Cycle 1
Health 2025-03-27 · Fire 2025-03-27
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Issaquah, WA
Avamere Rehabilitation Of Issaquah
2-star overall rating with 2-star inspections with $70,649 in total fines with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
805 Front Street, Issaquah, WA
(425) 392-1271
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1967-01-01
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
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,144
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9990
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.86
Baseline 17.56% · Performance 18.25% · Measure score 6.86 · Achievement 6.86 · Improvement 0
Healthcare-associated infections
6.45
Baseline 6.10% · Performance 5.91% · Measure score 6.45 · Achievement 6.45 · Improvement 1.21
Total nurse turnover
4.38
Baseline 31.32% · Performance 45.78% · Measure score 4.38 · Achievement 4.38 · Improvement 0
Adjusted total nurse staffing
0.62
Baseline 3.50 hours · Performance 3.25 hours · Measure score 0.62 · Achievement 0.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.97% |
10.72%
2.8 pts better
|
No Different than the National Rate · Eligible stays 196 · Observed rate 4.59% · Lower 95% interval 5.67% |
| Discharge to community | 64.38% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 200 · Observed rate 57% · Lower 95% interval 56.69% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.41% |
95.27%
1.9 pts worse
|
Numerator 85 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 77.55% |
53.69%
23.9 pts better
|
Numerator 38 · Denominator 49 |
| Discharge mobility score | 77.55% |
50.94%
26.6 pts better
|
Numerator 38 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 4.4% |
2.29%
2.1 pts worse
|
Numerator 4 · Denominator 91 · Adjusted rate 3.35% |
| Healthcare-associated infections requiring hospitalization | 5.91% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 4.07% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 25.6% |
8.2%
17.4 pts better
|
Numerator 32 · Denominator 125 |
| Staff flu vaccination coverage | 52.97% |
42%
11 pts better
|
Numerator 98 · Denominator 185 |
| Discharge function score | 73.47% |
56.45%
17 pts better
|
Numerator 36 · Denominator 49 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 24 · Denominator 25 |
| Transfer of health information to patient | 94.12% |
96.28%
2.2 pts worse
|
Numerator 48 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 39.47% |
25.2%
14.3 pts better
|
Numerator 15 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.4
About the same
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
96.0%
1 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 98.4% · Q4 90.6% · 4Q avg 97.0% |
| 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 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.6%
1.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 92.7% |
16.3%
76.4 pts worse
|
11.4%
81.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 85.9% · Q3 96.6% · Q4 90.2% · 4Q avg 92.7% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.8%
1.4 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.8% · Q3 7.3% · Q4 3.4% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
12.1%
4.5 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.8% · Q3 5.5% · Q4 6.9% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
15.9%
1.8 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 15.7% · Q3 10.4% · Q4 12.2% · 4Q avg 14.1% · 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 | 21.5% |
20.0%
1.5 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 27.2% · Q3 11.6% · Q4 25.0% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
15.8%
8.1 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 22.8% · Q3 23.5% · Q4 22.6% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.2%
0.5 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
23.5%
2.5 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 25.3% · Q3 19.5% · Q4 21.2% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.7%
2.1 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.7% · Q3 2.6% · Q4 3.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
87.7%
3.3 pts better
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 91.4% · Q3 89.4% · Q4 88.7% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
13.2%
5.6 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 19.4% · Expected 11.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.5% |
82.0%
4.5 pts better
|
79.7%
6.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
19.9%
7.7 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 31.3% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-06 · Fire 2024-02-06
31 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
25 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-25
F · Potential for more than minimal harm
2024-02-06
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-06
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-29
D · Potential for more than minimal harm
2022-10-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
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 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
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 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
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 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-03-27
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 2025-05-14
D · Potential for more than minimal harm
2025-03-27
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-05-14
J · Immediate jeopardy
2024-02-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-20
G · Actual harm
2024-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-20
G · Actual harm
2024-02-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
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 2024-03-20
E · Potential for more than minimal harm
2024-02-06
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 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
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 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
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 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F688 · Quality of Life and Care Deficiencies
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 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
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 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
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 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F725 · Nursing and Physician Services Deficiencies
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 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
D · Potential for more than minimal harm
2023-11-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-09
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 2023-12-12
G · Actual harm
2023-06-15
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 2023-07-05
F · Potential for more than minimal harm
2023-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-04-27
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-27
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-06-07
E · Potential for more than minimal harm
2022-10-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-10-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-10-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-10-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-10-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-10-12
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 2022-11-16
D · Potential for more than minimal harm
2022-10-12
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 2022-11-16
D · Potential for more than minimal harm
2022-10-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-10-12
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 2022-11-16
D · Potential for more than minimal harm
2022-10-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-11-16
Penalties and ownership
What sits behind the stars
$48,663
2024-02-06
Fine
Fine · fine $48,663
Fine
$21,986
2023-04-27
Fine
Fine · fine $21,986
Fine
Ownership
Ariso LLC
5% Or Greater Direct Ownership Interest · Organization
Ari Operations, LLC
5% Or Greater Indirect Ownership Interest · Organization
Avamere Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Dillon, Richard
5% Or Greater Indirect Ownership Interest · Individual
Miller, Karl
5% Or Greater Indirect Ownership Interest · Individual
Miller, Karl
Operational/Managerial Control · Individual
Odermott, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Tabor, Carl
Operational/Managerial Control · Individual
Tabor, Carl
Corporate Officer · Individual
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