Cycle 1
Health 2025-11-21 · Fire 2025-11-21
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Issaquah, WA
Marianwood Health And Rehabilitation
3-star overall rating with 3-star inspections with $110,562 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3725 Providence Point Drive Southeast, Issaquah, WA
(425) 391-2800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.82
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
794
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0184
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.81% · Performance 16.66% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.35
Baseline 5.87% · Performance 5.34% · Measure score 8.35 · Achievement 8.35 · Improvement 5.56
Total nurse turnover
3.02
Baseline 38.81% · Performance 51.35% · Measure score 3.02 · Achievement 3.02 · Improvement 0
Adjusted total nurse staffing
4.11
Baseline 3.86 hours · Performance 4.25 hours · Measure score 4.11 · Achievement 4.11 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.27% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 4.28% · Lower 95% interval 6.2% |
| Discharge to community | 70.63% |
50.57%
20.1 pts better
|
Better than the National Rate · Eligible stays 183 · Observed rate 67.76% · Lower 95% interval 63.24% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 92 · Denominator 92 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 92 |
| Discharge self-care score | 58.54% |
53.69%
4.9 pts better
|
Numerator 48 · Denominator 82 |
| Discharge mobility score | 25.61% |
50.94%
25.3 pts worse
|
Numerator 21 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 92 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.34% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 1.82% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 17.8% |
8.2%
9.6 pts better
|
Numerator 21 · Denominator 118 |
| Staff flu vaccination coverage | 71.2% |
42%
29.2 pts better
|
Numerator 89 · Denominator 125 |
| Discharge function score | 31.71% |
56.45%
24.7 pts worse
|
Numerator 26 · Denominator 82 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.72% |
96.28%
0.4 pts better
|
Numerator 59 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 41.86% |
25.2%
16.7 pts better
|
Numerator 18 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.4
0.7 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
96.0%
11.8 pts worse
|
93.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 90.5% · Q3 78.3% · Q4 80.7% · 4Q avg 84.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.8% |
93.8%
1 pts worse
|
95.5%
2.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
2.6%
2.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
16.3%
14.5 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 5.4% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.8%
1.8 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.6% · Q3 7.3% · Q4 12.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
12.1%
4.4 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 18.0% · Q3 15.5% · Q4 13.0% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
15.9%
6.2 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 21.7% · Q3 21.7% · Q4 18.8% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.3% |
20.0%
2.3 pts worse
|
16.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
15.8%
1.9 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 15.1% · Q3 14.3% · Q4 8.3% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.2%
1.5 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.2% · Q3 0.0% · Q4 3.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.7%
2.6 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 7.9% · Q3 3.5% · Q4 3.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
23.5%
0.6 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 20.7% · Q3 23.3% · Q4 21.3% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.7%
1.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.5% · Q3 1.2% · Q4 4.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
87.7%
2.3 pts worse
|
81.7%
3.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 86.6% · Q3 93.6% · Q4 92.4% · 4Q avg 85.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
13.2%
6.4 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 18.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.4%
0.2 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.5% · Q3 0.5% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.2% |
82.0%
5.8 pts worse
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.4% |
19.9%
6.5 pts better
|
23.9%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 13.6% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
29 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2023-04-25 · Fire 2023-04-25
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-11-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-22
E · Potential for more than minimal harm
2025-11-21
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-22
F · Potential for more than minimal harm
2024-08-01
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-01
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-08-29
F · Potential for more than minimal harm
2023-04-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-04-25
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 2023-05-26
E · Potential for more than minimal harm
2023-04-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-21
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 2026-01-06
D · Potential for more than minimal harm
2025-11-21
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 2026-01-06
D · Potential for more than minimal harm
2025-11-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-21
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 2026-01-06
D · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-21
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 2026-01-06
D · Potential for more than minimal harm
2025-11-21
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 2026-01-06
G · Actual harm
2025-02-28
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 2025-03-21
E · Potential for more than minimal harm
2025-02-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-21
D · Potential for more than minimal harm
2024-09-25
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 2024-10-09
K · Immediate jeopardy
2024-08-01
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 2024-09-09
F · Potential for more than minimal harm
2024-08-01
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 2024-09-09
F · Potential for more than minimal harm
2024-08-01
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 2024-09-09
E · Potential for more than minimal harm
2024-08-01
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 2024-09-09
E · Potential for more than minimal harm
2024-08-01
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-01
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 2024-09-09
E · Potential for more than minimal harm
2024-08-01
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 2024-09-09
E · Potential for more than minimal harm
2024-08-01
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-01
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 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
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 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
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 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
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 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
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 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-01
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 2024-09-09
D · Potential for more than minimal harm
2024-04-12
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-05-17
G · Actual harm
2023-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
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 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
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 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
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 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
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 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-06-07
Penalties and ownership
What sits behind the stars
$31,694
2025-02-28
Fine
Fine · fine $31,694
Fine
$32,880
2024-08-01
Fine
Fine · fine $32,880
Fine
$45,988
2023-04-25
Fine
Fine · fine $45,988
Fine
Ownership
Burnam, Soon
Corporate Officer · Individual
Dittakavi, Neelima
Operational/Managerial Control · Individual
Stolarczyk, Lisa
Operational/Managerial Control · Individual
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