Cycle 1
Health 2025-03-20 · Fire 2025-03-20
13 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Seattle, WA
Columbia Lutheran Home
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
4700 Phinney Avenue North, Seattle, WA
(206) 632-7400
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,215
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.74
Composite VBP score used to determine payment impact.
Payment multiplier
1.0140
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.97
Baseline 18.55% · Performance 18.20% · Measure score 6.97 · Achievement 6.97 · Improvement 1.79
Healthcare-associated infections
7.57
Baseline 5.96% · Performance 5.57% · Measure score 7.57 · Achievement 7.57 · Improvement 3.51
Total nurse turnover
7.42
Baseline 40.70% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 4.15
Adjusted total nurse staffing
1.53
Baseline 3.89 hours · Performance 3.51 hours · Measure score 1.53 · Achievement 1.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.47% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 307 · Observed rate 5.86% · Lower 95% interval 6.2% |
| Discharge to community | 67.03% |
50.57%
16.5 pts better
|
Better than the National Rate · Eligible stays 331 · Observed rate 63.14% · Lower 95% interval 62.43% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 88.24% |
95.27%
7 pts worse
|
Numerator 195 · Denominator 221 |
| Falls with major injury | 0.9% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 221 |
| Discharge self-care score | 43.6% |
53.69%
10.1 pts worse
|
Numerator 75 · Denominator 172 |
| Discharge mobility score | 40.12% |
50.94%
10.8 pts worse
|
Numerator 69 · Denominator 172 |
| Pressure ulcers or injuries, new or worsened | 1.36% |
2.29%
0.9 pts better
|
Numerator 3 · Denominator 221 · Adjusted rate 1.01% |
| Healthcare-associated infections requiring hospitalization | 5.57% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 199 · Observed rate 3.52% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 15.58% |
8.2%
7.4 pts better
|
Numerator 24 · Denominator 154 |
| Staff flu vaccination coverage | 8.09% |
42%
33.9 pts worse
|
Numerator 14 · Denominator 173 |
| Discharge function score | 48.26% |
56.45%
8.2 pts worse
|
Numerator 83 · Denominator 172 |
| Transfer of health information to provider | 76.6% |
95.95%
19.4 pts worse
|
Numerator 36 · Denominator 47 |
| Transfer of health information to patient | 98.03% |
96.28%
1.8 pts better
|
Numerator 149 · Denominator 152 |
| Resident COVID-19 vaccinations up to date | 32% |
25.2%
6.8 pts better
|
Numerator 40 · Denominator 125 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.4
About the same
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 2.7 · Expected 3.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.5
1.2 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.4 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
96.0%
1.3 pts worse
|
93.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 85.4% · Q2 95.5% · Q3 97.9% · Q4 100.0% · 4Q avg 94.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 69.6% |
93.8%
24.2 pts worse
|
95.5%
25.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.6%
1.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 48.9% |
16.3%
32.6 pts worse
|
11.4%
37.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.5% · Q2 59.5% · Q3 46.3% · Q4 36.2% · 4Q avg 48.9% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
5.8%
5 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 9.5% · Q3 11.4% · Q4 4.3% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
12.1%
7.1 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.8% · Q3 8.9% · Q4 2.1% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
15.9%
2.2 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.3% · Q3 14.7% · Q4 15.4% · 4Q avg 13.7% · 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 | 9.2% |
20.0%
10.8 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 18.0% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.2% |
15.8%
10.4 pts worse
|
14.9%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 46.3% · Q3 26.2% · Q4 11.1% · 4Q avg 26.2% · 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 | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
23.5%
5 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.2% · Q2 25.0% · Q3 32.1% · Q4 14.9% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.7%
1.6 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.4% · Q3 7.0% · Q4 4.7% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
87.7%
7.6 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 94.0% · Q3 99.0% · Q4 98.9% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
13.2%
6.4 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.4%
0.4 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 2.8% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.6% |
82.0%
5.4 pts worse
|
79.7%
3.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
19.9%
3.5 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 20.0% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-28 · Fire 2024-02-28
23 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-03-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-20
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 2025-04-21
D · Potential for more than minimal harm
2025-03-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-04-21
F · Potential for more than minimal harm
2024-02-28
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 2024-04-08
F · Potential for more than minimal harm
2024-02-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-02-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-02-28
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-08
F · Potential for more than minimal harm
2022-11-03
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-03
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-03
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 2022-11-30
E · Potential for more than minimal harm
2022-11-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-11-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-11-03
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 2022-11-30
D · Potential for more than minimal harm
2022-11-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-11-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-11-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-20
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 2025-04-28
E · Potential for more than minimal harm
2025-03-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
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 2025-04-28
D · Potential for more than minimal harm
2025-03-20
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 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
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 2025-04-28
F · Potential for more than minimal harm
2024-02-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-09
F · Potential for more than minimal harm
2024-02-28
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 2024-04-09
E · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-28
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 2024-04-09
D · Potential for more than minimal harm
2023-11-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
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 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-06
E · Potential for more than minimal harm
2022-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
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 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
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 2022-12-02
D · Potential for more than minimal harm
2022-11-03
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 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-02
Penalties and ownership
What sits behind the stars
Ownership
Alabach, Caroline
Corporate Director · Individual
Heyer, David
Operational/Managerial Control · Individual
Heyer, David
Corporate Officer · Individual
Mahler, Keith
Corporate Director · Individual
Mcginness, Charlotte
Corporate Director · Individual
Ramsey, Deborah
Corporate Director · Individual
Sears, Cindy
Corporate Director · Individual
Smith, Janet
Corporate Director · Individual
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