Cycle 1
Health 2025-03-19 · Fire 2025-03-19
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Aberdeen, WA
Grays Harbor Health & Rehabilitation Center
5-star overall rating with 5-star inspections with $8,190 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
920 Anderson Drive, Aberdeen, WA
(360) 532-5122
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.01
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
4.19
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,883
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0007
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.31
Baseline 14.60% · Performance 18.97% · Measure score 5.31 · Achievement 5.31 · Improvement 0
Healthcare-associated infections
3.99
Baseline 6.52% · Performance 6.64% · Measure score 3.99 · Achievement 3.99 · Improvement 0
Total nurse turnover
4.62
Baseline 68.66% · Performance 46.25% · Measure score 4.62 · Achievement 4.26 · Improvement 4.62
Adjusted total nurse staffing
4.95
Baseline 4.02 hours · Performance 4.49 hours · Measure score 4.95 · Achievement 4.95 · Improvement 2.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.77% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 261 · Observed rate 7.66% · Lower 95% interval 6.71% |
| Discharge to community | 50.76% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 292 · Observed rate 48.63% · Lower 95% interval 44.81% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.29% |
95.27%
About the same
|
Numerator 182 · Denominator 191 |
| Falls with major injury | 2.09% |
0.77%
1.3 pts worse
|
Numerator 4 · Denominator 191 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 80 · Denominator 132 |
| Discharge mobility score | 39.39% |
50.94%
11.5 pts worse
|
Numerator 52 · Denominator 132 |
| Pressure ulcers or injuries, new or worsened | 2.09% |
2.29%
0.2 pts better
|
Numerator 4 · Denominator 191 · Adjusted rate 2.25% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 174 · Observed rate 5.17% · Lower 95% interval 4.31% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 114 |
| Staff flu vaccination coverage | 79.26% |
42%
37.3 pts better
|
Numerator 107 · Denominator 135 |
| Discharge function score | 68.18% |
56.45%
11.7 pts better
|
Numerator 90 · Denominator 132 |
| Transfer of health information to provider | 98.9% |
95.95%
3 pts better
|
Numerator 90 · Denominator 91 |
| Transfer of health information to patient | 95.16% |
96.28%
1.1 pts worse
|
Numerator 59 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 61.32% |
25.2%
36.1 pts better
|
Numerator 65 · Denominator 106 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.5
1.8 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
96.0%
2.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.7% · Q4 98.0% · 4Q avg 98.9% |
| 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 6.1% |
16.3%
10.2 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.4% · Q3 10.3% · Q4 8.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.8%
1.7 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.8% · Q3 7.0% · Q4 2.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
12.1%
3.5 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.1% · Q3 4.5% · Q4 6.1% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
15.9%
0.6 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.8% · Q3 17.1% · Q4 16.3% · 4Q avg 15.3% · 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 | 10.3% |
20.0%
9.7 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
15.8%
5.3 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 18.9% · Q3 7.7% · Q4 4.4% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.2%
0.7 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
23.5%
3.7 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 27.6% · Q3 22.4% · Q4 9.4% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.7%
0.5 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.4% · Q3 3.5% · Q4 8.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
87.7%
2.9 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 89.2% · Q3 87.6% · Q4 88.4% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
13.2%
0.4 pts better
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 12.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.4%
0.7 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.0% · Q3 2.3% · Q4 2.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
82.0%
10.8 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
19.9%
2.6 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 17.9% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-24 · Fire 2023-03-24
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-19
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 2025-03-31
F · Potential for more than minimal harm
2025-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-21
F · Potential for more than minimal harm
2024-02-23
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-03-24
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-03-19
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 2025-04-22
D · Potential for more than minimal harm
2025-03-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-19
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 2025-04-22
D · Potential for more than minimal harm
2025-03-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-19
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 2025-04-22
D · Potential for more than minimal harm
2024-02-23
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-23
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 2024-03-19
D · Potential for more than minimal harm
2024-02-23
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-23
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-19
D · Potential for more than minimal harm
2023-08-29
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-06
G · Actual harm
2023-05-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-03-24
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 2023-04-14
D · Potential for more than minimal harm
2023-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$8,190
2023-05-03
Fine
Fine · fine $8,190
Fine
Ownership
Avalon Of Washington LLC
5% Or Greater Direct Ownership Interest · Organization
Avalon Care LLC
5% Or Greater Indirect Ownership Interest · Organization
Avalon Health Care Management Of Washington LLC
Operational/Managerial Control · Organization
Avalon Health Care Management, Inc.
Operational/Managerial Control · Organization
Avalon Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Holding, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Bowen, Lane
Corporate Director · Individual
Bowen, Lane
Corporate Officer · Individual
Burton, Harold
Corporate Director · Individual
Cooke, Peter
Corporate Director · Individual
Dangerfield, David
Corporate Director · Individual
Franklin, Christie
Corporate Director · Individual
Hash, Alan
Corporate Officer · Individual
Kirton, Charles
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Charles
Corporate Director · Individual
Kirton, Charles
Corporate Officer · Individual
Kirton, Hyrum
Corporate Director · Individual
Owens, Mary
Corporate Officer · Individual
Paquette, Sebastian
Corporate Director · Individual
Robinson, Donna
W-2 Managing Employee · Individual
Stuart, Anne
Corporate Director · Individual
Stuart, Anne
Corporate Officer · Individual
Swinton, Brian
Corporate Director · Individual
Tippets, Carl
Corporate Director · Individual
Woltil, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Pacific Care And Rehabilitation
Hoquiam, WA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Montesano Health-Rehab Center
Montesano, WA
0-star overall rating with 0-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Willapa Harbor Care
Raymond, WA
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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