Cycle 1
Health 2024-11-14 · Fire 2024-11-14
39 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bremerton, WA
Belmont Terrace
2-star overall rating with 1-star inspections with $9,750 in total fines with 39 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
560 Lebo Boulevard, Bremerton, WA
(360) 479-1515
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-12-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.98
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.90
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
52%
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
2,146
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0058
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.31
Baseline 15.63% · Performance 17.12% · Measure score 9.31 · Achievement 9.31 · Improvement 0
Healthcare-associated infections
7.65
Baseline 5.78% · Performance 5.55% · Measure score 7.65 · Achievement 7.65 · Improvement 2.48
Total nurse turnover
0
Performance 63.71% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.62
Baseline 3.71 hours · Performance 4.11 hours · Measure score 3.62 · Achievement 3.62 · Improvement 1.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 195 · Observed rate 12.82% · Lower 95% interval 8.39% |
| Discharge to community | 47.31% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 203 · Observed rate 38.42% · Lower 95% interval 39.95% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 72 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 30 · Denominator 55 |
| Discharge mobility score | 61.82% |
50.94%
10.9 pts better
|
Numerator 34 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 75 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.55% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 3.09% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 146 |
| Staff flu vaccination coverage | 43.39% |
42%
1.4 pts better
|
Numerator 82 · Denominator 189 |
| Discharge function score | 56.36% |
56.45%
0.1 pts worse
|
Numerator 31 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 44.23% |
25.2%
19 pts better
|
Numerator 23 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
96.0%
1.9 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.1% |
93.8%
1.7 pts worse
|
95.5%
3.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
2.6%
0.4 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.6% · Q3 3.6% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
16.3%
7.4 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 6.7% · Q3 9.5% · Q4 3.9% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.8%
1.8 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 4.3% · Q4 3.8% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
12.1%
6.2 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.0% · Q3 4.3% · Q4 1.9% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
15.9%
6.3 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.3% · Q3 7.3% · Q4 6.5% · 4Q avg 9.6% · 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 | 17.2% |
20.0%
2.8 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 8.2% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
15.8%
3.1 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 20.8% · Q3 6.5% · Q4 5.8% · 4Q avg 12.7% · 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 | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
23.5%
4.4 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 24.5% · Q3 23.6% · Q4 27.6% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
4.7%
4.4 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
87.7%
4 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 94.1% · Q3 92.0% · Q4 91.7% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
13.2%
4 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.4%
0.5 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.1% · Q4 1.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
82.0%
7.9 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
19.9%
3.3 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.8% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-13 · Fire 2023-10-13
18 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-11-29 · Fire 2022-11-29
37 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-14
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-11-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-11-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-11-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-11-14
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 2024-12-10
F · Potential for more than minimal harm
2023-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-10
F · Potential for more than minimal harm
2022-11-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-13
F · Potential for more than minimal harm
2022-11-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-14
F · Potential for more than minimal harm
2022-11-29
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-11-17
F · Potential for more than minimal harm
2022-11-29
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-04-01
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-01
F690 · Quality of Life and Care Deficiencies
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 2025-04-25
D · Potential for more than minimal harm
2025-04-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-01
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-01
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-04-25
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F808 · Nutrition and Dietary Deficiencies
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
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 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-31
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-31
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-31
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-05
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 2024-02-27
D · Potential for more than minimal harm
2024-01-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-05
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-02-27
E · Potential for more than minimal harm
2023-10-13
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-10-13
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 2023-11-27
E · Potential for more than minimal harm
2023-10-13
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 2023-11-27
E · Potential for more than minimal harm
2023-10-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-10-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-10-13
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 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-13
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 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-13
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-08-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-22
G · Actual harm
2023-05-09
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 2023-06-10
D · Potential for more than minimal harm
2023-04-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-26
E · Potential for more than minimal harm
2022-11-29
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-29
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 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
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 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
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 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F808 · Nutrition and Dietary Deficiencies
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 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-01-06
Penalties and ownership
What sits behind the stars
$9,750
2023-05-09
Fine
Fine · fine $9,750
Fine
Ownership
Pennant Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Actriv Healthcare LLC
Operational/Managerial Control · Organization
Burnam, Soon
Corporate Officer · Individual
Canary, Adam
Operational/Managerial Control · Individual
Farnsworth, Stephen
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Port, Barry
Corporate Officer · Individual
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