Cycle 1
Health 2024-11-26 · Fire 2024-11-26
36 health deficiencies
Top issue: Resident Rights (9 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Edmonds, WA
Edmonds Post Acute
2-star overall rating with 2-star inspections with $26,520 in total fines with 36 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
21400 72nd Avenue West, Edmonds, WA
(425) 775-1961
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kalesta Healthcare Group
Operator or chain grouping
Approved since
1977-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,275
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.60% · Performance 23.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.23% · Performance 8.64% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 58.11% · Performance 67.74% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.78
Baseline 3.29 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 1.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 5.88% · Lower 95% interval 6.11% |
| Discharge to community | 59.94% |
50.57%
9.4 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 54.35% · Lower 95% interval 49.34% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.75% |
95.27%
3.5 pts better
|
Numerator 79 · Denominator 80 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 2 · Denominator 80 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 20 · Denominator 48 |
| Discharge mobility score | 47.92% |
50.94%
3 pts worse
|
Numerator 23 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 80 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.64% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 12.07% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 17 · Denominator 119 |
| Staff flu vaccination coverage | 33.91% |
42%
8.1 pts worse
|
Numerator 79 · Denominator 233 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 26 · Denominator 48 |
| Transfer of health information to provider | 96.3% |
95.95%
0.3 pts better
|
Numerator 26 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 44 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 12 · Denominator 44 |
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% |
96.0%
2.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.6% · Q3 100.0% · Q4 98.3% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
93.8%
3.6 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.6%
0.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 5.4% · Q4 5.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
16.3%
14.6 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.8%
1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.2% · Q3 0.0% · Q4 4.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
12.1%
2.5 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.9% · Q3 6.2% · Q4 9.8% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
15.9%
4.5 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.4% · Q3 17.9% · Q4 20.5% · 4Q avg 20.4% · 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 | 24.5% |
20.0%
4.5 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
15.8%
3.4 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 14.3% · Q3 11.9% · Q4 16.3% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.2%
0.4 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 2.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.7%
0.2 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 0.0% · Q4 1.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
23.5%
1.1 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 28.1% · Q3 24.1% · Q4 29.5% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.7%
0.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.5% · Q3 7.4% · Q4 2.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
87.7%
3.3 pts better
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 92.3% · Q3 88.6% · Q4 90.6% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
13.2%
1 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.4%
1.4 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 5.2% · Q4 3.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
82.0%
6.1 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
19.9%
5.5 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 24.2% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
23 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
26 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Cycle 3
Health 2022-05-27 · Fire 2022-05-27
36 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-08-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
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 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
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 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-30
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 2023-10-04
E · Potential for more than minimal harm
2023-08-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-08-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-30
K523 · Services Deficiencies
Fire Safety
Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2023-10-04
F · Potential for more than minimal harm
2022-05-27
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-27
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-20
F · Potential for more than minimal harm
2022-05-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-27
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-02
F · Potential for more than minimal harm
2022-05-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-06-20
F · Potential for more than minimal harm
2022-05-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-02
F · Potential for more than minimal harm
2022-05-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-06-20
F · Potential for more than minimal harm
2022-05-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-20
F · Potential for more than minimal harm
2022-05-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-05-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-05-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-26
E · Potential for more than minimal harm
2022-05-27
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-08-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-17
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 2025-12-12
E · Potential for more than minimal harm
2025-04-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-21
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 2025-05-20
D · Potential for more than minimal harm
2025-03-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-10
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 2025-03-06
F · Potential for more than minimal harm
2024-11-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-26
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 2025-01-10
E · Potential for more than minimal harm
2024-11-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-26
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 2025-01-10
E · Potential for more than minimal harm
2024-11-26
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 2025-01-10
E · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
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 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
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 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
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 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-01-10
C · Minimal harm
2024-11-26
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-09-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-06-05
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 2024-07-03
D · Potential for more than minimal harm
2024-06-05
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 2024-07-03
D · Potential for more than minimal harm
2024-05-28
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 2024-07-03
D · Potential for more than minimal harm
2024-04-08
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 2024-05-22
D · Potential for more than minimal harm
2024-04-08
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 2024-05-22
D · Potential for more than minimal harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-08-30
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 2023-10-12
E · Potential for more than minimal harm
2023-08-30
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-30
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 2023-10-12
E · Potential for more than minimal harm
2023-08-30
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 2023-10-12
E · Potential for more than minimal harm
2023-08-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
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 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
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 2023-10-12
D · Potential for more than minimal harm
2023-08-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-12
G · Actual harm
2023-04-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-13
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 2023-05-17
D · Potential for more than minimal harm
2023-04-13
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 2023-05-17
D · Potential for more than minimal harm
2023-04-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-05
F · Potential for more than minimal harm
2022-05-27
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 2022-07-11
F · Potential for more than minimal harm
2022-05-27
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-07-11
E · Potential for more than minimal harm
2022-05-27
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 2022-07-11
E · Potential for more than minimal harm
2022-05-27
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 2022-07-11
E · Potential for more than minimal harm
2022-05-27
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 2022-07-11
E · Potential for more than minimal harm
2022-05-27
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 2022-07-11
E · Potential for more than minimal harm
2022-05-27
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 2022-07-11
E · Potential for more than minimal harm
2022-05-27
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 2022-07-11
E · Potential for more than minimal harm
2022-05-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
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 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-05-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-07-11
Penalties and ownership
What sits behind the stars
$26,520
2023-04-13
Fine
Fine · fine $26,520
Fine
Ownership
Clawson, Scott
5% Or Greater Indirect Ownership Interest · Individual
Williams, Ryan
5% Or Greater Indirect Ownership Interest · Individual
Clawson, Scott
Operational/Managerial Control · Individual
Fryling, Alarik
Operational/Managerial Control · Individual
Kalesta Healthcare Group, LLC
5% Or Greater Direct Ownership Interest · Organization
Reedy-Matrone, Brandon
Operational/Managerial Control · Individual
Williams, Ryan
Operational/Managerial Control · Individual
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4-star overall rating with 3-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
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3-star overall rating with 3-star inspections with $12,735 in total fines with 10 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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