6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Port Orchard, WA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2051 Pottery Avenue, Port Orchard, WA
(360) 876-4461
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
96
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1972-04-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 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
RN hours / resident day
0.60
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
4,487
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9927
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.53
Baseline 19.53% · Performance 19.79% · Measure score 3.53 · Achievement 3.53 · Improvement 0
Healthcare-associated infections
9.35
Baseline 5.95% · Performance 5.04% · Measure score 9.35 · Achievement 9.35 · Improvement 9
Total nurse turnover
1.7
Performance 56.73% · Measure score 1.7 · Achievement 1.7 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.33
Baseline 3.83 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 264 · Observed rate 9.47% · Lower 95% interval 6.96% |
| Discharge to community | 64.45% |
50.57%
13.9 pts better
|
Better than the National Rate · Eligible stays 297 · Observed rate 57.58% · Lower 95% interval 58.89% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 134 · Denominator 134 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 134 |
| Discharge self-care score | 59.38% |
53.69%
5.7 pts better
|
Numerator 38 · Denominator 64 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 36 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 134 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.04% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 2.34% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 2.22% |
8.2%
6 pts worse
|
Numerator 3 · Denominator 135 |
| Staff flu vaccination coverage | 44.75% |
42%
2.8 pts better
|
Numerator 81 · Denominator 181 |
| Discharge function score | 60.94% |
56.45%
4.5 pts better
|
Numerator 39 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 12.33% |
25.2%
12.9 pts worse
|
Numerator 9 · Denominator 73 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.4
0.9 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.6%
0.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.7% · Q3 3.9% · Q4 2.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 61.7% |
16.3%
45.4 pts worse
|
11.4%
50.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.4% · Q2 59.6% · Q3 65.2% · Q4 60.9% · 4Q avg 61.7% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.8%
2.3 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 0.0% · Q4 8.5% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
12.1%
12.8 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 25.5% · Q3 27.7% · Q4 23.4% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
15.9%
2.2 pts worse
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 15.2% · Q3 17.5% · Q4 17.8% · 4Q avg 18.1% · 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 | 15.1% |
20.0%
4.9 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
15.8%
5.4 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 30.8% · Q3 11.6% · Q4 14.0% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
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% · 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 | 21.6% |
23.5%
1.9 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 18.9% · Q3 18.6% · Q4 21.0% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.7%
2.2 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.3% · Q3 2.5% · Q4 1.3% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
87.7%
10.7 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 98.5% · Q3 97.8% · Q4 98.0% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.6% |
13.2%
10.4 pts worse
|
12.0%
11.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 24.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.4%
0.9 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
82.0%
13 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
19.9%
10.3 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 31.5% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-13
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-25
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-25
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-09
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-21
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-06
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-20
Inspection history
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-07
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-07
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 2025-10-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-07
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-13
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 2024-09-27
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-09-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-09-27
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-09-27
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-09-27
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-27
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 2024-09-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-27
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-30
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-24
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-05
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-05
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-05
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-05
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-05
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-05
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-05
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 2023-11-05
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
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