Cycle 1
Health 2025-01-08 · Fire 2025-01-08
27 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
29 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Seattle, WA
Ballard Center
2-star overall rating with 2-star inspections with 27 recent health deficiencies with 29 fire-safety deficiencies in the latest cycle
820 Northwest 95th Street, Seattle, WA
(206) 782-0100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.94
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,921
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.72% · Performance 21.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.24
Baseline 5.65% · Performance 6.57% · Measure score 4.24 · Achievement 4.24 · Improvement 0
Total nurse turnover
3.35
Baseline 57.14% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 1.71
Adjusted total nurse staffing
3.77
Baseline 3.48 hours · Performance 4.15 hours · Measure score 3.77 · Achievement 3.77 · Improvement 2.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 4.08% · Lower 95% interval 5.97% |
| Discharge to community | 36.7% |
50.57%
13.9 pts worse
|
Worse than the National Rate · Eligible stays 54 · Observed rate 27.78% · Lower 95% interval 26.87% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 87.76% |
95.27%
7.5 pts worse
|
Numerator 43 · Denominator 49 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 49 |
| Discharge self-care score | 36.67% |
53.69%
17 pts worse
|
Numerator 11 · Denominator 30 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 10 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 3.86% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 26.67% |
8.2%
18.5 pts better
|
Numerator 16 · Denominator 60 |
| Staff flu vaccination coverage | 50.7% |
42%
8.7 pts better
|
Numerator 36 · Denominator 71 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 10 · Denominator 30 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · 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 97.7% · Q2 95.7% · Q3 96.8% · Q4 97.8% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.8% |
93.8%
2 pts worse
|
95.5%
3.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
2.6%
0.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 2.2% · Q4 4.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
16.3%
14.5 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 6.3% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.8%
2.5 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 11.1% · Q3 8.9% · Q4 2.3% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.7% |
12.1%
2.4 pts better
|
19.6%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.7% · Q3 9.8% · Q4 10.0% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
15.9%
2.4 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.3% · Q3 16.7% · Q4 13.9% · 4Q avg 13.5% · 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 | 10.7% |
20.0%
9.3 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 2.9% · Q3 12.5% · Q4 11.0% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
15.8%
8.2 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 2.2% · Q3 8.8% · Q4 11.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.2%
0.9 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
23.5%
2.7 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 17.2% · Q3 28.7% · Q4 20.9% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.7%
1.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 8.7% · Q3 4.3% · Q4 6.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.6% |
87.7%
2.1 pts worse
|
81.7%
3.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 91.3% · Q3 86.2% · Q4 71.2% · 4Q avg 85.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.5% |
13.2%
8.3 pts worse
|
12.0%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 24.4% · Expected 12.7% · 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 | 83.2% |
82.0%
1.2 pts better
|
79.7%
3.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
19.9%
9.9 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 31.1% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-13 · Fire 2023-09-13
19 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
28 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2022-07-30 · Fire 2022-07-30
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-08
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-01-08
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-01-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-01-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
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 2025-02-10
F · Potential for more than minimal harm
2025-01-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-08
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 2025-03-06
F · Potential for more than minimal harm
2025-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-01-08
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 2025-02-10
E · Potential for more than minimal harm
2025-01-08
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-08
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-10
F · Potential for more than minimal harm
2023-09-13
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-09-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-09-13
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-09-13
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
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 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-09-13
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 2023-10-19
F · Potential for more than minimal harm
2023-09-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-13
K523 · Services Deficiencies
Fire Safety
Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2023-10-19
F · Potential for more than minimal harm
2022-07-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-07-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-07-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-07-30
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-07-30
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-07-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-07-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-30
E · Potential for more than minimal harm
2022-07-30
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-30
E · Potential for more than minimal harm
2022-07-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
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 2026-01-26
E · Potential for more than minimal harm
2025-11-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-14
E · Potential for more than minimal harm
2025-11-14
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 2025-12-14
D · Potential for more than minimal harm
2025-05-08
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 2025-05-12
D · Potential for more than minimal harm
2025-04-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-28
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 2025-04-04
D · Potential for more than minimal harm
2025-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-01-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-08
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 2025-02-07
E · Potential for more than minimal harm
2025-01-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-07
C · Minimal harm
2025-01-08
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-02-03
D · Potential for more than minimal harm
2024-02-28
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-04-04
D · Potential for more than minimal harm
2023-10-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-10-28
F · Potential for more than minimal harm
2023-09-13
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-13
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 2023-10-25
E · Potential for more than minimal harm
2023-09-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-13
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 2023-10-25
D · Potential for more than minimal harm
2023-09-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-25
E · Potential for more than minimal harm
2022-07-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-07-30
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 2022-08-31
D · Potential for more than minimal harm
2022-07-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-30
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 2022-08-31
D · Potential for more than minimal harm
2022-07-30
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 2022-08-31
D · Potential for more than minimal harm
2022-07-30
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 2022-08-31
D · Potential for more than minimal harm
2022-07-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-31
Penalties and ownership
What sits behind the stars
$0
2023-09-13
Payment Denial
Payment Denial · denial start 2023-12-13 · 1 days
1 day denial
Ownership
9560 Pico LLC
5% Or Greater Indirect Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bhumkar, Nishita
Operational/Managerial Control · Individual
Bold Quail Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Bq Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Brito, Jose
Operational/Managerial Control · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Bq Jv Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
General Partnership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Jv Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
General Partnership Interest · Organization
Newgen LLC
5% Or Greater Indirect Ownership Interest · Organization
Pico Ar LLC
5% Or Greater Indirect Ownership Interest · Organization
Robin, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Robin, Aaron
Corporate Officer · Individual
Shaw, Pamela
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sun Healthcare Group Inc
General Partnership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
General Partnership Interest · Organization
Tress, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Tress, Avrohom
Corporate Officer · Individual
Welltower Op LLC
5% Or Greater Direct Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Zac Properties Xi LLC
General Partnership Interest · Organization
Zhou, Tianziang
Operational/Managerial Control · Individual
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