Cycle 1
Health 2024-11-04 · Fire 2024-11-04
26 health deficiencies
Top issue: Infection Control (6 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Seattle, WA
Cascades Of St Anne
3-star overall rating with 2-star inspections with 26 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3540 Northeast 110th Street, Seattle, WA
(206) 363-7733
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascades Healthcare
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 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
1.37
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,903
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.71
Baseline 20.55% · Performance 19.25% · Measure score 4.71 · Achievement 4.71 · Improvement 3.19
Healthcare-associated infections
1.37
Baseline 7.32% · Performance 7.42% · Measure score 1.37 · Achievement 1.37 · Improvement 0
Total nurse turnover
1.15
Baseline 27.27% · Performance 58.97% · Measure score 1.15 · Achievement 1.15 · Improvement 0
Adjusted total nurse staffing
1.60
Baseline 3.68 hours · Performance 3.53 hours · Measure score 1.60 · Achievement 1.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.42% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 11.9% · Lower 95% interval 8.15% |
| Discharge to community | 53.5% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 48.91% · Lower 95% interval 44.98% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 71 · Denominator 71 |
| Falls with major injury | 2.82% |
0.77%
2 pts worse
|
Numerator 2 · Denominator 71 |
| Discharge self-care score | 35.85% |
53.69%
17.8 pts worse
|
Numerator 19 · Denominator 53 |
| Discharge mobility score | 66.04% |
50.94%
15.1 pts better
|
Numerator 35 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 1.41% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 71 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 7.5% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 7.81% |
8.2%
0.4 pts worse
|
Numerator 5 · Denominator 64 |
| Staff flu vaccination coverage | 12.12% |
42%
29.9 pts worse
|
Numerator 12 · Denominator 99 |
| Discharge function score | 56.6% |
56.45%
0.1 pts better
|
Numerator 30 · Denominator 53 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.3% |
96.28%
1 pts better
|
Numerator 36 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 2.5% |
25.2%
22.7 pts worse
|
Numerator 1 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.4
0.1 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.3 · Expected 2.9 · 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 1.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
93.8%
About the same
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
2.6%
2.9 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.4% · Q3 4.2% · Q4 6.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 69.7% |
16.3%
53.4 pts worse
|
11.4%
58.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.5% · Q2 60.0% · Q3 77.3% · Q4 78.6% · 4Q avg 69.7% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.8%
2.8 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
12.1%
5.5 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.8% · Q3 8.7% · Q4 6.9% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
15.9%
1.2 pts worse
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.3% |
20.0%
9.7 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
15.8%
2.3 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 13.6% · Q4 24.0% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
23.5%
2 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 27.1% · Q3 23.7% · Q4 33.2% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.7%
1.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 9.1% · Q4 3.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
87.7%
9.8 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 96.8% · Q3 98.6% · Q4 96.6% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.8% |
13.2%
11.4 pts better
|
12.0%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.8% · Observed 1.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.4%
1.3 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 5.1% · Q4 2.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
82.0%
14.9 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
19.9%
1.7 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 14.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-28 · Fire 2023-07-28
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
32 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Cycle 3
Health 2022-04-27 · Fire 2022-04-27
22 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-04
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-04
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-12-03
F · Potential for more than minimal harm
2024-11-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-11-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-11-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-03
F · Potential for more than minimal harm
2024-11-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-12-03
F · Potential for more than minimal harm
2024-11-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-22
F · Potential for more than minimal harm
2024-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-11-04
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-01-06
F · Potential for more than minimal harm
2024-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-04
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-03
F · Potential for more than minimal harm
2023-07-28
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
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 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-28
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 2023-09-05
F · Potential for more than minimal harm
2023-07-28
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-07-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-07-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-07-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-05
E · Potential for more than minimal harm
2022-04-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-04-20
E · Potential for more than minimal harm
2022-04-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-20
D · Potential for more than minimal harm
2022-04-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-20
D · Potential for more than minimal harm
2022-04-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-03-11
D · Potential for more than minimal harm
2026-01-21
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 2026-03-11
D · Potential for more than minimal harm
2025-12-11
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.
Not marked corrected
D · Potential for more than minimal harm
2025-04-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
E · Potential for more than minimal harm
2024-11-04
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-11-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-11-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-11-04
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 2024-12-07
E · Potential for more than minimal harm
2024-11-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-11-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
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 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
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 2024-12-07
D · Potential for more than minimal harm
2024-11-04
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 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
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 2024-12-07
D · Potential for more than minimal harm
2024-11-04
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 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-11-04
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-10-17
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 2024-11-07
D · Potential for more than minimal harm
2024-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-03-11
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-04-24
G · Actual harm
2023-12-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-26
G · Actual harm
2023-12-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-07-28
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 2023-09-08
F · Potential for more than minimal harm
2023-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-28
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 2023-09-08
D · Potential for more than minimal harm
2023-07-28
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-09-08
E · Potential for more than minimal harm
2022-04-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
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 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-27
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-06-01
Penalties and ownership
What sits behind the stars
$0
2024-09-09
Payment Denial
Payment Denial · denial start 2024-12-09 · 30 days
30 day denial
$0
2024-05-20
Payment Denial
Payment Denial · denial start 2024-08-20 · 1 days
1 day denial
Ownership
Furuma Flp
5% Or Greater Direct Ownership Interest · Organization
Liberty Rae Flp
5% Or Greater Direct Ownership Interest · Organization
Nordmark Flp
5% Or Greater Direct Ownership Interest · Organization
Sunburst Grove Flp
5% Or Greater Direct Ownership Interest · Organization
Moore, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Quest Flp
5% Or Greater Direct Ownership Interest · Organization
Crump, Jason
Corporate Director · Individual
Fullmer, Chad
Corporate Director · Individual
Furuma Flp
5% Or Greater Mortgage Interest · Organization
Liberty Rae Flp
5% Or Greater Mortgage Interest · Organization
Ly, Yaya
Operational/Managerial Control · Individual
Mcspadden, Darin
Corporate Officer · Individual
Moore, Thomas
5% Or Greater Mortgage Interest · Individual
Nordmark Flp
5% Or Greater Mortgage Interest · Organization
Quest Flp
5% Or Greater Mortgage Interest · Organization
Raskind, Daniel
Operational/Managerial Control · Individual
Sunburst Grove Flp
5% Or Greater Mortgage Interest · Organization
Thornton Creek Holdings LLC
5% Or Greater Mortgage Interest · Organization
White, Derek
Corporate Director · Individual
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