Cycle 1
Health 2024-10-15 · Fire 2024-10-15
27 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Portland, OR
Friendship Health Center
1-star overall rating with 1-star inspections with Special Focus status with $103,564 in total fines with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3320 Se Holgate Blvd, Portland, OR
(503) 231-1411
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-02-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,532
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0110
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.93
Performance 18.68% · Measure score 5.93 · Achievement 5.93 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.55
Performance 6.18% · Measure score 5.55 · Achievement 5.55 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0.9
Baseline 59.02% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.06 hours · Performance 6.36 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 6.77% |
| Discharge to community | 61.96% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 68 · Observed rate 61.76% · Lower 95% interval 50.81% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 83.33% |
95.27%
11.9 pts worse
|
Numerator 30 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 96.3% |
53.69%
42.6 pts better
|
Numerator 26 · Denominator 27 |
| Discharge mobility score | 88.89% |
50.94%
38 pts better
|
Numerator 24 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 34.48% |
8.2%
26.3 pts better
|
Numerator 40 · Denominator 116 |
| Staff flu vaccination coverage | 44% |
42%
2 pts better
|
Numerator 66 · Denominator 150 |
| Discharge function score | 96.3% |
56.45%
39.8 pts better
|
Numerator 26 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 27 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
95.5%
2.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 96.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.2%
3.3 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.4%
1.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.8% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
4.7%
0.1 pts worse
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.9% · Q3 4.5% · Q4 13.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.0%
2.8 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 3.8% · Q4 1.9% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
12.5%
2.6 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 11.3% · Q3 9.6% · Q4 9.4% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
14.7%
4 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.2% · Q3 10.5% · Q4 13.2% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.0% |
24.1%
2.1 pts better
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
15.8%
0.2 pts worse
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 6.8% · Q3 15.7% · Q4 11.8% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.7%
0.2 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.6% · Q3 0.0% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 1.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
22.2%
1.1 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 22.7% · Q3 28.1% · Q4 25.8% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 11.6% |
6.5%
5.1 pts worse
|
5.1%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 12.9% · Q3 13.6% · Q4 14.5% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
85.4%
10 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 95.2% · Q3 94.2% · Q4 90.2% · 4Q avg 95.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.7%
1 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.5% · Q3 2.1% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.6% |
81.2%
0.4 pts better
|
79.7%
1.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-30 · Fire 2023-06-30
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-05-04 · Fire 2022-05-04
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-10-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-30
F · Potential for more than minimal harm
2024-10-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-30
F · Potential for more than minimal harm
2024-10-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-30
F · Potential for more than minimal harm
2024-10-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-30
F · Potential for more than minimal harm
2023-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-06-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-30
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 2023-07-18
D · Potential for more than minimal harm
2023-06-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-07-18
F · Potential for more than minimal harm
2022-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-23
E · Potential for more than minimal harm
2022-05-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-23
D · Potential for more than minimal harm
2022-05-04
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-06-23
D · Potential for more than minimal harm
2022-05-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-31
J · Immediate jeopardy
2024-10-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-30
G · Actual harm
2024-10-15
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-15
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-11-30
F · Potential for more than minimal harm
2024-10-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-15
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 2024-11-30
E · Potential for more than minimal harm
2024-10-15
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 2024-11-30
E · Potential for more than minimal harm
2024-10-15
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 2024-11-30
E · Potential for more than minimal harm
2024-10-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-15
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 2024-11-30
E · Potential for more than minimal harm
2024-10-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-15
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 2024-11-30
E · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
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 2024-11-30
D · Potential for more than minimal harm
2024-10-15
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-30
G · Actual harm
2024-07-30
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 2024-09-17
D · Potential for more than minimal harm
2024-07-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-07-30
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-07-30
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 2024-09-17
F · Potential for more than minimal harm
2023-09-18
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-09-18
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 2023-10-24
E · Potential for more than minimal harm
2023-09-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-09-18
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 2023-10-24
E · Potential for more than minimal harm
2023-09-18
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 2023-10-24
D · Potential for more than minimal harm
2023-09-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-06-30
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 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
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 2023-07-24
D · Potential for more than minimal harm
2023-06-30
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 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-30
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 2023-07-24
E · Potential for more than minimal harm
2022-05-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-23
D · Potential for more than minimal harm
2022-05-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-23
D · Potential for more than minimal harm
2022-05-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-23
D · Potential for more than minimal harm
2022-05-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-23
D · Potential for more than minimal harm
2022-05-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-17
C · Minimal harm
2022-05-04
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 2022-06-23
Penalties and ownership
What sits behind the stars
$94,744
2024-10-15
Fine
Fine · fine $94,744
Fine
$8,820
2024-07-30
Fine
Fine · fine $8,820
Fine
Ownership
Blades, Jeff
Corporate Director · Individual
Broaddus, Jerry
Corporate Director · Individual
Corda, Gordon
Corporate Officer · Individual
Deitz, Ruth
Corporate Officer · Individual
Deitz, Ruth
W-2 Managing Employee · Individual
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