical Records Director did not confirm the email address for sending the records and was unable to contact the attorney's office for confirmation. As a result, the records were not sent 22 working days after the request was received. The Administrator was unaware of the delay and acknowledged the response was not timely.
The facility failed to maintain its Respiratory Protection Program for N95 masks during a COVID-19 outbreak, with significant delays in fit testing for several staff members. This oversight occurred despite the facility's policy requiring fit testing upon hire and annually, placing staff and residents at risk during the outbreak.
A resident was mistakenly given COVID-19 reagent solution as eye drops due to a mix-up by an RN who confused the bottles. The reagent, a chemical not meant for bodily use, was improperly stored on the medication cart. The resident, who was cognitively intact and required assistance with ADLs, experienced a burning sensation in the eye. The incident highlighted a failure to follow medication administration policy.
A resident with osteomyelitis was supposed to receive IV antibiotic therapy, but due to a missed continuation order by the Charge Nurse, the therapy was discontinued prematurely. This resulted in the resident missing seven doses of the antibiotic, which was identified as a significant medication error by the Consultant Pharmacist. The error was discovered by the Resident Care Manager during a follow-up on the resident's IV access site.
Infection Control Failures With PPE Use and Catheter Care
Penalty
Summary
The facility failed to consistently implement infection prevention and control measures for residents with COVID-19, including proper donning, use, and doffing of PPE, ensuring PPE was readily available at multiple nursing teams, and preventing cross contamination during catheter-related care. Survey observations and interviews showed staff entering COVID-19 positive resident rooms wearing PPE incorrectly, including N95 masks worn over face masks, soiled PPE being worn from one room to another, and PPE being removed or handled in ways that did not follow the stated process. Staff also reported confusion about which PPE was required and where supplies such as face masks and eye protection were located. At Team 4, a nursing assistant entered COVID-19 positive rooms wearing a gown, eye protection, gloves, and an N95 mask over a face mask, then moved between rooms while still wearing soiled PPE. The same staff member removed PPE inside a resident room, discarded items in the room, and then handled eye protection with a gloved hand after touching a disinfectant wipe. A housekeeper stated eye protection was not required if none was available on the PPE cart, and the cart outside the room had no eye protection. An LPN at Team 4 also wore an N95 over a face mask, removed PPE in the resident room, and then placed soiled eye protection on top of a glove box before cleaning it with a gloved hand and a disinfectant wipe. At Team 2, a nursing assistant was observed wearing a face mask and two N95 masks at the same time and stated they preferred to wear both. A laundry aide entered a COVID-19 positive room wearing a gown that was not secured at the neck or back, causing it to fall forward while the aide leaned over the resident, and the aide stated they did not know which mask or whether eye protection was required. Another LPN wore a face mask instead of an N95 and cleaned and reused a disposable face shield marked single use, stating they were unsure if that was the correct process. At Team 1, a nursing assistant wore an N95 over a face mask in a COVID-19 positive room and then continued wearing the contaminated face mask in non-COVID-19 rooms after removing the N95. Another LPN exited a COVID-19 positive room and kept the face mask on, stating they did not want to remove it and that there was no room on the PPE cart for extra face masks. Resident 71 had a history of stroke, urinary retention, and prostate cancer, with moderately impaired cognition and a retention catheter. The resident also had an antibiotic cream ordered for a rash around the urethral area. During observation, an LPN applied ointment to the resident's bottom and then used the same contaminated gloves to apply the antibiotic ointment to the tip of the urethral opening without performing hand hygiene or changing gloves. The DNS later stated it was not the facility's practice to use contaminated gloves when applying ointment to the urethra area and that the nurse should have changed gloves before completing the treatment.
Incomplete ABN for Medicare Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (ABN) for Resident 32, who was covered by Medicare Part A until 06/01/2025 with the first non-covered day listed as 06/02/2025. Resident 32 had diagnoses including anxiety disorders, arthritis, and heart failure, and the 09/10/2025 comprehensive assessment showed the resident required supervision or moderate assistance from one staff member for activities of daily living and had moderately impaired cognition. Review of the ABN dated 06/02/2025 showed the form was incomplete, with no selections marked for the care the resident had received and would no longer receive under Medicare Part A, although an estimated cost of $729.89 per day/item or service was listed. The ABN was signed by Resident 32 on 06/06/2025. Staff D, the Business Office Manager, stated the form should have identified which services would be continued and should have been provided when the notice of non-coverage was given on 05/27/2025. Staff E, the Social Services Director, stated the ABN provided to Resident 32 was not complete and that the process for presenting a completed ABN was not followed. Staff B, the Director of Nursing Services, stated the ABN should have been completed with no blank areas and the resident should have been notified of the change in coverage on the same day it occurred.
PASARR Level II Not Completed for Resident Requiring Evaluation
Penalty
Summary
The facility failed to ensure a PASARR Level II assessment was completed for one resident reviewed for PASARR services. Resident 58 was admitted with diagnoses including heart failure, anxiety, and depression, and the comprehensive assessment showed the resident required assistance from one to two staff members for activities of daily living and had intact cognition. The resident’s Level I PASARR dated 07/29/2025 indicated that a Level II evaluation was required. The Social Services Director stated the facility’s process included auditing Level I screenings for accuracy and sending for a Level II when indicated, and stated that Resident 58’s Level II evaluation was sent for on 07/30/2025. However, the Level II evaluation had not been received, and the Social Services Director stated there was no notation of follow-up in the resident’s medical record and no follow-up email for the resident. The Director of Nursing stated the Social Services Director had been trained on the PASARR Level I and II referral process and that the process was not followed for completing PASARR Level II evaluations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications and vaccines were properly stored in 1 of 3 medication rooms reviewed, the Team 4 medication room. During observation, the medication refrigerator contained 2 vials of Apisol and pneumococcal vaccines, and the temperature log showed repeated missed documentation across multiple months, with the refrigerator expected to be checked and documented twice daily. The refrigerator also had water collected on top of a locked medication container, a soaked towel with a reddish/brown tint underneath it, ice buildup in the freezer section, and three wet medication boxes that were expired. Staff stated the refrigerator should be checked each shift and that expired medications should be removed, but they were unaware of the water in the refrigerator. The facility also failed to ensure medications were properly labeled in 2 of 5 medication carts reviewed, the Team 1 and Team 4 medication carts. One cart contained a vial of insulin dated 8/19, and staff stated the vial was good for 30 days once opened. Another cart contained multiple insulin vials and pens with inconsistent labeling, including vials with no open date, handwritten expiration dates, one vial with an open date and handwritten expiration date, one insulin pen with an open date but no expiration date, and one insulin pen with no open date and an expiration date. Staff stated there were discrepancies about what staff were to label when vials and pens were opened, and that pharmacy-provided stickers with open date, expiration date, and initials were inconsistently used.
Failure to Assess and Manage CHF According to Physician Orders
Penalty
Summary
Facility staff failed to accurately assess and manage a resident's congestive heart failure (CHF) according to physician orders. The resident, who had diagnoses including CHF, COPD, and atrial fibrillation, was admitted with a care plan that required monitoring for changes in lung sounds, cough, edema, and weight. Physician orders specified that a diuretic (furosemide) should be administered if the resident's weight increased by two pounds in one day or if leg swelling developed, and that daily weights should be recorded with clinician notification for significant weight gain. Although daily weights were documented, staff did not administer the diuretic, as they only monitored for weight gain and were unaware that leg swelling was also an indication for the medication. Interviews and record reviews revealed that staff did not specifically assess or document the presence or absence of leg, ankle, or foot swelling, despite concerns raised by the resident's representative about swelling and weight gain. Nursing staff, including RNs and LPNs, confirmed they were not monitoring for edema as required by the physician's order and did not recognize that swelling alone should have prompted administration of the diuretic. The Director of Nursing also acknowledged that staff did not monitor or document swelling and was unaware of the full scope of the medication order.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of six out of seven sampled residents. This deficiency was identified through interviews and record reviews. For Resident 32, the MDS assessment inaccurately indicated the use of an anticoagulant medication, while the resident was actually prescribed an antiplatelet medication, clopidogrel bisulfate. Similarly, Resident 84's MDS assessment incorrectly showed the use of an anticoagulant, whereas the resident was prescribed aspirin, another antiplatelet medication. Resident 79's MDS assessment also inaccurately reflected the use of an anticoagulant, while the resident was prescribed clopidogrel bisulfate. Resident 3's MDS assessment inaccurately indicated the use of an anticoagulant medication, while the resident was actually prescribed clopidogrel bisulfate, an antiplatelet medication. For Resident 29, the MDS assessment failed to reflect the need for a state level II PASRR process, despite a completed PASRR indicating such a requirement. Lastly, Resident 96's MDS assessment inaccurately documented the discharge status as to a critical access hospital, while the resident was actually discharged to home with family. Interviews with facility staff revealed acknowledgment of the inaccuracies in the MDS assessments. Staff C, the Assistant Director of Nursing Services, confirmed the incorrect coding of medications for Residents 32, 84, 79, and 3. Staff J, the Resident Care Manager/LPN, admitted to marking the incorrect discharge status for Resident 96. The Director of Nursing Services, Staff B, was aware of the discrepancies and indicated that education would be provided to the Resident Care Managers to address these issues.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy and procedures, specifically in the areas of resident protection, identification, reporting, and investigation, for one resident reviewed for abuse and neglect. The deficiency involved Resident 47, who was cognitively intact and able to communicate their needs. The resident reported that a Nursing Assistant (Staff I) was rough and impatient during care, which was communicated to a Charge Nurse (Staff F). Despite this, Staff I continued to be assigned to care for Resident 47, contrary to the facility's policy that required the alleged perpetrator to be immediately suspended. Interviews with various staff members revealed that the concerns about Staff I's behavior had been ongoing for about a month and a half. Staff G, a Licensed Practical Nurse, confirmed that Staff I was not supposed to enter Resident 47's room, yet continued to do so. Staff E, a Social Service Assistant, noted that Resident 47 expressed a preference not to have Staff I care for them, but did not report abuse or neglect during a follow-up interview. However, Staff H, another Nursing Assistant, reported that Resident 47 had ongoing concerns about Staff I's rough handling, which included waking the resident at night and causing bruising. The Director of Nursing Services (Staff B) was unaware of the abuse allegations and stated that the correct process for reporting and investigating such allegations was not followed. Staff B acknowledged that the allegations should have been reported and investigated, and that Staff I should have been removed from the schedule to protect Resident 47. This failure to adhere to the facility's abuse prevention policy placed Resident 47 at risk for continued exposure to potential abuse and neglect.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect to the State Agency for one resident, identified as Resident 47, who was reviewed for abuse/neglect. This deficiency was identified through interviews and record reviews. The facility's policy on abuse/neglect/misappropriation/exploitation, revised in October 2022, mandates the prevention, identification, reporting, and investigation of such incidents. The policy also requires immediate suspension of the alleged perpetrator and ensuring the resident's safety. However, the facility did not adhere to this policy, as the allegations made by Resident 47 were not reported to the State Agency. Resident 47, who was cognitively intact and able to communicate their needs, reported that a Nursing Assistant, Staff I, was rough and impatient during care, resulting in bruises. The resident had informed a Charge Nurse, Staff F, about the rough handling, but the incident was not logged or reported. Interviews with other staff members, including a Licensed Practical Nurse and another Nursing Assistant, revealed that they were aware of the allegations but assumed the reporting and investigation had been completed. The Director of Nursing Services, Staff B, was unaware of the allegations and acknowledged that the correct reporting process was not followed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as Resident 47, who was cognitively intact and able to communicate their needs. The resident reported that a Nursing Assistant, Staff I, was rough and impatient during care, resulting in bruises. Despite informing facility staff about the incident, no investigation was documented in the facility's incident investigation log from March through September 2024. Interviews with staff revealed that both a Licensed Practical Nurse and a Charge Nurse were aware of the resident's concerns about rough treatment by Staff I. However, the Director of Nursing Services was not informed of the allegations, which should have been investigated immediately. The failure to follow the correct process left the resident unprotected, as Staff I was not removed from the schedule pending an investigation.
Failure to Monitor Cardiac Status and Notify Physician
Penalty
Summary
The facility failed to ensure that residents received treatment and services in accordance with professional standards of practice, specifically regarding the monitoring of cardiac status through daily weights and physician notification of significant weight changes. Resident 1, who was admitted with diagnoses including congestive heart failure, diabetes, and a history of cerebral vascular accident, had a physician's order for daily weights with instructions to notify the physician if there was a weight gain of three pounds or more in a 24-hour period. However, the facility missed multiple daily weights across several months and failed to notify the physician of significant weight gains on several occasions, including a five-pound gain over several days in October. Interviews with facility staff revealed that the registered nurse and licensed practical nurse/charge nurse were aware that the physician should have been notified of weight gains exceeding three pounds. Despite this knowledge, the physician was not contacted, and re-weighs were not conducted to verify the accuracy of the data. This lack of action placed residents at an increased risk for unidentified complications and deterioration in their health status, as the facility did not adhere to the prescribed monitoring and notification protocols.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident identified as a trauma survivor, specifically Resident 47. The facility's policy on trauma-informed care, revised in October 2022, mandates that residents with a history of trauma should receive culturally competent care to prevent re-traumatization. However, the facility did not conduct a trauma-informed care assessment for Resident 47, who had a documented history of physical abuse as a child and was triggered by the unpredictable mood swings of a nursing assistant, Staff I. This lack of assessment and identification of potential triggers placed the resident at risk of re-traumatization. Resident 47, who was admitted with diagnoses including heart failure, depression, and insomnia, reported feeling afraid due to Staff I's unpredictable behavior, which reminded them of their abusive significant other. Despite the resident's cognitive ability to express their needs, the facility did not identify or document potential triggers related to the resident's trauma history. Interviews with various staff members, including nursing assistants and social service staff, revealed a lack of awareness and communication regarding the resident's potential triggers and trauma history. The facility's Director of Nursing Services (DNS) acknowledged that the correct process for trauma-informed care was not followed for Resident 47. The DNS stated that a trauma-informed care assessment should have been completed to identify traumatic events, potential triggers, and interventions to prevent re-traumatization. The failure to conduct this assessment and develop a care plan with preventative interventions was a significant oversight, as it did not align with the facility's policy and placed the resident at risk for re-traumatization.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had an acceptable indication for the use of an antipsychotic medication. The resident, who was admitted with mental health diagnoses including dementia without behavioral disturbances, anxiety, and depression, was prescribed an antipsychotic medication without a mental health diagnosis or identified target behaviors to justify its use. The comprehensive assessment indicated the resident was cognitively intact with anxiety and moderate depression, but did not identify issues with psychosis. The resident's medical records showed they were taking several psychoactive medications, including an antipsychotic for anxiety, without a documented diagnosis or associated behavior to support its use. Behavior monitoring flow sheets from August to early October showed no documented behaviors related to psychosis, sadness, hopelessness, worrying, or ruminating. During a psychoactive medication review meeting, it was noted that the resident was unaware of when the antipsychotic was started, and the diagnosis for its use was anxiety and dementia, with targeted behaviors identified as sadness and hopelessness. However, there was no clinical indication or justification for the antipsychotic medication.
Failure to Provide Timely Access to Resident Records
Penalty
Summary
The facility failed to provide copies of personal and medical records to a resident, as required by regulations, which violated the resident's rights. The deficiency involved Resident 1, who was admitted with diagnoses of muscle wasting, contusion of the scalp, and repeated falls. The resident had intact cognition and required assistance with personal care. A written request for the resident's records was submitted by a local attorney's office on behalf of the resident, including a signed consent form and specific instructions for electronic delivery. The request was received by the facility on July 30, 2024. Despite receiving the request, the facility did not fulfill it in a timely manner. Staff D, the Medical Records Assistant, began gathering records and informed the Administrator and Medical Records Director. However, Staff C, the Medical Records Director, failed to confirm the email address for sending the records and did not successfully contact the attorney's office for confirmation. As of August 29, 2024, 22 working days later, the records had not been sent. The Administrator was unaware of the delay and acknowledged that 22 working days was not a timely response, indicating a lack of awareness of the facility's response time requirement for record requests.
Failure to Maintain Respiratory Protection Program During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain their Respiratory Protection Program (RPP) for N95 respirator masks, which are essential for protecting staff and residents during a COVID-19 outbreak. Specifically, the facility did not conduct initial and annual fit testing for four out of five staff members reviewed for infection control practices. This deficiency was identified during an active COVID-19 outbreak that began on May 28, 2024, resulting in infections among 17 residents and 21 staff members. The facility's policy required fit testing upon hire and annually, but records showed significant delays in completing these tests for several staff members. Staff D, E, and F were hired in 2024 and experienced delays ranging from 21 to 68 days after hire before completing their fit testing, with some tests occurring after the outbreak had already begun. Staff G, hired in 2022, had no records of fit testing completed in 2024. Interviews with the Staff Development Director and the Administrator confirmed that the facility was behind on fit testing schedules, acknowledging that the expected fit testing had not been completed as required. This oversight placed both staff and residents at continued risk of exposure to COVID-19 during the outbreak.
Medication Error: COVID-19 Reagent Solution Used as Eye Drops
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who was mistakenly administered COVID-19 reagent solution as eye drops. The incident occurred when a registered nurse, Staff E, confused the reagent solution with the resident's prescribed eye drops due to the similar appearance of the bottles. This error was discovered when the resident began experiencing a burning sensation in the eye. The COVID-19 reagent solution, a chemical not intended for bodily use, was improperly stored on the medication cart, contributing to the mix-up. Resident 2, who was cognitively intact and required assistance with activities of daily living, was admitted to the facility with a pelvic fracture, head contusion, and bladder infection. The incident was documented in the facility's incident reporting log and involved a medication error by Staff E. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that the reagent solution should not have been stored on the medication cart, and Staff E did not adhere to the facility's medication administration policy.
Significant Medication Error Due to Missed Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when physician's orders were not implemented timely. Resident 1, who was readmitted to the facility with osteomyelitis, diabetes mellitus, and peripheral vascular disease, was supposed to receive intravenous antibiotic therapy as per the orders of an Infectious Disease specialist. The orders were to continue the IV antibiotic, Ampicillin-Sulbactam, for three more weeks. However, the Charge Nurse, Staff C, who was responsible for processing physician orders, missed the continuation order, resulting in the discontinuation of the antibiotic therapy after the last dose was administered. This oversight led to Resident 1 missing seven doses of the prescribed antibiotic, which was identified as a significant medication error by the Consultant Pharmacist. The error was discovered by Staff D, the Resident Care Manager, who was following up on the resident's IV access site. Despite the recognition of the incident as a medication error, the Director of Nursing, Staff B, did not consider it to be significant. The facility's incident investigation confirmed that the continuation order was not processed, leading to the medication errors.
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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.
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Nursing homes near Yakima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Village | 1.1 mi | ★★★★★ | 34 | 0 |
| Landmark Care And Rehabilitation | 1.4 mi | ★★★★★ | 2 | 0 |
| Crescent Health Care | 1.5 mi | ★★★★★ | 19 | 0 |
| Summitview Rehab And Health Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Yakima Valley School | 3.5 mi | ★★★★★ | 13 | 0 |
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