Cycle 1
Health 2025-03-21 · Fire 2025-03-21
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Soap Lake, WA
Mckay Healthcare & Rehab Ctr
4-star overall rating with 4-star inspections with $113,505 in total fines with 6 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
127 Second Avenue Southwest, Soap Lake, WA
(509) 246-1111
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
37
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,703
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.06
Performance 51.16% · Measure score 3.06 · Achievement 3.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.74
Baseline 3.38 hours · Performance 3.86 hours · Measure score 2.74 · Achievement 2.74 · Improvement 1.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.33% |
8.2%
1.1 pts better
|
Numerator 7 · Denominator 75 |
| Staff flu vaccination coverage | 15.79% |
42%
26.2 pts worse
|
Numerator 18 · Denominator 114 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
96.0%
1.7 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 91.4% · Q3 100.0% · Q4 100.0% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
93.8%
2.1 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
2.6%
1.3 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.7% · Q3 3.2% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.7% |
16.3%
0.6 pts better
|
11.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 14.3% · Q3 10.7% · Q4 10.3% · 4Q avg 15.7% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
5.8%
3.4 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 12.5% · Q3 10.7% · Q4 7.4% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
12.1%
0.3 pts worse
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 12.1% · Q3 10.7% · Q4 10.7% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
15.9%
8.2 pts worse
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 26.7% · Q3 19.2% · Q4 20.0% · 4Q avg 24.1% · 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 | 48.9% |
20.0%
28.9 pts worse
|
16.3%
32.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 48.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.7% |
15.8%
8.9 pts worse
|
14.9%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 23.1% · Q3 4.5% · Q4 34.8% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 3.2% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.7% |
23.5%
16.2 pts worse
|
19.8%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 42.7% · Q3 44.8% · Q4 44.5% · 4Q avg 39.7% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.7%
2.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 6.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.9% |
87.7%
10.8 pts worse
|
81.7%
4.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 81.8% · Q4 66.7% · 4Q avg 76.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.5% |
1.4%
7.1 pts worse
|
1.6%
6.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.0% |
82.0%
12 pts worse
|
79.7%
9.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
25 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
33 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-21
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-17
F · Potential for more than minimal harm
2025-03-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-21
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 2025-04-14
D · Potential for more than minimal harm
2025-03-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-14
F · Potential for more than minimal harm
2024-02-09
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-02-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-09
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-09
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 2024-03-12
D · Potential for more than minimal harm
2024-02-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-12
F · Potential for more than minimal harm
2023-01-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-01-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-23
F · Potential for more than minimal harm
2023-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-25
F · Potential for more than minimal harm
2023-01-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-01-25
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 2023-02-03
F · Potential for more than minimal harm
2023-01-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-30
F · Potential for more than minimal harm
2023-01-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-02-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-21
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 2025-04-22
D · Potential for more than minimal harm
2025-03-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-21
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-21
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 2025-04-22
E · Potential for more than minimal harm
2025-01-07
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 2025-01-27
D · Potential for more than minimal harm
2025-01-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-08-22
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 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-06-26
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 2024-07-23
D · Potential for more than minimal harm
2024-04-25
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 2024-05-01
G · Actual harm
2024-02-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-25
F · Potential for more than minimal harm
2024-02-09
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 2024-03-25
E · Potential for more than minimal harm
2024-02-09
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 2024-03-25
E · Potential for more than minimal harm
2024-02-09
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 2024-03-25
E · Potential for more than minimal harm
2024-02-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-02-09
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 2024-03-25
E · Potential for more than minimal harm
2024-02-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
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 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
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 2024-03-25
D · Potential for more than minimal harm
2024-02-09
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 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-25
D · Potential for more than minimal harm
2023-08-23
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 2023-09-15
F · Potential for more than minimal harm
2023-01-25
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 2023-03-10
F · Potential for more than minimal harm
2023-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-25
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 2023-03-10
E · Potential for more than minimal harm
2023-01-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-25
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 2023-03-10
D · Potential for more than minimal harm
2023-01-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-25
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 2023-03-10
Penalties and ownership
What sits behind the stars
$113,505
2024-02-09
Fine
Fine · fine $113,505
Fine
Ownership
Carlson, Barbara
Corporate Director · Individual
Dillenburg, Jean
Corporate Director · Individual
Gaertner, Erica
W-2 Managing Employee · Individual
Palmer, Theresa
W-2 Managing Employee · Individual
Public Hospital District 4 Of Grant County
Operational/Managerial Control · Organization
Rang, Cindi
Corporate Director · Individual
Spencer, Judy
Corporate Director · Individual
Wellein, Stephen
Corporate Director · Individual
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