Cycle 1
Health 2025-08-27 · Fire 2025-08-27
25 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Des Moines, WA
Puget Sound Transitional Care
2-star overall rating with 2-star inspections with 25 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2800 South 224th Street,, Des Moines, WA
(206) 824-0600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
165
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2004-02-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
2.38
Nurse aide staffing
Weekend hours
3.37
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
26%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
96.0%
2.7 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.5% |
93.8%
4.3 pts worse
|
95.5%
6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
2.6%
1.7 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 32.5% |
16.3%
16.2 pts worse
|
11.4%
21.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.8%
2.1 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
12.1%
7.1 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
15.9%
3.9 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.2% |
20.0%
19.2 pts worse
|
16.3%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
15.8%
9 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
23.5%
2.8 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.7%
1.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
87.7%
4.9 pts better
|
81.7%
10.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
13.2%
3.3 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
82.0%
13.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
19.9%
0.1 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-05-19 · Fire 2023-05-19
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-08-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-19
F · Potential for more than minimal harm
2024-06-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-08
F · Potential for more than minimal harm
2023-05-19
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-05-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-05-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-05-19
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-19
F · Potential for more than minimal harm
2023-05-19
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 2023-06-19
E · Potential for more than minimal harm
2023-05-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-05-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-19
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 2023-05-30
D · Potential for more than minimal harm
2023-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-27
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-08-27
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 2025-10-09
E · Potential for more than minimal harm
2025-08-27
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 2025-10-09
E · Potential for more than minimal harm
2025-08-27
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 2025-10-09
E · Potential for more than minimal harm
2025-08-27
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 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
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 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
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 2025-10-09
D · Potential for more than minimal harm
2025-08-27
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 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
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 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-08-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-10-09
J · Immediate jeopardy
2025-07-01
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 2025-07-31
E · Potential for more than minimal harm
2025-07-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-01
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 2025-07-31
D · Potential for more than minimal harm
2025-07-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-31
F · Potential for more than minimal harm
2024-06-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-06-12
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
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 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
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 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-17
F · Potential for more than minimal harm
2023-05-19
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 2023-07-14
F · Potential for more than minimal harm
2023-05-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-19
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 2023-07-14
E · Potential for more than minimal harm
2023-05-19
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
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 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
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 2023-07-14
D · Potential for more than minimal harm
2023-05-19
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 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
Ownership
Actriv Healthcare LLC
Operational/Managerial Control · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Eastside Healthcare Staffing LLC
Operational/Managerial Control · Organization
Jenkins, Tracy
Operational/Managerial Control · Individual
Port, Barry
Corporate Director · Individual
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