Cycle 1
Health 2025-03-27 · Fire 2025-03-27
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Carson City, NV
Ormsby Post Acute Rehabilitation
1-star overall rating with 1-star inspections with Special Focus status with $60,464 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3050 N Ormsby Road, Carson City, NV
(775) 841-4646
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
120
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1999-03-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,985
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.79
Baseline 17.93% · Performance 19.21% · Measure score 4.79 · Achievement 4.79 · Improvement 0
Healthcare-associated infections
6.45
Baseline 7.34% · Performance 5.91% · Measure score 6.45 · Achievement 6.45 · Improvement 5.61
Total nurse turnover
0
Baseline 66.00% · Performance 65.82% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.51
Baseline 3 hours · Performance 3.79 hours · Measure score 2.51 · Achievement 2.51 · Improvement 2.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 10.06% · Lower 95% interval 7.36% |
| Discharge to community | 54.03% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 48.03% · Lower 95% interval 44.86% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 76 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 28.3% |
53.69%
25.4 pts worse
|
Numerator 15 · Denominator 53 |
| Discharge mobility score | 24.53% |
50.94%
26.4 pts worse
|
Numerator 13 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 4 · Denominator 78 · Adjusted rate 5.04% |
| Healthcare-associated infections requiring hospitalization | 5.91% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 3.85% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 3.54% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 113 |
| Staff flu vaccination coverage | 42.47% |
42%
0.5 pts better
|
Numerator 79 · Denominator 186 |
| Discharge function score | 28.3% |
56.45%
28.2 pts worse
|
Numerator 15 · Denominator 53 |
| Transfer of health information to provider | 97.92% |
95.95%
2 pts better
|
Numerator 47 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 7 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.5
1.5 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.5%
6.7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 98.6% · Q4 98.6% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.3% |
89.6%
0.7 pts better
|
95.5%
5.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.3%
1.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
4.9%
3.8 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.6%
3.1 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 3.1% · Q4 1.6% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
22.2%
1.4 pts worse
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 23.4% · Q3 23.1% · Q4 22.1% · 4Q avg 23.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
18.5%
3 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 18.8% · Q3 15.7% · Q4 12.0% · 4Q avg 15.5% · 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 | 25.6% |
19.1%
6.5 pts worse
|
16.3%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 43.1% · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
14.2%
1.7 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.4% · Q3 20.6% · Q4 6.2% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 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 | 1.1% |
1.8%
0.7 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
16.5%
1.7 pts better
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 11.1% · Q3 7.0% · Q4 25.5% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.5%
3.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.7% · Q3 1.6% · Q4 1.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.8% |
84.1%
1.3 pts worse
|
81.7%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 64.6% · Q2 85.7% · Q3 86.8% · Q4 86.9% · 4Q avg 82.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
9.8%
2 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 13.2% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 2.2% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
80.7%
1.4 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
23.4%
5.4 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 18.9% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-29 · Fire 2024-05-29
45 health deficiencies
Top issue: Administration (8 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-05 · Fire 2023-07-05
45 health deficiencies
Top issue: Administration (10 deficiencies)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-11
F · Potential for more than minimal harm
2024-05-29
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 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-29
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-29
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-18
C · Minimal harm
2024-05-29
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-07-18
E · Potential for more than minimal harm
2023-07-05
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-07-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-07-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-27
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 2025-04-14
E · Potential for more than minimal harm
2025-03-27
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 2025-04-14
D · Potential for more than minimal harm
2025-03-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-27
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-27
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 2025-04-14
D · Potential for more than minimal harm
2025-03-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-27
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 2025-04-14
D · Potential for more than minimal harm
2025-03-27
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 2025-04-14
D · Potential for more than minimal harm
2025-03-27
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-14
D · Potential for more than minimal harm
2024-09-18
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 2024-11-03
D · Potential for more than minimal harm
2024-09-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-09-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-09-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-03
J · Immediate jeopardy
2024-05-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-05-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-05-29
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 2024-07-24
F · Potential for more than minimal harm
2024-05-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-05-29
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-05-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-05-29
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-29
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 2024-07-24
E · Potential for more than minimal harm
2024-05-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-29
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-29
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-29
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-29
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
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 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
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 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
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 2024-07-24
D · Potential for more than minimal harm
2024-05-29
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 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
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 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-29
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-07-24
C · Minimal harm
2024-05-29
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-07-24
C · Minimal harm
2024-05-29
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-02-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-16
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 2024-03-11
D · Potential for more than minimal harm
2024-02-16
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 2024-03-11
D · Potential for more than minimal harm
2024-02-16
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 2024-03-11
D · Potential for more than minimal harm
2023-10-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-30
F · Potential for more than minimal harm
2023-07-05
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 2023-08-15
F · Potential for more than minimal harm
2023-07-05
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-05
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 2023-08-15
F · Potential for more than minimal harm
2023-07-05
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 2023-08-15
F · Potential for more than minimal harm
2023-07-05
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-05
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 2023-07-29
E · Potential for more than minimal harm
2023-07-05
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-05
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-05
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-05
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-05
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
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 2023-07-29
D · Potential for more than minimal harm
2023-07-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-07-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-07-05
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-08-15
C · Minimal harm
2023-07-05
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 2023-08-15
D · Potential for more than minimal harm
2023-04-27
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 2023-06-08
D · Potential for more than minimal harm
2023-03-01
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 2023-03-31
D · Potential for more than minimal harm
2023-03-01
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 2023-03-31
D · Potential for more than minimal harm
2023-03-01
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 2023-03-31
D · Potential for more than minimal harm
2023-03-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-01
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
$60,464
2024-05-29
Fine
Fine · fine $60,464
Fine
$0
2024-05-29
Payment Denial
Payment Denial · denial start 2024-07-18 · 6 days
6 day denial
Ownership
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Earl, Steven
Operational/Managerial Control · Individual
Goodie, Antoine
Operational/Managerial Control · Individual
Nevada SNF Consulting LLC
Operational/Managerial Control · Organization
Ormsby SNF Operations LLC
Operational/Managerial Control · Organization
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Perlman, Harold
Operational/Managerial Control · Individual
Porterfield, Kelly
Operational/Managerial Control · Individual
Riker, Michelle
Operational/Managerial Control · Individual
Rojas, Aleli
Operational/Managerial Control · Individual
Spielman, Shimon
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
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#3
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