Cycle 1
Health 2025-05-09 · Fire 2025-05-09
20 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
33 fire-safety deficiencies
Top issue: Emergency Preparedness (15 deficiencies)
Tacoma, WA
Eliseo
3-star overall rating with 2-star inspections with 20 recent health deficiencies with 33 fire-safety deficiencies in the latest cycle
1301 N Highlands Parkway, Tacoma, WA
(253) 752-7112
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
187
Certified beds
Average residents
126
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-01
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
0.64
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,217
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0052
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.47
Baseline 15.04% · Performance 17.04% · Measure score 9.47 · Achievement 9.47 · Improvement 0
Healthcare-associated infections
8.38
Baseline 5.09% · Performance 5.33% · Measure score 8.38 · Achievement 8.38 · Improvement 0
Total nurse turnover
0
Baseline 49.24% · Performance 64.38% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.52
Baseline 3.97 hours · Performance 3.80 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.86% |
10.72%
2.9 pts better
|
Better than the National Rate · Eligible stays 540 · Observed rate 5.74% · Lower 95% interval 5.99% |
| Discharge to community | 56.51% |
50.57%
5.9 pts better
|
Better than the National Rate · Eligible stays 562 · Observed rate 52.67% · Lower 95% interval 52.85% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.52% |
95.27%
0.8 pts worse
|
Numerator 276 · Denominator 292 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 292 |
| Discharge self-care score | 60.89% |
53.69%
7.2 pts better
|
Numerator 151 · Denominator 248 |
| Discharge mobility score | 58.06% |
50.94%
7.1 pts better
|
Numerator 144 · Denominator 248 |
| Pressure ulcers or injuries, new or worsened | 2.4% |
2.29%
0.1 pts worse
|
Numerator 7 · Denominator 292 · Adjusted rate 2.12% |
| Healthcare-associated infections requiring hospitalization | 5.33% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 289 · Observed rate 3.46% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 8.13% |
8.2%
0.1 pts worse
|
Numerator 23 · Denominator 283 |
| Staff flu vaccination coverage | 92.76% |
42%
50.8 pts better
|
Numerator 282 · Denominator 304 |
| Discharge function score | 68.15% |
56.45%
11.7 pts better
|
Numerator 169 · Denominator 248 |
| Transfer of health information to provider | 91.84% |
95.95%
4.1 pts worse
|
Numerator 45 · Denominator 49 |
| Transfer of health information to patient | 97.71% |
96.28%
1.4 pts better
|
Numerator 171 · Denominator 175 |
| Resident COVID-19 vaccinations up to date | 52.17% |
25.2%
27 pts better
|
Numerator 72 · Denominator 138 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
96.0%
3.7 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.6%
0.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 4.1% · Q4 3.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 81.9% |
16.3%
65.6 pts worse
|
11.4%
70.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 82.8% · Q3 80.0% · Q4 71.1% · 4Q avg 81.9% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.8%
2.2 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.5% · Q3 3.3% · Q4 4.3% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
12.1%
7.4 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 19.1% · Q3 22.8% · Q4 18.3% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
15.9%
1.8 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 12.2% · Q3 13.0% · Q4 19.0% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.1% |
20.0%
10.9 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 7.7% · Q3 10.4% · Q4 5.3% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
15.8%
2.7 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.3% · Q3 14.8% · Q4 14.6% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
23.5%
1.8 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 16.2% · Q3 17.9% · Q4 25.7% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.7%
2.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 2.9% · Q4 1.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
87.7%
4.3 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 93.5% · Q3 96.8% · Q4 95.4% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
13.2%
2.2 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 14.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
82.0%
12.6 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
19.9%
0.6 pts worse
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 19.3% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-08-04
F · Potential for more than minimal harm
2025-05-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-08-04
F · Potential for more than minimal harm
2025-05-09
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-04
F · Potential for more than minimal harm
2025-05-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-05-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-09
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-09
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 2025-06-12
E · Potential for more than minimal harm
2025-05-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-09
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 2025-06-12
D · Potential for more than minimal harm
2025-05-09
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 2025-06-12
D · Potential for more than minimal harm
2025-05-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-09
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2025-06-12
F · Potential for more than minimal harm
2024-06-05
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-05
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
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 2024-07-10
D · Potential for more than minimal harm
2024-06-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-07-10
F · Potential for more than minimal harm
2023-08-17
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-19
F · Potential for more than minimal harm
2023-08-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-19
F · Potential for more than minimal harm
2023-08-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-08-17
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-08-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-19
F · Potential for more than minimal harm
2023-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-19
F · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-17
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 2023-10-12
F · Potential for more than minimal harm
2023-08-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-08-17
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-17
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-03-04
E · Potential for more than minimal harm
2025-06-26
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 2025-08-01
D · Potential for more than minimal harm
2025-06-26
F571 · Resident Rights Deficiencies
Health
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-05-09
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 2025-06-22
E · Potential for more than minimal harm
2025-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-22
E · Potential for more than minimal harm
2025-05-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-22
E · Potential for more than minimal harm
2025-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
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 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
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 2025-06-22
D · Potential for more than minimal harm
2025-05-09
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 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-06-22
C · Minimal harm
2025-05-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-03-18
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 2025-04-30
D · Potential for more than minimal harm
2025-03-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-30
G · Actual harm
2024-10-25
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 2024-12-10
D · Potential for more than minimal harm
2024-09-18
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 2024-11-02
F · Potential for more than minimal harm
2024-06-05
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 2024-07-20
F · Potential for more than minimal harm
2024-06-05
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 2024-07-20
E · Potential for more than minimal harm
2024-06-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-06-05
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 2024-07-20
E · Potential for more than minimal harm
2024-06-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-06-05
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 2024-07-20
E · Potential for more than minimal harm
2024-06-05
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-06-05
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 2024-07-20
D · Potential for more than minimal harm
2024-06-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-05
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 2024-07-20
E · Potential for more than minimal harm
2024-03-12
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 2024-04-26
E · Potential for more than minimal harm
2024-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-26
D · Potential for more than minimal harm
2023-12-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-08-17
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 2023-10-04
E · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-17
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 2023-10-04
D · Potential for more than minimal harm
2023-08-17
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 2023-10-04
D · Potential for more than minimal harm
2023-08-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-17
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 2023-10-04
D · Potential for more than minimal harm
2023-08-17
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 2023-10-04
D · Potential for more than minimal harm
2023-04-04
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-05-17
Penalties and ownership
What sits behind the stars
Ownership
Hoffman, Daniel
Corporate Director · Individual
Hoffman, David
Corporate Officer · Individual
Kempe, Ron
Corporate Director · Individual
Leng, Janet
Corporate Director · Individual
Mcfeely, Kevin
Corporate Officer · Individual
Mcfeely, Kevin
W-2 Managing Employee · Individual
Monroe, Janet
Corporate Director · Individual
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