Cycle 1
Health 2025-03-17 · Fire 2025-03-17
30 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Corvallis, OR
Corvallis Manor
0-star overall rating with 0-star inspections with Special Focus status with $345,051 in total fines with 30 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
160 Ne Conifer Blvd, Corvallis, OR
(541) 757-1651
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Volare Health
Operator or chain grouping
Approved since
1978-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.39
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.82
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,643
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.87
Baseline 16.37% · Performance 20.57% · Measure score 1.87 · Achievement 1.87 · Improvement 0
Healthcare-associated infections
5.41
Baseline 5.99% · Performance 6.22% · Measure score 5.41 · Achievement 5.41 · Improvement 0
Total nurse turnover
0
Baseline 65.56% · Performance 67.83% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.59
Baseline 5.21 hours · Performance 4.67 hours · Measure score 5.59 · Achievement 5.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 6.86% · Lower 95% interval 6.87% |
| Discharge to community | 62.34% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 106 · Observed rate 58.49% · Lower 95% interval 53.14% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 82.02% |
95.27%
13.2 pts worse
|
Numerator 73 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 38.81% |
53.69%
14.9 pts worse
|
Numerator 26 · Denominator 67 |
| Discharge mobility score | 50.75% |
50.94%
0.2 pts worse
|
Numerator 34 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 2.25% |
2.29%
About the same
|
Numerator 2 · Denominator 89 · Adjusted rate 2.3% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 3.57% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 21.65% |
8.2%
13.4 pts better
|
Numerator 21 · Denominator 97 |
| Staff flu vaccination coverage | 48.6% |
42%
6.6 pts better
|
Numerator 52 · Denominator 107 |
| Discharge function score | 53.73% |
56.45%
2.7 pts worse
|
Numerator 36 · Denominator 67 |
| Transfer of health information to provider | 96.72% |
95.95%
0.8 pts better
|
Numerator 59 · Denominator 61 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.83% |
25.2%
4.4 pts worse
|
Numerator 10 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
95.5%
3.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
95.2%
3 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
2.4%
2.5 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.8% · Q3 6.7% · Q4 4.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 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 who lose too much weight | 6.5% |
5.0%
1.5 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 9.1% · Q3 2.8% · Q4 0.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.2% |
12.5%
9.3 pts better
|
19.6%
16.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.3% · Q3 2.8% · Q4 5.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
14.7%
2.7 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 20.0% · Q3 15.2% · Q4 16.7% · 4Q avg 17.4% · 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 | 27.4% |
24.1%
3.3 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
15.8%
6.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 11.6% · Q3 2.9% · Q4 10.0% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 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% |
2.0%
0.9 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
22.2%
0.4 pts better
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 24.6% · Q3 19.9% · Q4 27.2% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.5%
3.5 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.5% · Q3 2.6% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
85.4%
11.1 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 95.6% · Q3 97.2% · Q4 98.2% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
15.1%
1.2 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.7%
1 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.9% · 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 | 96.2% |
81.2%
15 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
21.6%
4.1 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 15.3% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
36 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-17
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-25
F · Potential for more than minimal harm
2023-12-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-01-19
F · Potential for more than minimal harm
2022-11-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-04
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-08
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-05
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 2026-01-05
G · Actual harm
2025-04-11
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 2025-04-29
D · Potential for more than minimal harm
2025-04-11
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 2025-04-29
E · Potential for more than minimal harm
2025-03-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
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 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-01-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-01-27
D · Potential for more than minimal harm
2025-01-09
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-11-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-06
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 2024-12-18
D · Potential for more than minimal harm
2024-09-13
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 2024-07-16
F · Potential for more than minimal harm
2024-06-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-21
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 2024-07-30
D · Potential for more than minimal harm
2023-12-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-25
D · Potential for more than minimal harm
2023-12-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-25
G · Actual harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-09
G · Actual harm
2023-12-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-19
G · Actual harm
2023-12-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-01
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 2024-01-19
E · Potential for more than minimal harm
2023-12-01
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 2024-01-19
E · Potential for more than minimal harm
2023-12-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-01
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 2024-01-19
E · Potential for more than minimal harm
2023-12-01
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-01
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 2024-02-20
E · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-09
E · Potential for more than minimal harm
2023-12-01
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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 2024-01-19
D · Potential for more than minimal harm
2023-12-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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
2023-12-01
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 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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 2024-01-19
D · Potential for more than minimal harm
2023-12-01
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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
2023-12-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
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 2024-01-19
D · Potential for more than minimal harm
2023-12-01
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-01
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-01-19
J · Immediate jeopardy
2023-10-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-15
J · Immediate jeopardy
2023-10-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-15
J · Immediate jeopardy
2023-09-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-07-19
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 2023-08-23
D · Potential for more than minimal harm
2023-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-23
E · Potential for more than minimal harm
2022-11-04
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 2022-12-20
E · Potential for more than minimal harm
2022-11-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-04
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 2022-12-20
E · Potential for more than minimal harm
2022-11-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-04
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 2022-12-20
D · Potential for more than minimal harm
2022-11-04
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 2022-12-20
D · Potential for more than minimal harm
2022-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-04
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 2022-12-20
D · Potential for more than minimal harm
2022-11-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-20
Penalties and ownership
What sits behind the stars
$25,220
2025-03-17
Fine
Fine · fine $25,220
Fine
$164,093
2023-12-01
Fine
Fine · fine $164,093
Fine
$0
2023-12-01
Payment Denial
Payment Denial · denial start 2024-03-14 · 26 days
26 day denial
$13,397
2023-10-19
Fine
Fine · fine $13,397
Fine
$13,397
2023-10-19
Fine
Fine · fine $13,397
Fine
$128,944
2023-09-25
Fine
Fine · fine $128,944
Fine
Ownership
Pac 12 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bruns, Maureen
Operational/Managerial Control · Individual
Conifer Propco LLC
5% Or Greater Mortgage Interest · Organization
Hagar, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Hagler, Alexander
5% Or Greater Indirect Ownership Interest · Individual
Henning, Tracey
Operational/Managerial Control · Individual
Knox Healthcare Pac 12 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Knox, Donald
5% Or Greater Indirect Ownership Interest · Individual
Knox, Donald
Operational/Managerial Control · Individual
Knox, Donald
Corporate Officer · Individual
Pac 12 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Pac 12 Pinnacle Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Schwartz, Eliezer
Operational/Managerial Control · Individual
Smith, Brian
Corporate Officer · Individual
Volare Health LLC
Operational/Managerial Control · Organization
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#3
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3-star overall rating with 3-star inspections with $17,934 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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