Cycle 1
Health 2025-05-14 · Fire 2025-05-14
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
23 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Anacortes, WA
Soundview Rehabilitation And Health Care Inc
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
1105 27th Street, Anacortes, WA
(360) 293-3174
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hyatt Family Facilities
Operator or chain grouping
Approved since
1978-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 health / 4 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
0.74
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
77%
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
4,270
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.34
Baseline 19.75% · Performance 18.96% · Measure score 5.34 · Achievement 5.34 · Improvement 2.43
Healthcare-associated infections
2.89
Baseline 6.24% · Performance 6.97% · Measure score 2.89 · Achievement 2.89 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.96
Baseline 3.94 hours · Performance 4.20 hours · Measure score 3.96 · Achievement 3.96 · Improvement 0.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.04% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 264 · Observed rate 11.74% · Lower 95% interval 9.45% |
| Discharge to community | 58.92% |
50.57%
8.4 pts better
|
Better than the National Rate · Eligible stays 266 · Observed rate 61.28% · Lower 95% interval 54.16% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.28% |
95.27%
2 pts better
|
Numerator 143 · Denominator 147 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 147 |
| Discharge self-care score | 62.07% |
53.69%
8.4 pts better
|
Numerator 72 · Denominator 116 |
| Discharge mobility score | 81.9% |
50.94%
31 pts better
|
Numerator 95 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 8.84% |
2.29%
6.5 pts worse
|
Numerator 13 · Denominator 147 · Adjusted rate 6.48% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 5.07% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 25.33% |
42%
16.7 pts worse
|
Numerator 19 · Denominator 75 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 87 · Denominator 116 |
| Transfer of health information to provider | 94.29% |
95.95%
1.7 pts worse
|
Numerator 33 · Denominator 35 |
| Transfer of health information to patient | 98.92% |
96.28%
2.6 pts better
|
Numerator 92 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 38.96% |
25.2%
13.8 pts better
|
Numerator 30 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
96.0%
2.8 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 100.0% · Q3 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
93.8%
1.7 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.6%
0.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
16.3%
14.9 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.8%
3.1 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
12.1%
1.7 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.0% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
15.9%
5.6 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
15.8%
3.6 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · 4Q avg 19.4% · Used in QM five-star |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.1% |
1.7%
7.4 pts worse
|
1.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q3 5.0% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.2% |
23.5%
13.7 pts worse
|
19.8%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.2% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.7%
0.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q3 0.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
87.7%
2.4 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 86.0% · Q3 90.2% · Q4 92.9% · 4Q avg 90.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.9% |
13.2%
10.7 pts worse
|
12.0%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 23.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.4%
1.1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.0% · Q3 3.5% · Q4 3.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.9% |
82.0%
1.9 pts better
|
79.7%
4.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
19.9%
5.5 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 21.5% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-29 · Fire 2024-05-29
34 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
25 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-03-13 · Fire 2023-03-13
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
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 2025-06-11
F · Potential for more than minimal harm
2025-05-14
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 2025-06-11
F · Potential for more than minimal harm
2025-05-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-05-14
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 2025-06-11
D · Potential for more than minimal harm
2025-05-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-11
F · Potential for more than minimal harm
2024-05-29
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
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 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-29
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 2024-06-25
E · Potential for more than minimal harm
2024-05-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-05-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-05-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-05-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-03-13
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-03-13
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-03-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-03-13
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-13
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 2023-04-12
E · Potential for more than minimal harm
2023-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-03-13
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-04-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-14
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 2025-06-20
F · Potential for more than minimal harm
2025-05-14
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 2025-06-20
F · Potential for more than minimal harm
2025-05-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
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 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-02-07
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-08-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-29
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-05-29
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 2024-07-17
F · Potential for more than minimal harm
2024-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-17
F · Potential for more than minimal harm
2024-05-29
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-05-29
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 2024-07-17
E · Potential for more than minimal harm
2024-05-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-05-29
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
E · Potential for more than minimal harm
2024-05-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-05-29
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
E · Potential for more than minimal harm
2024-05-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-05-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-05-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
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 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
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 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-05-29
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 2024-07-17
D · Potential for more than minimal harm
2024-05-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-07-17
G · Actual harm
2024-04-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-25
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-01-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-15
D · Potential for more than minimal harm
2023-06-02
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-02
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 2023-06-30
D · Potential for more than minimal harm
2023-06-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-03-13
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 2023-04-25
E · Potential for more than minimal harm
2023-03-13
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 2023-04-25
D · Potential for more than minimal harm
2023-03-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-13
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 2023-04-25
D · Potential for more than minimal harm
2023-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-13
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 2023-04-25
D · Potential for more than minimal harm
2023-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-13
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-13
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 2023-04-25
D · Potential for more than minimal harm
2023-03-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-13
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 2023-04-25
Penalties and ownership
What sits behind the stars
Ownership
Hyatt, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Avventura Senior Living Inc
Operational/Managerial Control · Organization
Berk, Heidi
W-2 Managing Employee · Individual
Hyatt Family Facilities LLC
Operational/Managerial Control · Organization
Hyatt, Jeffrey
Operational/Managerial Control · Individual
Hyatt, Jeffrey
Corporate Director · Individual
Hyatt, Jeffrey
Corporate Officer · Individual
Hyatt, Jeffrey
W-2 Managing Employee · Individual
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#3
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