Cycle 1
Health 2024-09-13 · Fire 2024-09-13
40 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Eugene, OR
Green Valley Rehabilitation Health Center
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $53,024 in total fines with 40 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1735 Adkins Street, Eugene, OR
(541) 683-5032
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Volare Health
Operator or chain grouping
Approved since
1983-07-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.35
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.77
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.11
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
5.03
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,718
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.48
Composite VBP score used to determine payment impact.
Payment multiplier
1.0094
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.48
Baseline 19.90% · Performance 18.89% · Measure score 5.48 · Achievement 5.48 · Improvement 3
Healthcare-associated infections
8.50
Baseline 5.68% · Performance 5.29% · Measure score 8.50 · Achievement 8.50 · Improvement 5.16
Total nurse turnover
2.11
Baseline 50.00% · Performance 55.06% · Measure score 2.11 · Achievement 2.11 · Improvement 0
Adjusted total nurse staffing
5.71
Baseline 4.67 hours · Performance 4.70 hours · Measure score 5.71 · Achievement 5.71 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.56% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 249 · Observed rate 7.23% · Lower 95% interval 7.08% |
| Discharge to community | 56.54% |
50.57%
6 pts better
|
Better than the National Rate · Eligible stays 257 · Observed rate 55.64% · Lower 95% interval 50.96% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 138 · Denominator 138 |
| Falls with major injury | 0.72% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 138 |
| Discharge self-care score | 58.97% |
53.69%
5.3 pts better
|
Numerator 69 · Denominator 117 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 63 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 138 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 5.29% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 2.4% · Lower 95% interval 2.82% |
| Staff COVID-19 vaccination coverage | 7.65% |
8.2%
0.5 pts worse
|
Numerator 13 · Denominator 170 |
| Staff flu vaccination coverage | 27.37% |
42%
14.6 pts worse
|
Numerator 49 · Denominator 179 |
| Discharge function score | 76.07% |
56.45%
19.6 pts better
|
Numerator 89 · Denominator 117 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 116 · Denominator 116 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.87% |
25.2%
2.7 pts better
|
Numerator 17 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
95.5%
3.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 98.6% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 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 | 1.9% |
2.4%
0.5 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.6% · Q4 2.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
4.7%
1.6 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 4.8% · Q4 6.2% · 4Q avg 3.1% |
| 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 0.0% · Q2 1.8% · Q3 1.8% · Q4 4.9% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
12.5%
1.8 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.7% · Q3 12.5% · Q4 9.8% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
14.7%
8 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.7% · Q3 5.0% · Q4 8.3% · 4Q avg 6.7% · 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 | 13.6% |
24.1%
10.5 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q4 18.3% · 4Q avg 13.6% · 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 5.1% · Q2 10.9% · Q3 7.3% · Q4 18.3% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.7%
0.9 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.0%
1.2 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.7% |
22.2%
2.5 pts better
|
19.8%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 20.9% · Q3 24.0% · Q4 17.3% · 4Q avg 19.7% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
6.5%
0.8 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.4% · Q3 8.3% · Q4 7.5% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
85.4%
5.8 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 92.0% · Q3 90.8% · Q4 91.1% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
15.1%
4 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 17.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.7%
1 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.5% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.2% |
81.2%
1 pts better
|
79.7%
2.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
21.6%
0.7 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 17.7% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-22 · Fire 2023-05-22
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-28 · Fire 2022-04-28
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-29
F · Potential for more than minimal harm
2023-05-22
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-05-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-23
E · Potential for more than minimal harm
2022-04-28
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 2022-06-17
D · Potential for more than minimal harm
2022-04-28
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 2022-06-17
D · Potential for more than minimal harm
2022-04-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-15
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 2026-02-20
D · Potential for more than minimal harm
2026-01-15
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 2026-02-20
D · Potential for more than minimal harm
2026-01-15
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 2026-02-20
D · Potential for more than minimal harm
2025-12-09
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-23
F · Potential for more than minimal harm
2025-02-05
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 2025-03-25
D · Potential for more than minimal harm
2025-02-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-25
G · Actual harm
2024-09-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-29
G · Actual harm
2024-09-13
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 2024-10-29
F · Potential for more than minimal harm
2024-09-13
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 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-13
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 2024-10-29
E · Potential for more than minimal harm
2024-09-13
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 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-13
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 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
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 2024-10-29
D · Potential for more than minimal harm
2024-09-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-02-29
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-02
E · Potential for more than minimal harm
2024-02-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-02
D · Potential for more than minimal harm
2023-11-28
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 2024-01-10
D · Potential for more than minimal harm
2023-11-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-28
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-05-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-22
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 2023-07-03
E · Potential for more than minimal harm
2023-05-22
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 2023-07-03
E · Potential for more than minimal harm
2023-05-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-05-22
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 2023-07-03
E · Potential for more than minimal harm
2023-05-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
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 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-22
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-03
D · Potential for more than minimal harm
2022-04-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-06-07
Penalties and ownership
What sits behind the stars
$53,024
2024-09-13
Fine
Fine · fine $53,024
Fine
Ownership
Pac 12 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Hagar, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Hagler, Alexander
5% Or Greater Indirect Ownership Interest · Individual
Kensington Or Propco LLC
5% Or Greater Mortgage Interest · Organization
Knox Healthcare Pac 12 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Knox, Donald
5% Or Greater Indirect Ownership Interest · Individual
Knox, Donald
Operational/Managerial Control · Individual
Knox, Donald
Corporate Officer · Individual
Maheia, Jason
Operational/Managerial Control · Individual
Morris, Christopher
Operational/Managerial Control · Individual
Pac 12 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Pac 12 Pinnacle Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Schwartz, Eliezer
Operational/Managerial Control · Individual
Smith, Brian
Corporate Officer · Individual
Volare Health LLC
Operational/Managerial Control · Organization
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $121,905 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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