Cycle 1
Health 2025-03-05 · Fire 2025-03-05
21 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
North Bend, WA
North Bend Post Acute
1-star overall rating with 1-star inspections with $228,151 in total fines with 21 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
219 Cedar Avenue South, North Bend, WA
(425) 888-2129
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-10-01
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
0.24
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.71
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
3.29
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.06
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,563
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
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
2.64
Baseline 80.70% · Performance 63.16% · Measure score 2.64 · Achievement 0 · Improvement 2.64
Adjusted total nurse staffing
3.24
Baseline 3.43 hours · Performance 4 hours · Measure score 3.24 · Achievement 3.24 · Improvement 1.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.51% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 17.31% · Lower 95% interval 8.23% |
| Discharge to community | 25.25% |
50.57%
25.3 pts worse
|
Worse than the National Rate · Eligible stays 44 · Observed rate 9.09% · Lower 95% interval 15.96% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 47.62% |
53.69%
6.1 pts worse
|
Numerator 10 · Denominator 21 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 7 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 3.19% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.49% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 67 |
| Staff flu vaccination coverage | 3.33% |
42%
38.7 pts worse
|
Numerator 4 · Denominator 120 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.7 |
1.4
0.3 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
96.0%
3.9 pts worse
|
93.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 98.1% · Q3 93.8% · Q4 83.3% · 4Q avg 92.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
93.8%
1 pts better
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| 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 1.9% · Q2 1.9% · Q3 2.1% · Q4 2.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
16.3%
10.1 pts better
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.5% · Q3 2.4% · Q4 9.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.8%
2.2 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.0% · Q3 4.4% · Q4 2.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
12.1%
0.9 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.8% · Q3 10.6% · Q4 12.8% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
15.9%
5.8 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.8% · Q3 10.8% · Q4 10.5% · 4Q avg 10.1% · 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 | 4.1% |
20.0%
15.9 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
15.8%
10.2 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.0% · Q3 8.5% · Q4 0.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.2%
1.7 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.6% · Q3 3.4% · Q4 2.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 24.7% |
23.5%
1.2 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 17.0% · Q3 40.2% · Q4 22.7% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 14.5% |
4.7%
9.8 pts worse
|
5.1%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 21.5% · Q3 13.3% · Q4 10.7% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.2% |
87.7%
24.5 pts worse
|
81.7%
18.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 61.8% · Q3 51.4% · Q4 64.5% · 4Q avg 63.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
13.2%
3.8 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 9.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.4%
About the same
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
82.0%
32 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.2% |
19.9%
4.7 pts better
|
23.9%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 14.3% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-12 · Fire 2023-12-12
35 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
37 fire-safety deficiencies
Top issue: Emergency Preparedness (20 deficiencies)
Cycle 3
Health 2022-08-12 · Fire 2022-08-12
48 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-23
F · Potential for more than minimal harm
2025-03-05
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-08
F · Potential for more than minimal harm
2025-03-05
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-08
F · Potential for more than minimal harm
2025-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-05
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 2025-04-03
E · Potential for more than minimal harm
2025-03-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-03
F · Potential for more than minimal harm
2023-12-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-12
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 2024-01-11
F · Potential for more than minimal harm
2023-12-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-22
F · Potential for more than minimal harm
2023-12-12
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 2024-01-11
D · Potential for more than minimal harm
2023-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-12
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-12
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-12
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-11
F · Potential for more than minimal harm
2022-08-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-12
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 2022-09-09
D · Potential for more than minimal harm
2022-08-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-05
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
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 2025-04-18
E · Potential for more than minimal harm
2025-03-05
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 2025-04-18
E · Potential for more than minimal harm
2025-03-05
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 2025-04-18
E · Potential for more than minimal harm
2025-03-05
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 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
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 2025-04-21
D · Potential for more than minimal harm
2025-03-05
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 2025-04-18
D · Potential for more than minimal harm
2025-03-05
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 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
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 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
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 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-04-18
D · Potential for more than minimal harm
2024-11-07
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-05
G · Actual harm
2023-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-12-12
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 2024-01-15
F · Potential for more than minimal harm
2023-12-12
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 2024-01-15
F · Potential for more than minimal harm
2023-12-12
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-12-12
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-12-12
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 2024-01-15
E · Potential for more than minimal harm
2023-12-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-12
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 2024-01-15
E · Potential for more than minimal harm
2023-12-12
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
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 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
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 2024-01-15
D · Potential for more than minimal harm
2023-12-12
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 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
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 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
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 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-12
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 2024-01-15
D · Potential for more than minimal harm
2023-12-12
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-01-15
B · Minimal harm
2023-12-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-15
G · Actual harm
2023-10-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-17
G · Actual harm
2023-10-04
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 2023-11-17
G · Actual harm
2023-10-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F843 · Administration Deficiencies
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-04
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-04
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 2023-11-17
E · Potential for more than minimal harm
2023-10-04
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-04
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 2023-11-17
E · Potential for more than minimal harm
2023-10-04
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-11-17
G · Actual harm
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-24
F · Potential for more than minimal harm
2022-08-12
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 2022-10-10
F · Potential for more than minimal harm
2022-08-12
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
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 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
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 2022-10-10
E · Potential for more than minimal harm
2022-08-12
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 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-12
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 2022-10-10
D · Potential for more than minimal harm
2022-08-12
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 2022-10-10
D · Potential for more than minimal harm
2022-08-12
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 2022-10-10
D · Potential for more than minimal harm
2022-08-12
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 2022-10-10
D · Potential for more than minimal harm
2022-08-12
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 2022-10-10
D · Potential for more than minimal harm
2022-08-12
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-12
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 2022-10-10
D · Potential for more than minimal harm
2022-08-12
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-10
Penalties and ownership
What sits behind the stars
$143,754
2023-12-12
Fine
Fine · fine $143,754
Fine
$0
2023-12-12
Payment Denial
Payment Denial · denial start 2024-03-12 · 10 days
10 day denial
$62,318
2023-10-04
Fine
Fine · fine $62,318
Fine
$22,079
2023-04-28
Fine
Fine · fine $22,079
Fine
Ownership
Anderson, Brandt
Operational/Managerial Control · Individual
De Oro, Brianna
Operational/Managerial Control · Individual
De Oro, Thomas
Operational/Managerial Control · Individual
Foundation Resource Center LLC
Operational/Managerial Control · Organization
Frost, Steven
Operational/Managerial Control · Individual
Hinga, Marjorie
Operational/Managerial Control · Individual
Kumari, Monika
Operational/Managerial Control · Individual
Lindahl, Jeffrey
Operational/Managerial Control · Individual
Lindahl, Kirkman
Operational/Managerial Control · Individual
Lindahl, Scott
Operational/Managerial Control · Individual
Nesterenko, Oksana
Operational/Managerial Control · Individual
Padua, Sarah
Operational/Managerial Control · Individual
Zwahlen, Jay
Operational/Managerial Control · Individual
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