Cycle 1
Health 2024-10-11 · Fire 2024-10-11
17 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Othello, WA
Othello Post Acute
3-star overall rating with 3-star inspections with $8,824 in total fines with 17 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
495 North Thirteenth Street, Othello, WA
(509) 488-9609
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kalesta Healthcare Group
Operator or chain grouping
Approved since
1980-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.24
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,780
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9917
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.20
Baseline 17.27% · Performance 18.56% · Measure score 6.20 · Achievement 6.20 · Improvement 0
Healthcare-associated infections
2.62
Baseline 5.55% · Performance 7.05% · Measure score 2.62 · Achievement 2.62 · Improvement 0
Total nurse turnover
4.16
Baseline 55.56% · Performance 46.67% · Measure score 4.16 · Achievement 4.16 · Improvement 2.39
Adjusted total nurse staffing
2.46
Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 16.67% · Lower 95% interval 6.63% |
| Discharge to community | 48.94% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 38.89% · Lower 95% interval 35.35% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 44 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 29.03% |
53.69%
24.7 pts worse
|
Numerator 9 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 4.44% |
2.29%
2.2 pts worse
|
Numerator 2 · Denominator 45 · Adjusted rate 3.94% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 10.53% |
8.2%
2.3 pts better
|
Numerator 6 · Denominator 57 |
| Staff flu vaccination coverage | 38.82% |
42%
3.2 pts worse
|
Numerator 33 · Denominator 85 |
| Discharge function score | 35.48% |
56.45%
21 pts worse
|
Numerator 11 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 31.03% |
25.2%
5.8 pts better
|
Numerator 9 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
96.0%
2.6 pts worse
|
93.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 75.0% · Q4 100.0% · 4Q avg 93.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
93.8%
3.3 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
16.3%
16.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.8%
1.3 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.6% |
12.1%
6.5 pts better
|
19.6%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.9% |
15.9%
12 pts better
|
16.7%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.6% |
0.1%
2.5 pts worse
|
0.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 5.0% · 4Q avg 2.6% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
15.8%
1.1 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.2%
0.9 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.1% |
23.5%
11.4 pts better
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.7%
0.6 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
87.7%
0.3 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.7% · Q2 85.0% · Q3 94.0% · Q4 100.0% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
13.2%
1 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.4%
2.4 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.8% · Q3 2.6% · Q4 3.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.7% |
82.0%
5.3 pts worse
|
79.7%
3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
19.9%
2.6 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 18.4% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-12 · Fire 2023-05-12
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2020-02-14 · Fire 2020-02-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-11
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 2024-11-07
D · Potential for more than minimal harm
2024-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-03-27
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-04-17
F · Potential for more than minimal harm
2023-05-12
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
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 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-12
F · Potential for more than minimal harm
2020-02-14
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-03-06
F · Potential for more than minimal harm
2020-02-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-02-27
F · Potential for more than minimal harm
2020-02-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-03-04
Inspection history
Recent health citations
G · Actual harm
2025-09-12
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 2025-10-10
D · Potential for more than minimal harm
2024-10-29
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-11
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 2024-11-13
E · Potential for more than minimal harm
2024-10-11
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 2024-11-13
E · Potential for more than minimal harm
2024-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-10-11
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 2024-11-13
E · Potential for more than minimal harm
2024-10-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
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 2024-11-13
D · Potential for more than minimal harm
2024-10-11
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
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 2024-11-13
D · Potential for more than minimal harm
2024-10-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
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 2024-11-13
D · Potential for more than minimal harm
2024-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
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 2024-11-13
D · Potential for more than minimal harm
2024-10-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
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 2024-11-13
D · Potential for more than minimal harm
2024-10-11
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-13
G · Actual harm
2024-05-21
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-17
G · Actual harm
2023-12-19
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 2024-01-17
G · Actual harm
2023-12-19
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-19
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 2024-01-17
D · Potential for more than minimal harm
2023-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-05-12
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 2023-06-19
D · Potential for more than minimal harm
2023-05-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-12
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 2023-06-19
D · Potential for more than minimal harm
2023-05-12
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 2023-06-19
F · Potential for more than minimal harm
2020-02-14
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 2020-03-06
E · Potential for more than minimal harm
2020-02-14
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 2020-03-06
D · Potential for more than minimal harm
2020-02-14
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 2020-03-06
D · Potential for more than minimal harm
2020-02-14
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 2020-03-06
Penalties and ownership
What sits behind the stars
$8,824
2024-05-21
Fine
Fine · fine $8,824
Fine
Ownership
Kalesta Healthcare Group, LLC
5% Or Greater Direct Ownership Interest · Organization
Clawson, Scott
5% Or Greater Indirect Ownership Interest · Individual
Williams, Ryan
5% Or Greater Indirect Ownership Interest · Individual
Porter, Micah
5% Or Greater Indirect Ownership Interest · Individual
Berg, Tracy
Operational/Managerial Control · Individual
Clawson, Scott
Operational/Managerial Control · Individual
Clawson, Scott
Corporate Officer · Individual
Sanders, Mark
Operational/Managerial Control · Individual
Williams, Ryan
Operational/Managerial Control · Individual
Williams, Ryan
Corporate Officer · Individual
Wilson, Benita
Operational/Managerial Control · Individual
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