Cycle 1
Health 2025-09-09 · Fire 2025-09-09
16 health deficiencies
Top issue: Resident Rights (5 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Yakima, WA
Garden Village
2-star overall rating with 2-star inspections with $102,166 in total fines with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
206 South Tenth Avenue, Yakima, WA
(509) 453-4854
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
81
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.49
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.37
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.17% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 13.79% · Lower 95% interval 7.09% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 94.59% |
95.27%
0.7 pts worse
|
Numerator 35 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.45% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.37% |
8.2%
0.8 pts worse
|
Numerator 7 · Denominator 95 |
| Staff flu vaccination coverage | 32.79% |
42%
9.2 pts worse
|
Numerator 40 · Denominator 122 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.52% |
25.2%
15.7 pts worse
|
Numerator 2 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
96.0%
9.2 pts worse
|
93.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.1% · Q2 73.1% · Q3 88.7% · Q4 100.0% · 4Q avg 86.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 74.7% |
93.8%
19.1 pts worse
|
95.5%
20.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 74.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
2.6%
3.3 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.7% · Q3 5.6% · Q4 2.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
16.3%
9.5 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 6.9% · Q3 2.9% · Q4 2.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.8%
0.3 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.1% · Q3 4.3% · Q4 0.0% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
12.1%
6.1 pts worse
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 17.3% · Q3 14.5% · Q4 19.2% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 49.5% |
15.9%
33.6 pts worse
|
16.7%
32.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 40.4% · Q3 52.1% · Q4 57.1% · 4Q avg 49.5% · 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 | 15.3% |
20.0%
4.7 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.3% · Q3 25.5% · Q4 11.0% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
15.8%
7 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 34.2% · Q3 19.7% · Q4 10.8% · 4Q avg 22.8% · 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 1.1% · Q2 0.9% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
23.5%
1.2 pts better
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 16.5% · Q3 24.0% · Q4 29.6% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.7%
1 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.6% · Q3 8.2% · Q4 5.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.8% |
87.7%
30.9 pts worse
|
81.7%
24.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 44.7% · Q3 64.3% · Q4 87.8% · 4Q avg 56.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.3% |
13.2%
15.1 pts worse
|
12.0%
16.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 30.8% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
1.4%
4.2 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.8% · Q4 9.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.4% |
82.0%
41.6 pts worse
|
79.7%
39.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
19.9%
About the same
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 19.2% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-29 · Fire 2024-10-29
28 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2023-08-31 · Fire 2023-08-31
21 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-09
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-09-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-09-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-09-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-09-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-09-09
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 2025-10-08
F · Potential for more than minimal harm
2025-09-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-09-09
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 2025-10-08
D · Potential for more than minimal harm
2025-09-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-09-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-05
F · Potential for more than minimal harm
2024-10-29
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-29
F · Potential for more than minimal harm
2024-10-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-29
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 2024-11-26
D · Potential for more than minimal harm
2024-10-29
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
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 2024-11-26
D · Potential for more than minimal harm
2024-10-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
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 2024-11-26
F · Potential for more than minimal harm
2023-08-31
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
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 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
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 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-31
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-12
F · Potential for more than minimal harm
2025-09-09
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 2025-10-17
E · Potential for more than minimal harm
2025-09-09
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 2025-10-17
E · Potential for more than minimal harm
2025-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-09
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 2025-10-17
D · Potential for more than minimal harm
2025-09-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-09
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 2025-10-17
D · Potential for more than minimal harm
2025-09-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-09-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-17
C · Minimal harm
2025-09-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-17
C · Minimal harm
2025-09-09
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 2025-10-17
D · Potential for more than minimal harm
2025-04-16
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-06
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 2025-03-27
D · Potential for more than minimal harm
2024-12-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-09
J · Immediate jeopardy
2024-10-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-09
G · Actual harm
2024-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-09
G · Actual harm
2024-10-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-09
F · Potential for more than minimal harm
2024-10-29
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 2025-01-09
F · Potential for more than minimal harm
2024-10-29
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 2025-01-09
E · Potential for more than minimal harm
2024-10-29
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 2025-01-09
E · Potential for more than minimal harm
2024-10-29
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 2025-01-09
E · Potential for more than minimal harm
2024-10-29
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-10-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-10-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
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 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
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 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
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 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
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 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-10-29
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 2025-01-09
D · Potential for more than minimal harm
2024-10-29
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 2025-01-09
D · Potential for more than minimal harm
2024-05-16
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 2024-06-07
D · Potential for more than minimal harm
2024-03-19
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-05
D · Potential for more than minimal harm
2023-12-08
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 2024-01-05
D · Potential for more than minimal harm
2023-12-08
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-05
G · Actual harm
2023-10-05
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 2023-10-14
F · Potential for more than minimal harm
2023-08-31
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 2023-10-14
F · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-08-31
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 2023-10-14
E · Potential for more than minimal harm
2023-08-31
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 2023-10-14
E · Potential for more than minimal harm
2023-08-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-08-31
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 2023-10-14
E · Potential for more than minimal harm
2023-08-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-08-31
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-08-31
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 2023-10-14
D · Potential for more than minimal harm
2023-08-31
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 2023-10-14
D · Potential for more than minimal harm
2023-08-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-08-31
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 2023-10-14
D · Potential for more than minimal harm
2023-08-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-08-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-08-31
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 2023-10-14
D · Potential for more than minimal harm
2023-08-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-14
K · Immediate jeopardy
2023-07-13
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 2023-08-11
E · Potential for more than minimal harm
2023-07-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-11
Penalties and ownership
What sits behind the stars
$52,507
2024-10-29
Fine
Fine · fine $52,507
Fine
$0
2024-10-29
Payment Denial
Payment Denial · denial start 2024-12-31 · 29 days
29 day denial
$22,164
2023-08-31
Fine
Fine · fine $22,164
Fine
$27,495
2023-07-13
Fine
Fine · fine $27,495
Fine
Ownership
Comprehensive Healthcare
5% Or Greater Direct Ownership Interest · Organization
Craig, Catherine
Corporate Director · Individual
Garrison, Amanda
W-2 Managing Employee · Individual
Nearby options
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3-star overall rating with 3-star inspections with $173,932 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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