Cycle 1
Health 2025-06-13 · Fire 2025-06-13
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Redmond, WA
Redmond Care And Rehabilitation Center
5-star overall rating with 5-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
7900 Willows Road Northeast, Redmond, WA
(425) 885-0808
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1968-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 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
0.88
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,666
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.89
Composite VBP score used to determine payment impact.
Payment multiplier
1.0098
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.34
Baseline 14.28% · Performance 18.50% · Measure score 6.34 · Achievement 6.34 · Improvement 0
Healthcare-associated infections
4.05
Baseline 4.98% · Performance 6.62% · Measure score 4.05 · Achievement 4.05 · Improvement 0
Total nurse turnover
10
Baseline 28.00% · Performance 22.64% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.57
Baseline 3.24 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0.60
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 335 · Observed rate 7.76% · Lower 95% interval 7.36% |
| Discharge to community | 68.9% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 351 · Observed rate 64.1% · Lower 95% interval 62.63% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 252 · Denominator 252 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 2 · Denominator 252 |
| Discharge self-care score | 58.24% |
53.69%
4.6 pts better
|
Numerator 106 · Denominator 182 |
| Discharge mobility score | 54.95% |
50.94%
4 pts better
|
Numerator 100 · Denominator 182 |
| Pressure ulcers or injuries, new or worsened | 1.19% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 252 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 240 · Observed rate 5.42% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 0.84% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 119 |
| Staff flu vaccination coverage | 81.15% |
42%
39.2 pts better
|
Numerator 99 · Denominator 122 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 104 · Denominator 182 |
| Transfer of health information to provider | 97.96% |
95.95%
2 pts better
|
Numerator 48 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 170 · Denominator 170 |
| Resident COVID-19 vaccinations up to date | 28.37% |
25.2%
3.2 pts better
|
Numerator 40 · Denominator 141 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
96.0%
3.4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.9% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
2.6%
2 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
16.3%
13.1 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 4.9% · Q4 2.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.8%
5.8 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 6.7% |
12.1%
5.4 pts better
|
19.6%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.5% · Q3 8.5% · Q4 8.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
15.9%
5 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 8.8% · Q3 10.0% · Q4 10.8% · 4Q avg 10.9% · 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 | 16.2% |
20.0%
3.8 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
15.8%
0.8 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.3% · Q3 19.6% · Q4 26.2% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.2%
0.7 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · 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 | 31.9% |
23.5%
8.4 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 36.2% · Q3 31.3% · Q4 29.4% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.7%
3.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
87.7%
8.2 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 95.4% · Q3 96.6% · Q4 95.0% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
13.2%
5.2 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.4%
0.2 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 2.8% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
82.0%
8.5 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
19.9%
4 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 13.8% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-05-21 · Fire 2023-05-21
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-13
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-13
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-15
F · Potential for more than minimal harm
2024-06-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-16
F · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-16
F · Potential for more than minimal harm
2023-05-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-21
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-13
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 2025-07-23
D · Potential for more than minimal harm
2025-06-13
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 2025-07-23
D · Potential for more than minimal harm
2025-06-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-13
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 2025-07-23
D · Potential for more than minimal harm
2025-06-13
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 2025-07-23
D · Potential for more than minimal harm
2025-06-13
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 2025-07-23
D · Potential for more than minimal harm
2025-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-03-18
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 2025-04-09
E · 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 2024-07-23
E · Potential for more than minimal harm
2024-06-12
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-06-12
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 2024-07-23
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 2024-07-23
D · Potential for more than minimal harm
2024-06-12
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-07-23
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 2024-07-23
D · Potential for more than minimal harm
2024-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-23
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 2024-07-23
E · Potential for more than minimal harm
2023-05-21
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 2023-06-28
D · Potential for more than minimal harm
2023-05-21
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 2023-06-28
D · Potential for more than minimal harm
2023-05-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-21
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 2023-06-28
D · Potential for more than minimal harm
2023-05-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-21
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 2023-06-28
D · Potential for more than minimal harm
2023-05-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-28
Penalties and ownership
What sits behind the stars
Ownership
Pennant Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Farnsworth, Stephen
Corporate Director · Individual
Holmes, Nathan
Operational/Managerial Control · Individual
Holmes, Nathan
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Taleghani, Masoud
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Corwin Center At Emerald Heights
Redmond, WA
4-star overall rating with 3-star inspections with $39,468 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Bellevue Post Acute
Bellevue, WA
3-star overall rating with 2-star inspections with 33 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Kirkland
Kirkland, WA
2-star overall rating with 2-star inspections with $103,155 in total fines with 21 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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