Cycle 1
Health 2025-06-06 · Fire 2025-06-06
44 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Seattle, WA
The Broadview Center
2-star overall rating with 1-star inspections with $16,981 in total fines with 44 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
13023 Greenwood Avenue North, Seattle, WA
(206) 364-1300
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
211
Certified beds
Average residents
125
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.78
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.49
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,007
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.30
Baseline 17.94% · Performance 19.90% · Measure score 3.30 · Achievement 3.30 · Improvement 0
Healthcare-associated infections
5.89
Baseline 5.80% · Performance 6.07% · Measure score 5.89 · Achievement 5.89 · 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
2.14
Baseline 4.13 hours · Performance 3.69 hours · Measure score 2.14 · Achievement 2.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.99% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 4.83% · Lower 95% interval 6.38% |
| Discharge to community | 51.17% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 48.46% · Lower 95% interval 42% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 81.58% |
95.27%
13.7 pts worse
|
Numerator 62 · Denominator 76 |
| Falls with major injury | 1.32% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 76 |
| Discharge self-care score | 65.52% |
53.69%
11.8 pts better
|
Numerator 38 · Denominator 58 |
| Discharge mobility score | 58.62% |
50.94%
7.7 pts better
|
Numerator 34 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 76 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.07% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 2.7% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 44.44% |
8.2%
36.2 pts better
|
Numerator 100 · Denominator 225 |
| Staff flu vaccination coverage | 45.14% |
42%
3.1 pts better
|
Numerator 144 · Denominator 319 |
| Discharge function score | 65.52% |
56.45%
9.1 pts better
|
Numerator 38 · Denominator 58 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 56.41% |
25.2%
31.2 pts better
|
Numerator 22 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.4
0.6 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
96.0%
3 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
93.8%
1.5 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
2.6%
About the same
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.0% · Q3 2.1% · Q4 3.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.9% |
16.3%
18.6 pts worse
|
11.4%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 21.5% · Q3 37.4% · Q4 45.2% · 4Q avg 34.9% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.8%
1.2 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.8% · Q3 10.8% · Q4 6.4% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.8% |
12.1%
5.3 pts better
|
19.6%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.7% · Q3 7.1% · Q4 7.1% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
15.9%
0.6 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.8% · Q3 16.4% · Q4 18.8% · 4Q avg 16.5% · 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 | 19.6% |
20.0%
0.4 pts better
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.1% · Q2 15.5% · Q3 18.1% · Q4 3.3% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
15.8%
2.8 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 21.1% · Q3 13.2% · Q4 1.3% · 4Q avg 13.0% · 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 · 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 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 | 26.9% |
23.5%
3.4 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 22.8% · Q3 30.8% · Q4 32.1% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.7%
3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 2.2% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
87.7%
3.8 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 95.2% · Q3 92.9% · Q4 82.9% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
13.2%
0.5 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 11.9% · Expected 10.5% · 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 1.2% · Q2 2.0% · Q3 2.3% · Q4 1.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.4% |
82.0%
6.6 pts worse
|
79.7%
4.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
19.9%
2.8 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.4% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-30 · Fire 2024-04-30
28 health deficiencies
Top issue: Resident Rights (9 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-02-10 · Fire 2023-02-10
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
32 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
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 2025-08-11
F · Potential for more than minimal harm
2025-06-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-11
F · Potential for more than minimal harm
2025-06-06
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 2025-07-07
F · Potential for more than minimal harm
2025-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-04-30
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-04-30
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-17
F · Potential for more than minimal harm
2024-04-30
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-04-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-04-30
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 2024-06-04
D · Potential for more than minimal harm
2024-04-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-04
K · Immediate jeopardy
2023-02-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
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 2023-03-09
F · Potential for more than minimal harm
2023-02-10
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 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-10
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 2023-03-09
F · Potential for more than minimal harm
2023-02-10
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-31
J · Immediate jeopardy
2025-09-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-30
F · Potential for more than minimal harm
2025-09-16
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-16
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 2025-10-30
E · Potential for more than minimal harm
2025-09-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-16
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-16
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 2025-10-30
D · Potential for more than minimal harm
2025-09-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-06-06
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-07-21
E · Potential for more than minimal harm
2025-06-06
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 2025-07-21
E · Potential for more than minimal harm
2025-06-06
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-21
E · Potential for more than minimal harm
2025-06-06
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 2025-07-21
E · Potential for more than minimal harm
2025-06-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-21
E · Potential for more than minimal harm
2025-06-06
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 2025-07-21
E · Potential for more than minimal harm
2025-06-06
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 2025-07-21
E · Potential for more than minimal harm
2025-06-06
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 2025-07-21
E · Potential for more than minimal harm
2025-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
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 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
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 2025-07-21
D · Potential for more than minimal harm
2025-06-06
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 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
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 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-06
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 2025-07-21
D · Potential for more than minimal harm
2025-06-06
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 2025-07-21
D · Potential for more than minimal harm
2025-06-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-21
C · Minimal harm
2025-06-06
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-05-28
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 2025-07-11
D · Potential for more than minimal harm
2025-05-12
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 2025-06-25
E · Potential for more than minimal harm
2024-04-30
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 2024-06-14
E · Potential for more than minimal harm
2024-04-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-30
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-30
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-30
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 2024-06-14
E · Potential for more than minimal harm
2024-04-30
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-04-30
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 2024-06-14
E · Potential for more than minimal harm
2024-04-30
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 2024-06-14
E · Potential for more than minimal harm
2024-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
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 2024-06-14
D · Potential for more than minimal harm
2024-04-30
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-30
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-31
E · Potential for more than minimal harm
2023-10-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-12-04
F · Potential for more than minimal harm
2023-02-10
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 2023-03-09
E · Potential for more than minimal harm
2023-02-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-02-10
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 2023-03-09
D · Potential for more than minimal harm
2023-02-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-10
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 2023-03-09
D · Potential for more than minimal harm
2023-02-10
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 2023-03-09
D · Potential for more than minimal harm
2023-02-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-10
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 2023-03-09
Penalties and ownership
What sits behind the stars
$16,981
2025-09-16
Fine
Fine · fine $16,981
Fine
Ownership
Chick, Kris
Corporate Director · Individual
Foss Home & Village
5% Or Greater Direct Ownership Interest · Organization
Heritage Bank
5% Or Greater Mortgage Interest · Organization
Mcfeely, Kevin
Corporate Officer · Individual
Molzahn, Laura
W-2 Managing Employee · Individual
Roach, Beverly
Corporate Director · Individual
Steinruck, James
W-2 Managing Employee · Individual
West, Jeffrey
Corporate Officer · Individual
Wildes, Judy
Corporate Director · Individual
Yari, Julie
Corporate Director · Individual
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