Cycle 1
Health 2025-06-13 · Fire 2025-06-13
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Yakima, WA
Landmark Care And Rehabilitation
1-star overall rating with 1-star inspections with $132,702 in total fines with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
710 North 39th Avenue, Yakima, WA
(509) 248-4102
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hyatt Family Facilities
Operator or chain grouping
Approved since
1979-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 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
0.77
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.47
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
4.02
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,915
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.30
Baseline 16.54% · Performance 17.59% · Measure score 8.30 · Achievement 8.30 · Improvement 0
Healthcare-associated infections
3.02
Baseline 6.16% · Performance 6.93% · Measure score 3.02 · Achievement 3.02 · Improvement 0
Total nurse turnover
0
Baseline 52.13% · Performance 67.72% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.53
Baseline 4.16 hours · Performance 3.80 hours · Measure score 2.53 · Achievement 2.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 285 · Observed rate 9.82% · Lower 95% interval 7.97% |
| Discharge to community | 62.62% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 313 · Observed rate 59.11% · Lower 95% interval 57.46% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 206 · Denominator 206 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 206 |
| Discharge self-care score | 79.64% |
53.69%
26 pts better
|
Numerator 133 · Denominator 167 |
| Discharge mobility score | 66.47% |
50.94%
15.5 pts better
|
Numerator 111 · Denominator 167 |
| Pressure ulcers or injuries, new or worsened | 3.4% |
2.29%
1.1 pts worse
|
Numerator 7 · Denominator 206 · Adjusted rate 4.13% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 6.42% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 26.09% |
8.2%
17.9 pts better
|
Numerator 30 · Denominator 115 |
| Staff flu vaccination coverage | 43.97% |
42%
2 pts better
|
Numerator 62 · Denominator 141 |
| Discharge function score | 77.25% |
56.45%
20.8 pts better
|
Numerator 129 · Denominator 167 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 97.12% |
96.28%
0.8 pts better
|
Numerator 135 · Denominator 139 |
| Resident COVID-19 vaccinations up to date | 45.87% |
25.2%
20.7 pts better
|
Numerator 50 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
96.0%
1.5 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 95.9% · Q3 98.0% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.6%
0.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 2.0% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
16.3%
11.1 pts better
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.0% · Q3 0.0% · Q4 8.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
5.8%
2.8 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.2% · Q3 12.2% · Q4 15.6% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
12.1%
3.2 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.3% · Q3 4.5% · Q4 19.6% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
15.9%
7.2 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.7% · Q3 11.6% · Q4 9.5% · 4Q avg 8.7% · 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 | 35.5% |
20.0%
15.5 pts worse
|
16.3%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
15.8%
7.3 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 34.1% · Q3 19.5% · Q4 15.0% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.2%
0.6 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.5% · Q3 2.1% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
23.5%
8.8 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 34.7% · Q3 24.5% · Q4 29.0% · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.7%
2.3 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.2% · Q3 7.1% · Q4 12.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
87.7%
1.5 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 72.6% · Q2 88.9% · Q3 98.4% · Q4 98.1% · 4Q avg 89.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
13.2%
0.1 pts better
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 12.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.4%
1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
82.0%
11.5 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
19.9%
1.9 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.4% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-22 · Fire 2024-05-22
33 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
18 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-04-12 · Fire 2023-04-12
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
15 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-06-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-06-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-30
F · Potential for more than minimal harm
2024-05-22
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
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 2024-06-17
F · Potential for more than minimal harm
2024-05-22
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 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-17
F · Potential for more than minimal harm
2023-04-12
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-13
F · Potential for more than minimal harm
2023-04-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-23
H · Actual harm
2025-06-13
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 2025-07-18
G · Actual harm
2025-06-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-18
F · Potential for more than minimal harm
2025-06-13
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 2025-07-18
E · Potential for more than minimal harm
2025-06-13
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 2025-07-18
E · Potential for more than minimal harm
2025-06-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-13
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 2025-07-18
D · Potential for more than minimal harm
2025-06-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-13
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-13
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 2025-07-18
D · Potential for more than minimal harm
2025-06-13
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-13
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 2025-07-18
D · Potential for more than minimal harm
2025-06-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-13
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-01-29
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 2025-03-04
D · Potential for more than minimal harm
2024-08-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-23
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 2024-10-03
D · Potential for more than minimal harm
2024-08-23
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 2024-10-03
D · Potential for more than minimal harm
2024-08-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-08
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 2024-09-04
G · Actual harm
2024-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-02
F · Potential for more than minimal harm
2024-05-22
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 2024-07-02
E · Potential for more than minimal harm
2024-05-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-22
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 2024-07-02
E · Potential for more than minimal harm
2024-05-22
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 2024-07-02
E · Potential for more than minimal harm
2024-05-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-22
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 2024-07-02
D · Potential for more than minimal harm
2024-05-22
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-02
J · Immediate jeopardy
2024-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-12
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-17
G · Actual harm
2024-02-16
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 2024-03-21
G · Actual harm
2024-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-21
D · Potential for more than minimal harm
2023-11-29
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-11-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-08-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-05-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-13
E · Potential for more than minimal harm
2023-04-12
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
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 2023-05-13
D · Potential for more than minimal harm
2023-04-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
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 2023-05-13
D · Potential for more than minimal harm
2023-04-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-13
D · Potential for more than minimal harm
2023-04-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-13
Penalties and ownership
What sits behind the stars
$90,229
2024-05-22
Fine
Fine · fine $90,229
Fine
$42,473
2024-02-16
Fine
Fine · fine $42,473
Fine
Ownership
Hyatt, Norman
5% Or Greater Direct Ownership Interest · Individual
Hyatt, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Berk, Heidi
W-2 Managing Employee · Individual
Dunn, Gloria
Operational/Managerial Control · Individual
Hyatt Family Facilities LLC
Operational/Managerial Control · Organization
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