Cycle 1
Health 2024-12-18 · Fire 2024-12-18
18 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Edmonds, WA
Pine Ridge Post Acute
3-star overall rating with 3-star inspections with $16,445 in total fines with 18 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
21008 76th Avenue West, Edmonds, WA
(425) 778-0107
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2016-03-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.91
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.46
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,286
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0132
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 14.08% · Performance 16.66% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
1.11
Baseline 4.58% · Performance 7.50% · Measure score 1.11 · Achievement 1.11 · Improvement 0
Total nurse turnover
5.79
Baseline 56.67% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.74
Adjusted total nurse staffing
6.29
Baseline 4.23 hours · Performance 4.87 hours · Measure score 6.29 · Achievement 6.29 · Improvement 3.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.85% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 465 · Observed rate 6.67% · Lower 95% interval 6.56% |
| Discharge to community | 62.87% |
50.57%
12.3 pts better
|
Better than the National Rate · Eligible stays 485 · Observed rate 60.41% · Lower 95% interval 58.7% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 256 · Denominator 256 |
| Falls with major injury | 0.39% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 256 |
| Discharge self-care score | 52.74% |
53.69%
0.9 pts worse
|
Numerator 106 · Denominator 201 |
| Discharge mobility score | 39.8% |
50.94%
11.1 pts worse
|
Numerator 80 · Denominator 201 |
| Pressure ulcers or injuries, new or worsened | 2.73% |
2.29%
0.4 pts worse
|
Numerator 7 · Denominator 256 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 291 · Observed rate 6.53% · Lower 95% interval 5.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 29.1% |
42%
12.9 pts worse
|
Numerator 39 · Denominator 134 |
| Discharge function score | 52.74% |
56.45%
3.7 pts worse
|
Numerator 106 · Denominator 201 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 180 · Denominator 180 |
| Resident COVID-19 vaccinations up to date | 23.31% |
25.2%
1.9 pts worse
|
Numerator 31 · Denominator 133 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
93.8%
3.3 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
2.6%
2.9 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 5.6% · Q4 8.3% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.3% |
16.3%
3 pts better
|
11.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.1% · Q3 17.6% · Q4 11.8% · 4Q avg 13.3% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
5.8%
5 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
12.1%
3.4 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.0% · Q3 11.1% · Q4 5.7% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
15.9%
10.7 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 6.7% · Q4 5.9% · 4Q avg 5.2% · 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 | 36.4% |
20.0%
16.4 pts worse
|
16.3%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
15.8%
9.2 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 30.0% · Q3 22.9% · Q4 22.9% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.2%
0.4 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 | 14.5% |
23.5%
9 pts better
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 10.3% · Q3 20.7% · Q4 15.4% · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
4.7%
6.8 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 15.4% · Q3 14.9% · Q4 5.9% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
87.7%
12.2 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.7% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
13.2%
0.7 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 13.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.4%
1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.5% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
82.0%
9.9 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
19.9%
1.9 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.2% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-28 · Fire 2023-08-28
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-18
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-16
F · Potential for more than minimal harm
2023-08-28
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-28
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-28
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-09-28
D · Potential for more than minimal harm
2022-03-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-03-14
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 2025-03-20
D · Potential for more than minimal harm
2025-03-14
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 2025-03-20
E · Potential for more than minimal harm
2024-12-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-18
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 2025-01-17
E · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
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 2025-01-17
D · Potential for more than minimal harm
2024-12-18
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 2025-01-17
D · Potential for more than minimal harm
2024-12-18
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 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
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 2025-01-17
D · Potential for more than minimal harm
2024-12-18
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 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-04-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-13
G · Actual harm
2024-02-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-02-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-02-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-16
F · Potential for more than minimal harm
2023-08-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-28
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 2023-09-26
D · Potential for more than minimal harm
2023-08-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-28
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 2023-09-26
D · Potential for more than minimal harm
2023-08-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-26
E · Potential for more than minimal harm
2022-03-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-29
E · Potential for more than minimal harm
2022-03-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-29
E · Potential for more than minimal harm
2022-03-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-04-29
E · Potential for more than minimal harm
2022-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-31
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 2022-04-29
D · Potential for more than minimal harm
2022-03-31
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 2022-04-29
D · Potential for more than minimal harm
2022-03-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-31
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 2022-04-29
Penalties and ownership
What sits behind the stars
$16,445
2024-02-08
Fine
Fine · fine $16,445
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Bhogal, Neeta
Operational/Managerial Control · Individual
Habtu, Netsanet
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Tappero, James
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Security Interest · Organization
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3-star overall rating with 3-star inspections with $12,735 in total fines with 10 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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