Cycle 1
Health 2025-03-14 · Fire 2025-03-14
30 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Tacoma, WA
Birch Creek Post Acute & Rehabilitation
2-star overall rating with 2-star inspections with 30 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
5601 S Orchard Street, Tacoma, WA
(253) 474-8421
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hill Valley Healthcare
Operator or chain grouping
Approved since
1984-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 2 overall / 2 health / 2 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
0.60
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,053
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9996
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.53
Baseline 17.34% · Performance 18.40% · Measure score 6.53 · Achievement 6.53 · Improvement 0
Healthcare-associated infections
5.22
Baseline 6.05% · Performance 6.27% · Measure score 5.22 · Achievement 5.22 · Improvement 0
Total nurse turnover
4.71
Baseline 52.63% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 2.45
Adjusted total nurse staffing
2.03
Baseline 3.78 hours · Performance 3.66 hours · Measure score 2.03 · Achievement 2.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 227 · Observed rate 11.45% · Lower 95% interval 8.21% |
| Discharge to community | 48.22% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 233 · Observed rate 40.77% · Lower 95% interval 41.77% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.83% |
95.27%
3.6 pts better
|
Numerator 169 · Denominator 171 |
| Falls with major injury | 1.17% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 171 |
| Discharge self-care score | 53.57% |
53.69%
0.1 pts worse
|
Numerator 60 · Denominator 112 |
| Discharge mobility score | 59.82% |
50.94%
8.9 pts better
|
Numerator 67 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 1.75% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 171 · Adjusted rate 1.59% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 5.92% · Lower 95% interval 3.94% |
| Staff COVID-19 vaccination coverage | 5.56% |
8.2%
2.6 pts worse
|
Numerator 9 · Denominator 162 |
| Staff flu vaccination coverage | 39.45% |
42%
2.5 pts worse
|
Numerator 157 · Denominator 398 |
| Discharge function score | 58.04% |
56.45%
1.6 pts better
|
Numerator 65 · Denominator 112 |
| Transfer of health information to provider | 41.51% |
95.95%
54.4 pts worse
|
Numerator 22 · Denominator 53 |
| Transfer of health information to patient | 93.85% |
96.28%
2.4 pts worse
|
Numerator 61 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 8 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 2.0 · Expected 3.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.8 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
96.0%
10.2 pts worse
|
93.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.7% · Q2 74.4% · Q3 91.2% · Q4 93.3% · 4Q avg 85.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.0% |
93.8%
18.8 pts worse
|
95.5%
20.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.6%
0.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.4% · Q3 3.3% · Q4 4.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
16.3%
7.3 pts better
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 13.6% · Q3 10.7% · Q4 5.8% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 11.3% |
5.8%
5.5 pts worse
|
5.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 13.3% · Q3 16.0% · Q4 13.3% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
12.1%
1.9 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 10.4% · Q3 10.5% · Q4 9.4% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
15.9%
8.4 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.1% · Q3 7.1% · Q4 5.7% · 4Q avg 7.5% · 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 | 14.0% |
20.0%
6 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 20.4% · Q3 18.5% · Q4 7.6% · 4Q avg 14.0% · 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 7.5% · Q2 15.3% · Q3 9.6% · Q4 17.7% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.2%
1 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
23.5%
2.1 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 28.8% · Q3 23.8% · Q4 18.1% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.7%
1.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.1% · Q3 3.8% · Q4 4.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
87.7%
12.4 pts worse
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.5% · Q2 75.4% · Q3 68.3% · Q4 75.5% · 4Q avg 75.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
13.2%
1.2 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 13.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.4%
0.7 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 1.6% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.3% |
82.0%
24.7 pts worse
|
79.7%
22.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
19.9%
5.4 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 27.5% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
22 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-04-26 · Fire 2023-04-26
15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-14
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 2025-04-08
E · Potential for more than minimal harm
2025-03-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-05-23
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-23
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-23
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-23
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-24
F · Potential for more than minimal harm
2023-04-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-26
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 2023-05-31
F · Potential for more than minimal harm
2023-04-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-26
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 2023-05-31
D · Potential for more than minimal harm
2023-04-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-19
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 2025-12-22
D · Potential for more than minimal harm
2025-11-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-08-11
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 2025-08-25
E · Potential for more than minimal harm
2025-07-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-06-30
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 2025-08-12
D · Potential for more than minimal harm
2025-06-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-12
F · Potential for more than minimal harm
2025-03-14
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 2025-04-21
E · Potential for more than minimal harm
2025-03-14
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 2025-04-21
E · Potential for more than minimal harm
2025-03-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-14
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 2025-04-21
E · Potential for more than minimal harm
2025-03-14
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 2025-04-21
E · Potential for more than minimal harm
2025-03-14
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 2025-04-21
E · Potential for more than minimal harm
2025-03-14
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 2025-04-21
E · Potential for more than minimal harm
2025-03-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-14
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 2025-04-21
D · Potential for more than minimal harm
2024-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-28
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-07-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
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 2024-08-06
E · Potential for more than minimal harm
2024-05-23
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 2024-07-02
E · Potential for more than minimal harm
2024-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-23
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 2024-07-02
E · Potential for more than minimal harm
2024-05-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-23
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-23
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 2024-07-02
E · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-23
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-23
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 2024-07-02
D · Potential for more than minimal harm
2024-05-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-23
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 2024-07-02
C · Minimal harm
2024-05-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-02
B · Minimal harm
2024-05-23
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 2024-07-02
B · Minimal harm
2024-05-23
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 2024-07-02
G · Actual harm
2024-03-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-30
F · Potential for more than minimal harm
2023-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-26
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 2023-06-06
E · Potential for more than minimal harm
2023-04-26
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 2023-06-06
E · Potential for more than minimal harm
2023-04-26
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 2023-06-06
E · Potential for more than minimal harm
2023-04-26
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 2023-06-06
E · Potential for more than minimal harm
2023-04-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
D · Potential for more than minimal harm
2023-04-26
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 2023-06-06
Penalties and ownership
What sits behind the stars
Ownership
Wash 6 SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Gig Harbor SNF Operations Manager LLC
Operational/Managerial Control · Organization
Idels, Shimon
Operational/Managerial Control · Individual
Idels, Shimon
Corporate Officer · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Steven
Operational/Managerial Control · Individual
Schwartz, Steven
Corporate Officer · Individual
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Orchard Park Health Care & Rehab Center
Tacoma, WA
1-star overall rating with 1-star inspections with $101,384 in total fines with 24 recent health deficiencies with 28 fire-safety deficiencies in the latest cycle
#2
Agility Health And Rehabilitation
University Place, WA
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Alaska Gardens Health And Rehabilitation
Tacoma, WA
1-star overall rating with 1-star inspections with Special Focus status with $196,648 in total fines with 29 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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